From the Guidelines
A big toe amputation is a serious surgical procedure that requires careful consideration and management to minimize morbidity, mortality, and improve quality of life, and it is essential to approach this procedure with a multidisciplinary team and follow established guidelines, such as those outlined in the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. When considering a big toe amputation, it is crucial to evaluate the patient's overall health, including the presence of diabetes, peripheral arterial disease, and other comorbidities. The procedure should be performed by a surgeon with thorough knowledge of the anatomy of the foot and the ways in which infection spreads through its fascial planes, as highlighted in the IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes 1. Some key points to consider when approaching a big toe amputation include:
- The need for careful preoperative evaluation and planning, including medical evaluations and potential cessation of certain medications like blood thinners
- The importance of proper wound care and management, including regular dressing changes, keeping the area clean and dry, and taking prescribed antibiotics to prevent infection
- The role of pain management, including medications like acetaminophen, NSAIDs, or prescription opioids if needed
- The importance of physical therapy in regaining balance and mobility, starting with gentle exercises and progressing to walking with assistive devices
- The need for specialized footwear with inserts to redistribute pressure and maintain balance
- The potential for complications like infection, poor wound healing, phantom pain, or balance issues, and the importance of monitoring for these complications
- The long-term adjustments that may be necessary, including gait training and possibly permanent use of specialized footwear. It is also essential to consider the patient's quality of life and functional status after the amputation, and to provide appropriate support and rehabilitation to help them adapt to the changes and prevent complications like altered gait patterns that could affect other joints.
From the Research
Big Toe Amputation: Key Considerations
- A history of previous amputation is the best predictor of amputation, and a history of lower extremity ulceration or amputation increases the risk for further ulceration, infection, and subsequent amputation 2
- Early diagnosis, control of risk factors, medical management, and timely revascularization may aid in avoiding limb loss 2
- Treatment combines patient education, orthoses, footwear, and off-loading, and patients at risk should understand the implications of loss of protective sensation and the importance of carefully monitoring their feet 2
Wound Care and Healing
- Negative pressure wound therapy (NPWT) may be useful for healing various types of wounds, but its effectiveness could not be empirically quantified due to poorly done studies and small sample sizes 3
- NPWT has been shown to be safe and effective in treating complex diabetic foot wounds, leading to a higher proportion of healed wounds and faster healing rates compared to standard care 4
- The goal of amputation is to remove necrosis or infection prior to its spread to the midfoot region, and orthopedic shoes or orthotic devices may be necessary after amputation to address concomitant deformities of the foot 5
Specific Considerations for Big Toe Amputation
- Big-toe amputations are not frequent entities, but re-plantation should always be considered to avoid unsatisfactory aesthetic and functional outcomes 6
- There are limited reports in literature on big-toe amputations, and long-term follow-up is necessary to assess the outcomes of such procedures 6
- Patients with diabetes are at higher risk of complications after amputation, and NPWT may be a useful treatment option for complex diabetic foot wounds 4