Comparison of Metatarsal Head Resection Versus Conservative Care in Treatment of Neuropathic Diabetic Foot Ulcers

Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis

BACKGROUND

Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU.

METHODS

We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed.

RESULTS

From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers.

CONCLUSIONS

Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

Surgical Options for Diabetic Toe Ulcers and Osteomyelitis Technical Tips and a Decision-Making Algorithm

INTRODUCTION

Diabetic foot ulcers (DFUs) reflect a pivotal event that could lead to serious complications such as amputation and death. Although conservative surgery was reported to have better outcomes when compared to nonsurgical standard of care of forefoot wounds, the surgical management of diabetic toe ulcers (DTUs) is hardly researched.

METHODS

The aim of this study is to describe the types and techniques of surgical procedures that could be needed when managing DTU. The proposed surgical techniques were based on their outcomes following an evidence-based search of the literature.

RESULTS

Six major types of procedures could be used to treat DTUs; (1) interphalangeal joint resection arthroplasty, (2) phalangectomy or internal pedal amputation, (3) distal Syme amputation, (4) percutaneous toe flexor tenotomy, (5) toe fillet flap, and (6) toe amputation. Details on technical tips are described.

CONCLUSION

Based on the location, ulcer grade of the ulcer and the status of the surrounding soft tissue, a surgical decision-making algorithm is proposed to assist surgeons when managing such prevalent conditions.Levels of Evidence: Level V: Expert review.

[Technical Orthopedics - Chronic Diabetic Foot Wounds]

Technical Orthopedics - Chronic Diabetic Foot Wounds Abstract: Chronic foot wounds are a very common and a growing problem. This review focuses on the treatment and the prophylaxis of diabetic foot ulcers from the perspective of technical orthopedics. Diabetic foot ulcers are of great importance for those affected, in particular because of the risk of infections and resulting amputations. With a good prophylaxis and consistent treatment, these complications can often be avoided.

Radiographic Bone Healing in Minimally Invasive Floating Metatarsal Osteotomy for Neuropathic Plantar Metatarsal Head Ulcers - A Retrospective Cohort Study

Minimally invasive floating metatarsal osteotomy is an option for treating neuropathic ulcers under the metatarsal heads. This study presents the radiographic results of the floating metatarsal osteotomy. We reviewed files and radiographs at least 4 months after a floating metatarsal osteotomy in patients with diabetic neuropathy. In 71 osteotomies in 54 patients with late onset diabetes (mean age 61 ± 9, mean HbA1c 7.9 ± 1.9%), the primary ulcer healed within 3.5 ± 1.4 weeks. Of 66 osteotomies where radiographs were available 10 had non-union (15%, all asymptomatic), 15 (23%) had hypertrophic callus formation and 41 (62%) had normal union. One patient developed an ulcer under the hypertrophic callus. This necessitated callus resection. Asymptomatic non-union may happen in 15% of floating osteotomies, but the osteotomies appear to be relatively safe and effective for neuropathic plantar metatarsal head ulcers. Hypertropic callus causing local re-ulceration is rare and can be managed surgically.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.

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.

The level of evidence of the publications on conservative surgery for the treatment of diabetic forefoot ulcers: A scoping review

OBJECTIVE

The diabetic foot disease is one of the most serious complications of diabetes causing high rates of amputations, premature deaths and healthcare cost. While standard non-surgical care is the mainstay of treatment of diabetic foot ulcers (DFU), many reports demonstrated that conservative surgery particularly in the forefoot, compared better in terms of clinical outcomes. Nevertheless, the quality of surgical articles dealing with diabetic ulcers of the forefoot is thought to be average. This paper aimed to quantify the level of evidence of the DFU surgical papers published in the literature.

LITERATURE SURVEY

PubMed was searched from inception till Feb 2020. All study designs but case reports were accepted for inclusion. Two outcomes were searched for: a) study design and b) level of evidence. The level of evidence of the studies was based on the classification developed by the Oxford Center for Evidence-based Medicine.

RESULTS

In total, 90 articles were included for analysis. Only 6 studies (6.7%) had a Level 1 level of evidence. One study had a Level 2 (1.1%) and 13 studies (14.4%) a Level 3. The majority of the included studies had a Level 4 of level of evidence with 70 studies (77.8%) being case-series.

CONCLUSION

It is surprising that a disease with such enormous health-related and financial burden did not generate enough interest among surgeons to invest more into high quality research. The findings should incite surgeons to get more involved in the treatment of forefoot diabetic wound and infection. Large comparative prospective high quality trials to assess the available surgical methods are needed.

Diabetic foot off loading and ulcer remission: Exploring surgical off-loading

INTRODUCTION

Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration.

METHODS

We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations.

RESULTS

Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements.

CONCLUSIONS AND IMPLICATIONS

Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.

