Wound Medicine 4 (2014) 37–41

Contents lists available at ScienceDirect

Wound Medicine
journal homepage: www.elsevier.com/locate/wndm

The Too Few Toes principle: A formula for limb-sparing low-level

amputation planning
John D. Miller, Michelle Zhubrak, Nicholas A. Giovinco, Joseph L. Mills,
David G. Armstrong *
Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, United States

A R T I C L E I N F O A B S T R A C T

Article history: Both single and multiple toe amputations biomechanically alter foot function to varying degrees. In
Received 5 February 2014 patients with diabetic neuropathy, these changes often lead to increases in deformity, plantar pressure
Accepted 6 February 2014 and risk for ulceration, infection and reamputation. While a philosophy that strives to maximize limb
Available online 15 February 2014
length and function by performing the fewest and most distal amputations possible is likely a good one,
we believe that a basic ‘‘formula’’ might help serve as a guide for surgeons to balance limb function with
Keywords: tissue preservation. Digital amputations that exceed a ‘‘hallux plus one lesser toe’’ or ‘‘lesser toe plus
Amputation
two’’ digital/ray amputations in our experience often surpass a threshold of mechanical function. For any
Forefoot
Planning
clinical scenario in which amputation would extend beyond this threshold, a transmetatarsal
Toe amputation (TMA) or pan metatarsal head resection (PMHR) should strongly be considered to avoid
Surgery costly foot complications and the need for excessive revisional surgery. Such an approach still maintains
Resection an underlying philosophy of functional limb preservation. We are unaware of any other attempt to
standardize the advancement of surgical intervention from multiple toe resections to a full metatarsal
level or higher resection. Therefore, we present this simple formula for surgical planning in the hopes of
providing the most durable and efficient care of the high-risk diabetic foot when multiple toe
amputations are needed.
ß 2014 Elsevier GmbH. All rights reserved.

Although much has been written about hallux and partial
forefoot amputations, there are no articles, to the best of our
knowledge, which specifically address the sequelae of multiple toe
amputations or the minimal number of residual toes required to
maintain and preserve a biomechanically stable and functional
foot. The purpose of this article is to suggest an algorithm for
optimizing effective shoeing and ambulation in the diabetic
patient requiring amputation.
Recent data reveal that the US spends one in five health care
dollars on the care of diabetic patients, with the total economic
cost of diabetes estimated at over $245 billion. In 2008 alone,
surgeons performed 67,000 foot amputations on diabetic patients
in the US [1], many of which were attempts at limb salvage.
Although amputations are a necessary component of the treatment
protocol, they may result in the need for additional revisional
operations that are associated with some morbidity and serial loss
* Corresponding author.
E-mail addresses: Armstrong@usa.net, john.d.miller@dmu.edu
(D.G. Armstrong).
of function, further increasing the cost to the patient and
healthcare system.
The hallux and medial column has an outsized influence on gait
and function [2]. Amputations of the first ray affect the natural
biomechanics of the foot and have been shown to produce a lateral
redistribution of the patient’s ambulatory load postoperatively [3].
This redistribution of stress during weight bearing places the
remaining foot at increased risk for developing new ulcerations,
which commonly lead to additional amputations [4,5]. Partial first
ray resections are associated with a high re-amputation rate, with
nearly 50% of these patients requiring a subsequent more proximal
amputation [6,7]. When modification of the hallux alone causes
this predictable complication rate, it is reasonable to anticipate
that additional toe resections would create an even greater
imbalance of pressure on the remaining extremity. This imbalance
further escalates the patients’ risk of future complications.
Limited research has examined the biomechanical changes of
forefoot pressure following resections of the lesser toes [8]. Despite
this paucity of peer reviewed literature, many practitioners
anecdotally relate the elusive results in patient satisfaction
following amputation [9]. Digital resections of the forefoot put

http://dx.doi.org/10.1016/j.wndm.2014.02.001
2213-9095/ß 2014 Elsevier GmbH. All rights reserved.
38 J.D. Miller et al. / Wound Medicine 4 (2014) 37–41

