DISCOURSE AND DIALOGUE
Letter to the Editor Partial or Total Calcanectomy as an Alternative to Below-the-Knee Amputation for Limb Salvage To The Editor: We read with interest the article, ‘‘Partial or Total Calcanectomy as an Alternative to Below-the-Knee Amputation for Limb Salvage,’’ by Valerie Schade, DPM, which appeared in the September/October 2012 issue, and we would like to comment on the author’s conclusion that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis. Earlier work on total calcanectomies for osteomyelitis, published by our group, concluded that this was a surgical alternative to below-the-knee amputations (BKAs);1 however, ongoing work has questioned this finding. We published data suggesting that both partial and total calcanectomy represent a tenuous alternative to BKA in patients with diabetic foot ulcers.2 Proximal ipsilateral amputation due to failed wound healing was required in 6 of 17 (35%) partial calcanectomy patients and 5 of 16 (31%) total calcanectomy patients. These proximal amputations occurred at 0.7 years after the index procedure with partial calcanectomy and 0.3 years after with total calcanectomy. In terms of mortality, both partial and total calcanectomy had higher mortality rates at three and five year follow-up compared to BKA. We used a validated measure to assess postoperative ambulatory function3 and found that partial (4.3/6.0) and total (3.3/6.0) calcanectomy did result in better ambulatory function compared to BKA (2.8/6.0) when complete healing occurs. However, these gains in functional outcome were achieved by only approximately two-thirds of patients, with the remaining one-third requiring conversion to BKA, and perhaps equally important is the often unpredictable postoperative course required to achieve healing. The prolonged healing time and corresponding negative impact on quality of life should be considered with calcanectomy procedures. In a patient population with limited life expectancy and higher operative risk, an operation with such variable postoperative healing is of questionable worth. Our conclusion is that risks of partial and
total calcanectomy in diabetic patients with foot ulcers appear to outweigh the benefits. Our study was unfortunately limited by small numbers, and we were unable to stratify risk factors within cohorts to predict which patients were likely to require revision surgery. Our review has influenced our practice in that we do not recommend partial or total calcanectomy surgery for limb salvage in diabetic patients with osteomyelitis. The foot and ankle literature contains only small series that report outcomes of these partial foot amputations, and the functional outcome reporting is sporadic, nonuniform, and often nonvalidated. We would emphasize the use of validated instruments to determine functional outcome, which will increase the generalizability of outcomes for future meta-analyses and provide for better surgical decision-making in foot and ankle surgery.
References 1. BAUMHAUER JF, FRAGA CJ, GOULD JS, ET AL: Total calcanectomy for the treatment of chronic calcaneal osteomyelitis. Foot Ankle Int 19: 849,1998. 2. BROWN ML, TANG W, PATEL A, ET AL: Partial foot amputation in patients with diabetic foot ulcers. Foot Ankle Int 33: 707, 2012. 3. VOLPICELLI L J, CHAMBERS RB, WAGNER FW: Ambulation levels of bilateral lower-extremity amputees. analysis of one hundred and three cases. J Bone Joint Surg Am 65: 599, 1983.
