Keller procedure for the treatment of resistant plantar ulceration of the hallux

Outcomes of Keller Gap Arthroplasty for Plantar Hallux Interphalangeal Joint Ulcers in Patients With Diabetes Mellitus

BACKGROUND

Hallux ulcers are known for their recurrence and associated risk for future amputations. Traditional nonsurgical external offloading methods have poor compliance rates, and the data is sparse on surgical offloading of hallux ulcers. We performed this study to analyze the outcomes of Keller excision gap arthroplasty of the first metatarsophalangeal joint in patients with a neuropathic plantar hallux interphalangeal joint (IPJ) ulcer in patients with diabetes mellitus.

METHODS

A retrospective study of 105 diabetic patients with a plantar hallux IPJ ulcer who underwent a Keller excision gap arthroplasty between December 2014 and June 2020 was done. A total of 122 great toes had been operated upon for hallux IPJ ulcers. We studied the long-term wound healing rates from patient records and then did a prospective survey of the postreview period.

RESULTS

All the hallux IPJ ulcers healed well in the immediate postoperative period. Six patients reported a recurrence of the ulcer at the original site during a mean follow-up period of 30 months. For these 6 patients, the mean time to recurrence of ulcer after operation was 2.5 years.

CONCLUSION

At an average of 30 months, we found the Keller gap arthroplasty for treatment of noninfected and nonischemic diabetic foot hallux IPJ ulcers was associated with an ulcer recurrence rate of 5%.

LEVEL OF EVIDENCE

Level IV, cohort study.

A Meta-Analysis of the Outcomes of Resection Arthroplasty for Resistant Hallucal Diabetic Ulcers

The standard medical care (SC) of non-infected diabetic foot ulcers (DFUs) has been reported to yield varying rates of wound healing with high recurrence rate in non-infected wounds. Conservative surgery has been advanced as an alternative to SC in treating resistant non-complicated and complicated DFUs. Studies reporting resection arthroplasty (RA) of the first metatarsal head stated high healing rates with less recurrence. The aim of this meta-analysis is to quantitatively assess the efficacy of the RA procedure. Based on 9 included studies (3 case-control and 6 case-series) with 225 patients (244 feet, 244 hallucal plantar ulcers) and a mean follow-up period was of 22.8 ±13.3 months, the weighted estimates of comparative studies (RA vs. SC) were as follows: healing rate (100% vs. 79.9%, p = .0001), time to heal (3.3 ±0.28 vs. 8.4 ±1.5 weeks, p = .002), recurrence rate (5.7% vs. 25.4%, p = .001) and transfer rate (4.5% vs. 1.4%, p = .1). Similar values were found when analyzing case-series of non-infected and infected wounds treated with RA. Based on the available evidence, resection arthroplasty of the first ray is to be considered an effective conservative surgery in treating resistant or complicated hallucal neuropathic ulcers. Further prospective controlled trials are warranted to validate the review findings.

Proximal Derotation Phalangeal Osteotomy for Medial First Toe Diabetic Ulcer

BACKGROUND

Foot ulcers are a common complication in diabetic patients. Mild callus formation due to a plantar pressure can lead to an ulcer formation with potentially hazardous sequelae. Eliminating the pressure from the ulcer is essential for a proper healing process. Proximal derotation phalangeal osteotomy is a relatively simple procedure that can redistribute the planter pressure points over the hallux.

METHODS

Thirteen patients underwent proximal derotation phalangeal osteotomy to relieve the bony pressure causing an ulcer in the first toe, which was refractory to non-operative treatment. Twelve patients had diabetes type 2 and one had Charcot-Marie-Tooth disease.

RESULTS

Ulcers were completely resolved in all 13 patients in an average time of 4.3 (range 2-8) weeks. Four patients (31%) had mild complications that resolved well. No further surgery was required at 1-year follow-up.

CONCLUSION

Proximal derotation phalangeal osteotomy enabled ulcer healing in refractory cases.