the remaining extremity under increased load, exacerbating the

risk for complication [5]. Lesser toe amputations, when compli-
cated by peripheral artery disease and other predisposing factors
(especially neuropathy and deformity), increase the possibility of
re-ulceration with infection and gangrene, and ultimately, a need
for further revisional surgery [10].
Aragon-Sanchez et al. explored the inpatient mortality of the
diabetic patient undergoing amputation [11]. Kerr et al. expanded
this area of research, reporting that patients with diabetic foot
ulcers experienced increased lengths of inpatient hospitalization,
even if the original admission was unrelated to podiatric issues
[12]. Kerr’s findings were later reinforced by Nirantharakumar.
Using the NICE guideline, which defines foot disease as the
presence of neuropathy, peripheral arterial disease, foot deformity,
active infection, ulceration or gangrene in at least one lower
extremity, Nirantharakumar found that the odds of inpatient
mortality and length of stay were respectively 31% and 101%
greater in patients with a type of foot disease when compared to
those without any foot disease [13].
These works, along with the findings of Boulton et al. [14],
Brownrigg et al. [15], Ghanassia et al. [16], Morbach et al. [17],
Moulik et al. [18], describe a definitive correlation between the
presence of diabetes related foot ulcers and a downward spiral in
patient quality of life. If saving one or two toes greatly increases the
Fig. 1. The likelihood of ulcer development secondary to the shoeing of this foot is
patient’s risk for additional surgery and extended hospital visits, extremely high.
the patient’s condition must be fully evaluated to decide which
method will minimize the risks to the patient and which route will
by performing a rear foot extrinsic tendon balancing procedure to
quickly return them to daily life. Due diligence on behalf of the
address the musculoskeletal changes [27].
surgeon in the initial selection of amputation level can prevent the
TMA healing rates described in the literature vary widely.
‘at risk’ post-surgical situation from placing the diabetic patient
However, investigators reported favorable results when postoper-
under greater financial, psychological, and physical burden.
ative success was defined as the patient’s ability to retain the foot
While multiple toe resections may leave the patient in an
unstable or ‘at risk’ predicament, a transmetatarsal amputation
(TMA) may arguably provide the patient with a better platform for
ambulation and recovery. TMA’s in an appropriate patient
preserve a large amount of the distal weight bearing length and
propulsive power of the foot while maintaining a relatively
energy-efficient gait [19–21]. Smaller studies have shown that
24% of patients who received partial first ray resections eventually
required a TMA as a secondary surgical intervention [6,7].
Additionally, one may consider performing a pan metatarsal
head resection (PMHR) to reduce plantar metatarsal stress in lieu
of a TMA. Armstrong and coworkers identified that decompres-
sion of the forefoot through PMHR leads to faster wound healing
and reduced recurrence in properly selected patients [22]. In
addition, prescriptive shoes and insoles may be easier to
effectively develop for a PMHR or TMA when compared to
multiple ray resections.
At a certain point in time the utility of salvaging one or two
digits reaches a point of diminishing returns, and the surgeon must
consider the negative biomechanical and ambulatory impact those
remaining digits might have. In cases where simply ‘too few toes’
will remain, the newly modified load demand on the diabetic foot
must be carefully considered. In addition, if given the choice pre-
operatively, the patient may prefer a single, definitive TMA to the
performance of lesser isolated resections that may result in
eventual recurrent forefoot ulcerations that require rehospitaliza-
tion and further operations.
TMA is not without risk. Thomas reported a 28% requirement
for more proximal reamputation following TMA [23], consistent
with other reports [24,25]. Factors affecting TMA healing rates
have a strong positive correlation with palpable pedal pulses [21]
and a negative correlation with the presence of end stage renal
disease and other co-morbidities [21]. Success of the TMA is also Fig. 2. Consider the difficulty this patient will have maintaining his balance. A
improved by minimizing soft-tissue stripping in the area of the transmetatarsal amputation would have given this patient a more durable and
collateral ligaments during distal metatarsal osteotomies [26], and predictable ambulatory base [8].
 J.D. Miller et al. / Wound Medicine 4 (2014) 37–41
Fig. 3. While it may have been the patient’s desire to keep the second toe and
