Functional and Quality of Life Outcomes in Ray Amputations vs. Transmetatarsal Amputation: A Comparative Study

Introduction: The loss of pedal rays through amputation negatively im- pacts gait, quality of life (QOL), and increases morbidity. Ray amputations, often performed for forefoot ulcerations or osteomyelitis, can result in significant functional impairment, and the choice between ray amputation and transmetatarsal amputation (TMA) remains a critical clinical decision. TMA is typically preferred for its predictable outcomes, but the functional impact of ray amputations, particularly of the lesser rays, is less well understood. This study compares the functional and QOL outcomes of ray amputations with TMA to guide surgical decision-making. Methods: A retrospective cohort study was conducted on patients who underwent ray or TMA (CPT codes 28119 and 28805) at Georgetown University Hospital between June 2021 and June 2023. Inclusion criteria included ambulatory patients aged ≥18 who completed functional and QOL questionnaires. Exclusion criteria included bilateral or proximal amputations. The primary outcomes included complications (major and minor), limb salvage, and mortality. Functional outcomes were assessed using the Lower Extremity Functional Scale (LEFS), and QOL was as- sessed with the SF-12 Health Survey. Results: We reviewed 95 patients (50 TMA, 45 ray amputations), with an average follow-up of 818.6 days. Limb salvage rates were high (97.9%), and complication rates were substantial (68.4%), with 38% of TMA and 35.6% of ray amputation patients requiring return to the operating room (ROR) for revision. Functional outcomes, as measured by LEFS and SF-12, showed no significant differences between the two groups (LEFS: 45.3 vs. 42.9; SF-12: 30.1 vs. 29.4). Minor complications were more frequent in the ray amputa- tion group, but major complications requiring re-operation were similar be- tween the two groups. Subgroup analysis revealed no significant differences in functional or QOL outcomes among different ray amputation types. Discussion: This study challenges the traditional preference for TMA by showing that ray amputations—whether of the 1st, 5th, central, or multiple rays—offer comparable functional outcomes with minimal differences in QOL. Ray amputations preserve more of the foot’s length, supporting normal gait mechanics and reducing functional loss compared to TMA. Although gait disturbances following ray amputation are common, partic- ularly with the 1st ray, these disruptions have a minimal impact on daily activities. Our findings suggest that ray amputations can be a viable alter- native to TMA, with similar functional outcomes and QOL with similar wound related issues. This study encourages reconsideration of traditional amputation strategies, especially for isolated ray amputations.