LEVEL OF EVIDENCE

Level III retrospective study.

Resection Arthroplasty for Resistant Ulcers Underlying the Hallux in Insensate Diabetics

BACKGROUND

Foot ulcers carry considerable morbidity in patients with peripheral neuropathy and frequently lead to foot amputation. The purpose of this study was to present our experience treating recalcitrant ulcers underlying the hallux interphalangeal joint in patients with diabetes mellitus (DM)-related neuropathy with a first metatarsophalangeal (MTPJ1) resection arthroplasty.

METHODS

We retrospectively reviewed the computerized medical files of patients with diabetic neuropathy treated with a MTPJ1 resection arthroplasty. We performed 28 arthroplasties on 20 patients with a mean age of 59 years. The patients had a diagnosis of DM for a mean of 10.7 years. Of the ulcers, 26 were grade 1A ulcers, and 2 were grade 2A ulcers (University of Texas score); the ulcer's mean age was 5.4 months. The mean dorsiflexion of the hallux before surgery was 46 degrees.

RESULTS

The primary ulcer recovered in a mean of 3.1 weeks. Major complications (wound dehiscence and infection) occurred in 6 of 28 operations. Patients returned to normal activity 4 weeks after all procedures except in the 6 patients with dehiscence. In a subgroup of patients with follow-up longer than a year, the ulcer recurred after 4 of 18 arthroplasties (22%) between 3 and 12 months due to postoperative hallux rigidus. In the remaining 14 of 18 arthroplasties (78%), there was no recurrence during a mean follow-up of 26 months.

CONCLUSION

MTPJ1 resection arthroplasty may be considered in a patient with resistant plantar hallux ulcerations, even in the absence of hallux rigidus. As with all operations on neuropathic feet in patients with DM, the surgeon and the patient should be aware that there is a significant likelihood of complications, but most are treatable.

LEVEL OF EVIDENCE

Level IV, case series.

Surgical complications associated with primary closure in patients with diabetic foot osteomyelitis

Background

The aim of this study was to determine the incidence of complications associated with primary closure in surgical procedures performed for diabetic foot osteomyelitis compared to those healed by secondary intention. In addition, further evaluation of the surgical digital debridement for osteomyelitis with primary closure as an alternative to patients with digital amputation was also examined in our study.

Methods

Comparative study that included 46 patients with diabetic foot ulcerations. Surgical debridement of the infected bone was performed on all patients. Depending on the surgical technique used, primary surgical closure was performed on 34 patients (73.9%, Group 1) while the rest of the 12 patients were allowed to heal by secondary intention (26.1%, Group 2). During surgical intervention, bone samples were collected for both microbiological and histopathological analyses. Post-surgical complications were recorded in both groups during the recovery period.

Results

The average healing time was 9.9±SD 8.4 weeks in Group 1 and 19.1±SD 16.9 weeks in Group 2 (p=0.008). The percentage of complications was 61.8% in Group 1 and 58.3% in Group 2 (p=0.834). In all patients with digital ulcerations that were necessary for an amputation, a primary surgical closure was performed with successful outcomes.

Discussion

Primary surgical closure was not associated with a greater number of complications. Patients who received primary surgical closure had faster healing rates and experienced a lower percentage of exudation (p=0.05), edema (p<0.001) and reinfection, factors that determine the delay in wound healing and affect the prognosis of the surgical outcome. Further research with a greater number of patients is required to better define the cases for which primary surgical closure may be indicated at different levels of the diabetic foot.