A Meta-Analysis of the Outcomes of Metatarsal Head Resection for the Treatment of Neuropathic Diabetic Foot Ulcers

Significance: Diabetic foot ulcers (DFUs) are associated with high morbidity, mortality, and health costs. Standard care (SC) associated with nonsurgical offloading is the mainstay treatment for DFUs, but it has high recurrence and infection rates. Metatarsal head resection (MHR) has been proposed as an effective surgical offloading technique for the treatment of plantar neuropathic DFUs, but with no evidence synthesis yet. Recent Advances: Based on PRISMA guidelines, a meta-analysis was conducted to assess the efficacy of MHR. Four electronic databases were searched for. Eleven studies met the inclusion criteria with a total of 477 patients (494 feet and 593 neuropathic forefoot ulcers). The studies included three retrospective comparative studies and eight case series. Critical Issues: Meta-analytical results of comparative studies on recent noninfected DFUs showed MHR having significantly better rates of healing, time to healing, ulcer recurrence, and infection than SC. Failure to heal, recurrence, and infection rates were 4 times higher in the SC group than in the MHR group, and the amputation rate was two times higher in the SC group than in the MHR group. The outcomes of the meta-analysis of case series on chronic and recalcitrant ulcers treated with MHR were similar. Future Directions: Considering the natural history of DFUs treated conservatively and the satisfactory outcomes with a significantly low complication rate of MHR, physicians should consider the use of MHR more often and include this technique in the early management of DFUs. Scope and Significance: DFU impose great public health burden around the globe. Standard of care using in-office debridement and topical agents is the usual mainstay of treatment. However, such conservative care is known to result in high rates of ulcer recurrence and complications. In this systematic review, we quantitatively investigate the outcomes of a surgical off-loading technique, the MHR in the treatment of chronic plantar neuropathic wounds. Translational Relevance: Many biochemical factors are implicated in the complex process of wound healing. In the case of diabetic neuropathic ulcers of the forefoot, additional mechanical factors induced by the presence of diabetic neuropathy lead to high pressure loads of the metatarsal heads on the plantar skin. With time, such chronic loads could favor ulcer formation. Removal of the causal mechanical factor could alleviate the pressure and allow wound healing. Clinical Relevance: Neuropathic plantar ulcers are difficult-to-heal wounds and chronicity is associated to frequent hospitalizations, higher rates of amputation, and mortality. Early removal of the indirect causal agent, the resection of the metatarsal head, after failure of a well-conducted conservative standard of care could be a needed solution for wound healing and consequently a potential for reducing complications and costs.

Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer

Although surgical offloading seems a more permanent solution for prevention and treatment of neuropathic plantar diabetic forefoot ulcers (DFUs), the evidence for this assumption is weak and needs further studies to be established. The aim of this retrospective study is to compare the healing efficacy, associated morbidity, and recurrence rates of surgical versus removable knee-high offloading for neuropathic plantar (DFUs) healing. From January 2016 to January 2018, 70 neuropathic plantar forefoot DFUs were nonrandomly assigned to either removable knee-high cam-walker (n = 35), or metatarsal head, or accessory bone resection (n = 35). The primary endpoints were the frequency and rate of complete healing, and the rate of ulcer area reduction within 4 months. The secondary endpoints were 4 months morbidity and ulcer recurrence within 12 months. After 4 months, complete healing was significantly inferior with cam-walker compared with surgical offloading; 24 (67.6%) versus 31 patients (88.6%), respectively, P = .015. Ulcer area reduction was 2.4 cm² (66.7%) versus 2.6 cm² (83.9%), P = .001, in the mechanical versus the surgical groups, respectively. The mean healing time was 3.6 ± 2.1 versus 2.8 ± 0.6 months in the mechanical versus the surgical groups, respectively, P = .012. Morbidity and recurrence show nonsignificant differences between both groups. Ulcer recurrence was noted in 5/35 (14.3%) versus 2/35 (5.7%), in mechanical versus surgical groups, respectively, P = .23. Therefore, metatarsal head/accessory bone resection offered improved healing efficacy but similar morbidity and recurrence to the removable cam-walker.

Metatarsal Head Resections in Diabetic Foot Patients: A Systematic Review

A systematic review and proportional meta-analysis were carried out to investigate the complications that occur after surgical metatarsal head resection in diabetic foot patients. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist recommendations were applied, and the selected studies were evaluated using a Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist. PubMed (Medline) and Embase (Elsevier) were searched in December 2019 to find clinical trials, cohort studies, or case series assessing the efficacy of the metatarsal head resection technique in diabetic foot patients. The systematic review covered 21 studies that satisfied the inclusion criteria and included 483 subjects. The outcomes evaluated were the time to heal, recurrence, reulceration, amputation, and other complications. The proportion of recurrence was 7.2% [confidence interval (CI) 4.0–10.4, p < 0.001], that of reulceration was 20.7% (CI 11.6–29.8, p < 0.001), and that of amputation was 7.6% (CI 3.4–11.8, p < 0.001). A heterogeneity test indicated I² = 72.6% (p < 0.001) for recurrences, I² = 94% (p < 0.001) for reulcerations, and I² = 79% (p < 0.001) for amputations. We conclude that metatarsal head resections in diabetic foot patients are correlated with significant complications, especially reulceration.

