What is the most durable construct for a forefoot amputation, traditional transmetatarsal amputation or a medial ray sparing procedure?

This discussion is prompted by a recent paper from Suh and colleagues from Seoul, South Korea that evaluates clinical outcomes from a retrospective cohort of 59 patients with either a traditional transmetatarsal amputation (TMA) (n=27) or first or first and second ray sparing amputation (n=32) that all required follow-up free flap coverage (1). Evaluating the function of different amputation constructs in the diabetic foot is an important issue because recurrent events are very common in patients with diabetes and a history of diabetic foot ulcer or amputation. The medial column of the foot is essential for ambulation and balance. If we can maintain the function of the first ray (the great toe, first metatarsophalangeal joint, first metatarsal and metatarsocuneiform joint complex) we may be able to create a more durable amputation with improved function. However, when adjacent toes and metatarsophalangeal joints are amputated, the foot compensates. Often the remaining first and second toe and metatarsophalangeal joints deform, the toes hammer, the toes deviate laterally, and the metatarsophalangeal joints dislocate. As the metatarsophalangeal joints dislocate, the metatarsal heads are often literally pushed through the sole of the foot. A midfoot amputation clearly changes the way our patients walk. There is very little power generation across the ankle joint, so the hip becomes the primary source for propulsion. It makes sense that people with residual toes require more surgery, just as Suh reports (1)