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Reply: Is Reconstruction Preserving the First Ray or First Two Rays Better than Full Transmetatarsal Amputation in Diabetic Foot?

Hong, Joon Pio (Jp) M.D., Ph.D., M.M.M.; Suh, Young Chul M.D.; Kushida-Contreras, Beatriz Hatse M.D.; Suh, HyunSuk Peter M.D., Ph.D.

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1315e-1316e
doi: 10.1097/PRS.0000000000005668

Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to Dr. Hong, Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 388-1 Poongnap-dong Songpa-gu, Seoul 138-736, Republic of Korea,, Twitter: @Jp_Joonpio_Hong, Facebook: joon.p.hong, Instagram: @jp_111

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We would like to thank Drs. Fu and Chen for their interest and comments regarding our article, “Is Reconstruction Preserving the First Ray or First Two Rays Better than Full Transmetatarsal Amputation in Diabetic Foot?”1. We agree that the patient population can be small when looking from a statistical perspective. However, having a diabetic foot with transmetatarsal amputation that is indicated for reconstruction is not frequently seen. Furthermore, our approach to maximal limb salvage, including what toe digits may be preserved, makes the incidence for transmetatarsal amputation and reconstruction far less. It is hoped that as the cases accumulate over the following years, we will be able to provide a sufficient number of cases to support the conclusion. The same can be said for follow-up. The longer the follow-up, the more likely we will have a conclusive result. We hope to continue this study for a longer period of time, despite the poor survival in the diabetic patient population. In addition, because of the rarity and difficulty of this reconstruction, there are many limits and properties we do not know that need further clarification.

However, the purpose of this study was to demonstrate a long-asked question: “Are transmetatarsal amputation and reconstruction worth sacrificing remnant viable tissues, including toes?” In the world of clinical reconstruction, there is currently no guide on the approach, and we hope to show that reconstruction may be feasible in these difficult diabetic feet. In addition, as reconstructive surgeons, we have to be aware of the orthoplastic concept, wherein soft-tissue coverage has to combine with ideal functional bone reconstruction. In this respect, this question can be considered important in the future direction of diabetic foot reconstruction.

As Drs. Fu and Chen state, there are many limitations to the article, as this article starts to address questions new to the field of reconstruction. Diabetic foot remains a very challenging and difficult field of reconstruction. We hope that our article will ignite further debate and studies in diabetic foot reconstruction.

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The authors have no financial interest to declare in relation to the content of this communication.

Joon Pio (Jp) Hong, M.D., Ph.D., M.M.M.Young Chul Suh, M.D.Beatriz Hatse Kushida-Contreras, M.D.HyunSuk Peter Suh, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryAsan Medical CenterUniversity of Ulsan College of MedicineSeoul, Korea

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1. Suh Y, Kushida-Contreras B, Suk H, et al. Is reconstruction preserving the first ray or first two rays better than full transmetatarsal amputation in diabetic foot? Plast Reconstr Surg. 2019;143:294–305.
Copyright © 2019 by the American Society of Plastic Surgeons