Functional outcome and patient satisfaction after flexor tenotomy for plantar ulcers of the toes

Ulcers of the toes may cause a severe physical burden, especially in patients with diabetes, in whom they occur most frequently. Several treatments have been proposed for the underlying anatomical abnormalities, but they vary in effectiveness. We evaluated our results in using flexor tenotomy to treat ulcers with underlying flexible clawing of the toes. For 42 toes from 23 patients, 15 of whom were diabetic, all ulcers healed. The mean healing time was 4 weeks (range, 1-8 weeks), the mean follow-up was 11 months (range, 1-27 months), and one recurrence and one complication occurred. Postoperative American Orthopaedic Foot Ankle Society Midfoot scores were available for 15 patients: the mean was 77 (range, 43-100). The mean visual analogue scale (VAS) for patient satisfaction increased from 3.9 points (range, 0-10 points) preoperatively to 7.7 (range, 5-10 points) postoperatively. Flexor tenotomy is a simple treatment with low complications and recurrence rates and provides good-to-excellent functional outcomes in treating flexible clawing of the toes and the associated ulceration.

Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging

AIMS

To assess efficacy of conservative management of neuropathic forefoot ulcers with underlying osteomyelitis in subjects with diabetes when magnetic resonance imaging (MRI) is used to confirm or establish diagnosis and to guide antibiotic duration.

METHODS

A retrospective cohort study over 6 years assessing rates of ulcer healing, relapse and amputation. Antibiotics were continued for 3-month cycles with interval MRI: if the lesion had healed and bone signal change resolved or improved, antibiotics were discontinued; if the lesion had not healed or there was no difference in bone signal change, antibiotics were continued for a further 3-month cycle; clinical or radiological deterioration resulted in endoluminal or open vascular surgical intervention where appropriate, or digital or more proximal amputation.

RESULTS

There were 53 episodes in 47 subjects (mean +/- sd age 62 +/- 13 years, duration of diabetes 19 +/- 13 years, glycated haemoglobin 8.4 +/- 1.6%; six with Type 1 diabetes and seven with end-stage renal failure). Successful healing without relapse was achieved in 40 episodes (75%) [median (range) duration of antibiotics 6 (3-12) months and follow-up post-cessation of antibiotics 15 (3-58) months]. Relapse occurred in six episodes (13%) at 31 (2-38) months post-cessation of antibiotics. There were one major (2%) and eight minor (15%) amputations. Five subjects have died (11%), all without foot ulcers.

CONCLUSIONS

High rates of healing and low rates of amputation were achieved. The use of MRI was associated with long courses of antibiotics, but particularly low relapse rate.

Neuropathic toe ulcers treated with toe flexor tenotomies

BACKGROUND

Foot ulcers are common causes of hospital admissions for infection and amputation in patients with neuropathy. This retrospective study evaluates the results of treating plantar neuropathic toe ulcers with percutaneous flexor tenotomy.

METHODS

From 1996 to 2003, 28 toe ulcers in 18 patients were treated with tenotomy of the toe flexors.

RESULTS

Fourteen of 18 patients had diabetic neuropathy. No patients were lost to followup. Average followup for the 28 ulcers was 36 (range 20 to 65) months. All ulcers healed. None of the 11 lesser toe ulcers recurred. Three of 17 first toe ulcers recurred but two that had repeat tenotomy healed and did not recur. There were no toe amputations, infections, or other complications of tenotomy. One patient had unrelated transtibial amputation.

CONCLUSIONS

No long-term results of treating toe ulcers with toe flexor tenotomy by other authors have been found. Toe flexor tenotomies appear to be effective and safe treatment for neuropathic toe ulcers.

Surgical management of diabetic foot infections and osteomyelitis

Foot ulceration and subsequent infection are a major complication of diabetes mellitus. Without proper diagnosis and treatment, these infections often lead to amputation. A multidisciplinary team approach is essential to maximize outcomes in the attempt to limit amputation and decrease patient morbidity. Mild to moderate diabetic foot infections often respond favorably to local wound care, offloading, and antibiotic therapy. When conservative measures fail or when faced with limb- or life-threatening infection, surgical intervention, whether it be incision and drainage or possible amputation, is warranted. The authors review underlying pathophysiology of diabetic foot infections and an evidenced-based approach to surgical management, with additional emphasis on treatment of osteomyelitis.