To the Editor.—In his study published in the Archives, "Prevention of Major Amputations in the Diabetic Patient," Dr Ger1 does well to remind us that major amputations can often be avoided in diabetic patients with toe and foot infections and necrosis. It presupposes circulation adequate for this purpose and demands locally aggressive surgery. I learned the same lesson when I first published my results of radical local débridement in 1968.2I have continued to use the same approach. I also agree that "ray" amputation is not always essential when there is a chronic infection of the metatarsophalangeal joint area. Local excision of the joint, as practiced by Dr Ger, or excision of the metatarsal head and débridement of the area through a dorsal incision3 is frequently successful.
Additional details regarding the peripheral circulation of these patients would help. Unless one good ankle pulse or at least