Borkosky Sara L, Roukis Thomas S
Podiatric Medicine and Surgery Residency Program, Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin, USA.
Diabet Foot Ankle. 2012;3. doi: 10.3402/dfa.v3i0.12169. Epub 2012 Jan 20.
Diabetes mellitus with peripheral sensory neuropathy frequently results in forefoot ulceration. Ulceration at the first ray level tends to be recalcitrant to local wound care modalities and off-loading techniques. If healing does occur, ulcer recurrence is common. When infection develops, partial first ray amputation in an effort to preserve maximum foot length is often performed. However, the survivorship of partial first ray amputations in this patient population and associated re-amputation rate remain unknown. Therefore, in an effort to determine the actual re-amputation rate following any form of partial first ray amputation in patients with diabetes mellitus and peripheral neuropathy, the authors conducted a systematic review. Only studies involving any form of partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy but without critical limb ischemia were included. Our search yielded a total of 24 references with 5 (20.8%) meeting our inclusion criteria involving 435 partial first ray amputations. The weighted mean age of patients was 59 years and the weighted mean follow-up was 26 months. The initial amputation level included the proximal phalanx base 167 (38.4%) times; first metatarsal head resection 96 (22.1%) times; first metatarsal-phalangeal joint disarticulation 53 (12.2%) times; first metatarsal mid-shaft 39 (9%) times; hallux fillet flap 32 (7.4%) times; first metatarsal base 29 (6.7%) times; and partial hallux 19 (4.4%) times. The incidence of re-amputation was 19.8% (86/435). The end stage, most proximal level, following re-amputation was an additional digit 32 (37.2%) times; transmetatarsal 28 (32.6%) times; below-knee 25 (29.1%) times; and LisFranc 1 (1.2%) time. The results of our systematic review reveal that one out of every five patients undergoing any version of a partial first ray amputation will eventually require more proximal re-amputation. These results reveal that partial first ray amputation for patients with diabetes and peripheral sensory neuropathy may not represent a durable, functional, or predictable foot-sparing amputation and that a more proximal amputation, such as a balanced transmetatarsal amputation, as the index amputation may be more beneficial to the patient. However, this remains a matter for conjecture due to the limited data available and, therefore, additional prospective investigations are warranted.
糖尿病伴周围感觉神经病变常导致前足溃疡。第一跖骨水平的溃疡往往对局部伤口护理方式和减负技术反应不佳。即使溃疡愈合，复发也很常见。当发生感染时，为保留最大足长，常进行第一跖骨部分截肢术。然而，该患者群体中第一跖骨部分截肢术的存活率及相关再截肢率尚不清楚。因此，为确定糖尿病和周围神经病变患者进行任何形式的第一跖骨部分截肢术后的实际再截肢率，作者进行了一项系统评价。纳入的研究仅涉及与糖尿病和周围感觉神经病变相关的任何形式的第一跖骨部分截肢术，且不伴有严重肢体缺血。我们的检索共得到24篇参考文献，其中5篇（20.8%）符合纳入标准，涉及435例第一跖骨部分截肢术。患者的加权平均年龄为59岁，加权平均随访时间为26个月。初始截肢水平包括近节趾骨基底167次（38.4%）；第一跖骨头切除96次（22.1%）；第一跖趾关节离断53次（12.2%）；第一跖骨中轴39次（9%）；拇趾皮瓣32次（7.4%）；第一跖骨基底29次（6.7%）；部分拇趾19次（4.4%）。再截肢发生率为19.8%（86/435）。再截肢后的终末期、最近端水平为额外趾截肢32次（37.2%）；经跖骨截肢28次（32.6%）；膝下截肢25次（29.1%）；LisFranc关节截肢1次（1.2%）。我们系统评价的结果显示，每五例接受任何形式第一跖骨部分截肢术的患者中就有一例最终需要更近端的再截肢。这些结果表明，糖尿病和周围感觉神经病变患者的第一跖骨部分截肢术可能并非持久、功能性或可预测的保足截肢术，而作为初次截肢术，更近端的截肢术，如平衡经跖骨截肢术，可能对患者更有益。然而，由于现有数据有限，这仍只是一种推测，因此有必要进行更多前瞻性研究。