MATTHEW L. BROWN, MD Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 JUDITH F. BAUMHAUER, MD, MPH Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 655, Rochester, NY, 14642
Author’s Response To The Editor: Dr. Brown and Dr. Baumhauer question the use of partial or total calcanectomy as a viable option for limb salvage in response to my previously published systematic review, which found that
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these procedures may be a viable option when they would definitely eradicate soft-tissue and osseous infections and allow for primary wound closure. Dr. Brown et al found these procedures to be fraught with an unpredictable postoperative course and associated with a higher morbidity and mortality rate compared to BKA. Their presented data, however, did not reach statistical significance for mortality rates at 1, 3, and 5 years when compared to BKA. Although the rate of more proximal ipsilateral amputation following partial or total calcanectomy was higher than that of BKA, it was only half the rate following Chopart amputation. Of the 10 patients who underwent a Chopart amputation in their study, 6 (60%) required a more proximal ipsilateral amputation at 2.3 6 1.4 years. Although these patients did succeed with limb salvage for a longer duration than those who required a partial or total calcanectomy, more than half still went on to more proximal amputation. Despite these findings, the authors concluded that a Chopart amputation may offer a good operative alternative to BKA, knowing the potential risk for more proximal amputation in approximately 3 years or less. Dr. Brown et al stated that the reason for conversion of partial and total calcanectomy to a more proximal ipsilateral amputation at 0.7 and 0.3 years respectively was failure in wound healing. This stated reason for conversion, and the short time frame in which it occurred, begs the question of whether the index procedure had eradicated all soft tissue and/or osseous infection. Consideration of the individual patient, their demographics, and
312
their clinical presentation must be taken into account to offer the patient the amputation level that would be the most likely to heal primarily. With this information, more proximal primary amputation may be the optimal procedure of choice. Patients in which a form of calcanectomy is a consideration often present with advanced stages of their comorbidities, such as advanced peripheral vascular disease, or a decompensated state, which has led to pressure ulceration of the heel. Dr. Brown et al did find worse outcomes following total calcanectomy compared to partial calcanectomy due to the severity and size of the heel ulceration, which is corroborated with the findings of my systematic review. A partial or total calcanectomy may still be a viable alternative to major amputation in patients with heel ulceration or calcaneal osteomyelitis, as failure of the procedure should be apparent relatively quickly, as noted by Dr. Brown et al as well. The level of more proximal ipsilateral amputation continues to remain unchanged. Combination of the information presented in my systematic review and the study by Dr. Brown et al should help surgeons make a better determination of the best level for primary amputation that would combine quality of life and limb salvage. VALERIE L. SCHADE, DPM, AACFAS Chief, Limb Preservation Service, Madigan Army Medical Center, 9040 Jackson Drive, MCHJ-CLS-V, Tacoma, WA, 98431-1100
May/June 2014 Vol 104 No 3 Journal of the American Podiatric Medical Association
Letter to the Editor Partial or Total Calcanectomy as an Alternative to Below-the-Knee Amputation for Limb Salvage To The Editor: We read with interest the article, ‘‘Partial or Total Calcanectomy as an Alternative to Below-the-Knee Amputation for Limb Salvage,’’ by Valerie Schade, DPM, which appeared in the September/October 2012 issue, and we would like to comment on the author’s conclusion that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis. Earlier work on total calcanectomies for osteomyelitis, published by our group, concluded that this was a surgical alternative to below-the-knee amputations (BKAs);1 however, ongoing work has questioned this finding. We published data suggesting that both partial and total calcanectomy represent a tenuous alternative to BKA in patients with diabetic foot ulcers.2 Proximal ipsilateral amputation due to failed wound healing was required in 6 of 17 (35%) partial calcanectomy patients and 5 of 16 (31%) total calcanectomy patients. These proximal amputations occurred at 0.7 years after the index procedure with partial calcanectomy and 0.3 years after with total calcanectomy. In terms of mortality, both partial and total calcanectomy had higher mortality rates at three and five year follow-up compared to BKA. We used a validated measure to assess postoperative ambulatory function3 and found that partial (4.3/6.0) and total (3.3/6.0) calcanectomy did result in better ambulatory function compared to BKA (2.8/6.0) when complete healing occurs. However, these gains in functional outcome were achieved by only approximately two-thirds of patients, with the remaining one-third requiring conversion to BKA, and perhaps equally important is the often unpredictable postoperative course required to achieve healing. The prolonged healing time and corresponding negative impact on quality of life should be considered with calcanectomy procedures. In a patient population with limited life expectancy and higher operative risk, an operation with such variable postoperative healing is of questionable worth. Our conclusion is that risks of partial and
total calcanectomy in diabetic patients with foot ulcers appear to outweigh the benefits. Our study was unfortunately limited by small numbers, and we were unable to stratify risk factors within cohorts to predict which patients were likely to require revision surgery. Our review has influenced our practice in that we do not recommend partial or total calcanectomy surgery for limb salvage in diabetic patients with osteomyelitis. The foot and ankle literature contains only small series that report outcomes of these partial foot amputations, and the functional outcome reporting is sporadic, nonuniform, and often nonvalidated. We would emphasize the use of validated instruments to determine functional outcome, which will increase the generalizability of outcomes for future meta-analyses and provide for better surgical decision-making in foot and ankle surgery.