Surgery Versus Nonsurgical Methods in Treating Neuropathic Plantar Forefoot Ulcers: A Meta-Analysis of Comparative Studies

The treatment of diabetic foot ulcers (DFUs) is usually based on local debridement, topical agents, and nonsurgical off-loading. When compared with nonsurgical methods, a number of articles reported better results with surgery. The aim of this meta-analysis was to collate quantitative evidence on the outcomes of surgery versus nonsurgical treatment (NST) of DFUs. Databases were searched from inception to September 2019. PRISMA guidelines were followed, and the Joanna Briggs Institute critical appraisal tools were used to appraise studies' quality. Nine studies were included totalizing 436 ulcers (216 treated with surgery and 220 DFUs with NST). The primary outcome was the healing rate. The secondary outcomes were time to heal, recurrence rate, transfer rate, infection rate, and amputation/revision surgery rate. The risk differences (RDs) between the healing rates following surgery and NST for infected and noninfected ulcers were 17% (95% confidence interval [CI] = 0.012-0.328, P = .03) and 19.2% (95% CI = 0.050-0.334, P = .008), respectively, in favor of surgery. The amputation/revision surgery rate was significantly better following surgery for both types of ulcers. Noninfected ulcers demonstrated significantly lesser time to heal, recurrence, and infection rates following surgery. This meta-analysis demonstrated that surgery was superior to NST in treating infected and noninfected neuropathic plantar wounds.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review

BACKGROUND

Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers.

METHODS

We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis.

RESULTS

We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia.

CONCLUSION

Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

Surgical Offloading Techniques Should be Used More Often and Earlier in Treating Forefoot Diabetic Ulcers: An Evidence-Based Review

Conservative treatment is the basis for diabetic foot ulcer (DFU) management, whereas surgical treatment is usually reserved for patients with failed, recurrent, or nonresponsive infected wounds. However, many reports demonstrated good to excellent results following surgery. Evidence synthesis on surgical offloading techniques and clear guidelines regarding the timing of surgery are lacking. The present study aimed to investigate the evidence behind surgical offloading techniques and propose a cutoff time for surgical indication following failed conservative treatment of neuropathic diabetic forefoot ulcers. Electronic databases were searched from inception to identify the best evidence level articles related to non-vascular surgical treatment of DFUs, such as metatarsal head resection, resection arthroplasty, metatarsal osteotomy, Achilles tendon lengthening, gastrocnemius recession, and flexor tenotomy, that have been employed for managing DFUs. Based on the highest level of evidence available, surgery was found to generate better values than standard conservative care for all outcomes except for the transfer rate. In particular, surgical bony offloading procedures demonstrated significantly better outcomes than standard conservative nonsurgical care in terms of higher healing rates, shorter healing durations, and lower recurrence rates. Moreover, 96% of DFUs healed in <1 month following surgical bony offloading, whereas 68% of ulcers healed within 3 months after standard care. The findings could challenge the classical guidelines of DFU management. This evidence-based review indicates that surgical offloading could be used more often and be proposed earlier during the course of ulcer management. The results imply that a period of 12 weeks could be considered a reasonable cutoff value to consider surgical treatment for patients with nonhealing DFUs.

Bone Reconstruction in the Diabetic Foot

Surgical bone reconstructive procedures of the foot and ankle in diabetic patients must be considered when performing evaluation of a diabetic foot for patients with preulcerative lesions and preexisting wounds. Preventive deformity correction can reduce the potential risk of ulceration, infection, and possible amputation in a patient with an at-risk foot type. It can also expedite wound healing and prevent further breakdown in a patient with lower extremity ulcerations. This article discusses different types of surgical bone reconstructive procedures as preventive and prophylactic deformity corrections to reduce osseous deformity, minimize preulcerative lesions, and increase limb-salvage rates in the compromised patient.

Complications associated with the approach to metatarsal head resection in diabetic foot osteomyelitis

The aim of this study was to evaluate the recovery time and the development of complications in the dorsal and plantar approach to metatarsal head resections (MHR) in patients with diabetic foot ulcers complicated by osteomyelitis. A retrospective study was carried out involving 108 patients who underwent MHRs for the treatment of diabetic foot osteomyelitis. Two cohorts were defined: dorsal approach with incision closed with sutures and plantar approach with ulcer healed using conservative treatment. The main outcomes were the weeks until healing and complications related to the approaches. Fifty-three patients (49.1%) underwent a plantar approach and 55 (50.9%) a dorsal approach. Both approaches rendered similar healing times. However, the patients undergoing a dorsal approach developed more post-surgical complications than patients treated through a plantar approach. The dorsal approach intervention was performed on smaller and shallower ulcers; however, more complications developed at follow up using this approach than through a plantar approach for MHR complicated with osteomyelitis.

New trends in the orthopaedic management of diabetic foot

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.