portions of the first, these toes are sources of ongoing risk. While the initial surgery
may heal, the long-term risk may not be favorable for the patient.
for ambulation without the use of a prosthetic [28]. While TMA is
not devoid of complications, the most common surgical revision is
simply a more proximal revision of the TMA, which likely retains
many of the advantages of the initial TMA [21]. Anthony and
colleagues reported that 89% of the patients who received a
revision of a TMA had significant co-morbidities, further outlining
the need for adequate pre-surgical planning and screening [29].
Ultimately, TMA is effective in maintaining limb length and
Fig. 4. Development of ulcer due to redistribution of plantar pressures following
multiple toe resections. Notice the medial drifting of the middle toe, this alteration
creates further bony deformity that will be prone to ulceration and reamputation.
39
Fig. 5. A healed TMA provides this patient with an excellent walking base. While
there may be some patient desire to retain a few more toes for cosmetic and
psychological reasons, it is easy to see the advantages a TMA may provide to an at
risk patient.
produces a similar gait pattern and exertive demand without
limitation of ambulatory status.
Pinzur and Marco et al. described the appropriate selection of
amputation level in terms of ‘biological amputation level’ with
regard to vascularity, nutrition, immune and infective status of
present wounds, and past histories of any co-morbidities such as
hypertension, diabetic neuropathy, renal or peripheral vascular
disease, and patient smoking history [30]. However, fully inclusive
Fig. 6. Patients receiving a partial TMA run the risks involved with both a TMA and
the risks inherent to leaving a remaining toe. A callous has already developed in the
new high pressure area.
40 J.D. Miller et al. / Wound Medicine 4 (2014) 37–41
Fig. 7. (a) Leaving a patient with only the 4th and 5th toes is a prime example of the
dangers in violating the proposed principle of Too Few Toes. This unsound
distribution resulted in an ulceration of the dorsal 5th toe (seen in (b)) and a deep
space infection that later required a TMA to resolve. Poor biomechanical planning
provided the patient with little benefit over an initial TMA, and left the patient with
an unsound residual foot requiring reamputation.
criteria should also include factors such as: the potential
survivorship of the patient with the risk of multiple surgeries;
the potential cost to the patient due to lost work time; insurance
co-pay or out of pocket expenses; and the biomechanical changes
in ambulation and subsequent mobilization [31].
Based on the latter considerations, it would seem prudent to
assess whether the remaining extremity will meet the functional
expectations of each patient without severely increasing their risk
for reamputation. Figs. 1 and 2 show potentially disastrous and
unstable ambulatory bases for patients which would likely
decrease patient satisfaction, mobility, and likely require revisional
surgery. While a surgeon may execute a perfect procedure in
operating room, the success of that operation will ultimately rely
on the patient’s compliance. Therefore, the empathetic surgeon
must always consider the life of the patient outside of the medical
office to ensure the best achievable outcome (Figs. 3–7).
Conclusion
The patient’s expectations, functional status, and long-term
outcome should always be a primary concern of the treating
physician or surgeon, especially when an amputation is needed.
Correct pairing of surgical options and patient expectations of
mobility and compliance will ensure maximum patient satisfaction,
standard of care, and life outcome. Forefoot operations which leave
the patient in an unstable condition at continued risk do the patient
more harm by exposing them to the possibility of sequential
operations and rehospitalization, ultimately decreasing their overall
satisfaction and increasing their delay in returning to normal life
activities. A TMA or, in some cases PMHR may facilitate mobility
without the use of prosthesis. We therefore suggest that when
contemplating any ablative forefoot operation which would exceed a
hallux plus one additional toe resection, or a lesser toe plus two
additional lesser toe resections, one should strongly consider more
definitive transmetatarsal amputation. Such an approach will often
provide a functional limb sparing approach without the long-term
morbidity associated with repeat ulceration, rehospitalization, and
multiple surgical revisions. The authors hope that this suggestion will
offer clinicians another ‘tool in the box’ to effectively manage medical
resources while maintaining patient function and satisfaction in the
at-risk diabetic individual who requires partial forefoot amputation.
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