References 1. BAUMHAUER JF, FRAGA CJ, GOULD JS, ET AL: Total calcanectomy for the treatment of chronic calcaneal osteomyelitis. Foot Ankle Int 19: 849,1998. 2. BROWN ML, TANG W, PATEL A, ET AL: Partial foot amputation in patients with diabetic foot ulcers. Foot Ankle Int 33: 707, 2012. 3. VOLPICELLI L J, CHAMBERS RB, WAGNER FW: Ambulation levels of bilateral lower-extremity amputees. analysis of one hundred and three cases. J Bone Joint Surg Am 65: 599, 1983.
MATTHEW L. BROWN, MD Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 JUDITH F. BAUMHAUER, MD, MPH Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 655, Rochester, NY, 14642
Author’s Response To The Editor: Dr. Brown and Dr. Baumhauer question the use of partial or total calcanectomy as a viable option for limb salvage in response to my previously published systematic review, which found that
Journal of the American Podiatric Medical Association Vol 104 No 3 May/June 2014
311
these procedures may be a viable option when they would definitely eradicate soft-tissue and osseous infections and allow for primary wound closure. Dr. Brown et al found these procedures to be fraught with an unpredictable postoperative course and associated with a higher morbidity and mortality rate compared to BKA. Their presented data, however, did not reach statistical significance for mortality rates at 1, 3, and 5 years when compared to BKA. Although the rate of more proximal ipsilateral amputation following partial or total calcanectomy was higher than that of BKA, it was only half the rate following Chopart amputation. Of the 10 patients who underwent a Chopart amputation in their study, 6 (60%) required a more proximal ipsilateral amputation at 2.3 6 1.4 years. Although these patients did succeed with limb salvage for a longer duration than those who required a partial or total calcanectomy, more than half still went on to more proximal amputation. Despite these findings, the authors concluded that a Chopart amputation may offer a good operative alternative to BKA, knowing the potential risk for more proximal amputation in approximately 3 years or less. Dr. Brown et al stated that the reason for conversion of partial and total calcanectomy to a more proximal ipsilateral amputation at 0.7 and 0.3 years respectively was failure in wound healing. This stated reason for conversion, and the short time frame in which it occurred, begs the question of whether the index procedure had eradicated all soft tissue and/or osseous infection. Consideration of the individual patient, their demographics, and
312
their clinical presentation must be taken into account to offer the patient the amputation level that would be the most likely to heal primarily. With this information, more proximal primary amputation may be the optimal procedure of choice. Patients in which a form of calcanectomy is a consideration often present with advanced stages of their comorbidities, such as advanced peripheral vascular disease, or a decompensated state, which has led to pressure ulceration of the heel. Dr. Brown et al did find worse outcomes following total calcanectomy compared to partial calcanectomy due to the severity and size of the heel ulceration, which is corroborated with the findings of my systematic review. A partial or total calcanectomy may still be a viable alternative to major amputation in patients with heel ulceration or calcaneal osteomyelitis, as failure of the procedure should be apparent relatively quickly, as noted by Dr. Brown et al as well. The level of more proximal ipsilateral amputation continues to remain unchanged. Combination of the information presented in my systematic review and the study by Dr. Brown et al should help surgeons make a better determination of the best level for primary amputation that would combine quality of life and limb salvage. VALERIE L. SCHADE, DPM, AACFAS Chief, Limb Preservation Service, Madigan Army Medical Center, 9040 Jackson Drive, MCHJ-CLS-V, Tacoma, WA, 98431-1100
May/June 2014 Vol 104 No 3 Journal of the American Podiatric Medical Association
