The closure. After toe amputation, the mainThe closure. After toe amputation, the main


The main limitation of this study is in its retrospective
nature and having to depend on the medical records to obtain the needed
information, as some important data was not uniformly reported in the charts
such as neuropathy. In addition, not all the patient had Duplex/Doppler or
laboratory test done during their admission especially in the presence of
palpable pedal pulses or depending on the clinical assessment of the treating
surgeon. Furthermore, the sample size was also relatively small (n = 85) but
our results were consistent with findings reported in the literature. Verification
by a prospective study with more rigorous data recording may be required.

 Many studies suggested
that DFU infection is associated with high amputation rate and bad outcome 16 17, but after undergoing minor
amputation no association was defined between the infectious status of the
wound pre-amputation and the re-intervention rate. In this study, the severity
of the infection measured by (IWGDF/IDSA) and the depth of the ulcer measured by
Wagner classification were not associated with significant difference in re-intervention
rate after toe amputation. In the presence of moderate or severe infection,
primary closure should be avoided and a strong consideration for delayed
primary closure or leaving the wound open for secondary closure.

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After toe amputation, the main problem that the surgeons face is the management of soft tissue wound.
Our study showed decrease in further intervention rate with delayed primary
closure compared to primary closure. When compared to secondary closure,
delayed primary closure was also associated with lower further intervention rate
but it was not statistically significant. Berceli et al compared the three
types of wound closure in diabetic and non-diabetic patients who had forefoot
osteomyelitis and found that delayed primary closure was associated with
fourfold decrease in time to healing and a 50% reduction in both early major
amputation and the need for repeat intervention.6 Lakstein et al
reviewed the results of 40 elective toe amputations with primary closure and
found that primary closure is a safe surgical option as 38 out of 40 wounds
healed but this study excluded patients with abscesses or extensive cellulites
or those who required vascular intervention.15 The advantage of the delayed primary
closure is that it allows the infection and edema to settle and avoids closing
the wound in a clean contaminated setting.

Our study showed that patients
treated with insulin had lower further intervention rate compared to those
treated with oral medications only. This effect of insulin on wound healing is
well known as insulin has been used to treat bed-sores in non-diabetic patients
since the 1930s, and it was shown to improve healing in patients with gangrene
and decubitus ulcers.14  In addition, patients on insulin may be achieving better glycemic
control than those on oral hypoglycemic therapy. Whether insulin should
be recommended for diabetic patients with foot ulcers who are only on oral
hypoglycemic therapy remains to be determined but may be encouraged.

The association between glycemic
control and wound healing is highly reported. Several studies showed strong
association between higher HbA1C level preoperatively and the outcomes such as
impaired wound healing, re-ulceration and re-amputation and postoperative
complications 7 13. Our study however did not
find significant difference in HbA1C value between further intervention and no
further intervention groups. This may be due to insufficient data, as HbA1C was
not taken in 21% of the patients.

Although ABI is used traditionally
to assess lower extremity circulation, its reliability in diabetic patients is
limited due to the high prevalence of large arteries calcification in those patients
that gives falsely elevated results. Medial arterial calcification affects 35 –
56 % of diabetic patients but it spares the small arteries of the toe which
makes toe pressure and toe brachial index more recommended in diabetic patients
for assessment of peripheral vascular disease severity.12 8

In various reports, non-invasive
vascular parameters were identified as predictors of healing after minor
amputation in diabetic patients such as the toe pressure and the Toe Brachial
Index (TBI). In concordance with our study, Caruana et al. and Vitti et al.
found that toe pressure and toe brachial index are better predictors of
likelihood of healing after minor amputation than the Ankle Brachial Index (ABI).
5 8

The negative effect of aging on
wound healing has been previously reported 11. In concordance with our
study, Vitti et al. found that age was a negative predictor of wound healing.8

In our study, 5 patients ended up with BKA which is one of the worst
outcomes in DFU patients. This outcome could be related to presenting with
high-grade ulcers; as those patients had Grade 4 ulcers according to Wagner
classification and moderate to severe infection according to IWGDF/IDSA
classification. In addition to the severity of peripheral artery disease as revascularization
was not an option in some and 2 patients failed to heal despite angioplasty and
bypass surgery.

72% of the patients in this study
had adequate wound healing and did not require any further debridement or
proximal amputation which is comparable to the healing rate of 64 and 82%
reported in other studies. 5 7

Although many studies discussed the
outcomes of major amputation in diabetic patients, few reports described toe
amputation outcomes. In our cohort of 384 patients with diabetic foot ulcer,
85(22%) underwent toe amputation which is the most common type of amputation in
diabetic patients (57% of all amputations done at AUBMC in the last 10 years).