Elective Amputation of the Toes in Severe Lymphedema of the Lower Leg: Rationale and Indications

Abstract

Conclusion: Elective toe amputation in combination with the Charles procedure reduces long-term morbidity associated with advanced lymphedema of the lower limb. Summary: In advanced lymphedema, the skin develops a peau d'orange appearance with papillomatosis and hyperkeratosis. These changes lead to gradual sealing of the intradigital spaces, with resulting bacterial and fungal infection and worsening of lymphedema. Between January 1990 and July 2006, the authors offered an elective Charles procedure along with disarticulation of the toes to their patients with stage III lymphedema (elephantiasis with a grossly increased volume of the limb associated with dermatosclerosis and papillomatosis lesions). Ten patients underwent an elective Charles procedure accompanied with toe disarticulations, and 24 patients underwent the Charles procedure alone. The Charles procedure was performed with a pneumatic tourniquet. Subcutaneous tissue and skin was excised down to the level of the deep muscle fascia from the knee to the dorsum of the foot. The wound was covered with 12- to 16/1000-inch split thickness skin grafts harvested from the ipsilateral leg. For those who underwent elective toe amputations, toe disarticulation at the metatarsal-phalangeal joint was combined with removal of the articular cartilage from the metatarsal heads. Average follow-up was 3.5 years. During follow-up, 20% of the patients who underwent combined Charles procedure and elective toe amputation experienced recurrent bouts of cellulitis of the foot or leg, 50% required at least one operation for excision of crypts within the skin-grafted areas, and none required more proximal amputations. In those patients who did not undergo elective toe amputation, 83% had multiple episodes of foot or leg cellulitis and 54% underwent at least one operation for foot or leg excision of crypts, and 80% subsequently required amputation of toes secondary to chronic ulceration, infection, or drainage from web spaces. Two patients required more proximal amputation, including one below knee amputation. Comment: Those who care for patients with advanced lymphedema realize that appropriate foot hygiene is the mainstay to reduce interdigital entry lesions, but such care can be ineffective in the terminal stages of lymphedema. These patients have deformity of the toes and limited mobility. The increased weight and volume of the affected limbs prevents them from performing appropriate foot hygiene. This is an aggressive approach to the treatment of end-stage lymphedema. Nevertheless, if a decision has been made to perform a Charles procedure, the authors' data suggest the addition of toe amputations is reasonable.