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

Early Outcomes and Complications of Surgically Treated Diabetic Hallucal Infection

BACKGROUND

Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal diabetic foot infection (DFI) treated with either conservative surgery or amputation.

METHODS

This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all diabetic foot ulcer (DFU) were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups.

RESULTS

Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (P = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the reamputation rate for the amputation group was 23.1% (P = 0.2).

CONCLUSIONS

The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seem to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to magnetic resonance imaging bone infection signal could be considered to minimize the risk of subsequent surgeries and reamputations.

Interphalangeal Resection Arthroplasty for the Prevention and Treatment of Diabetic Deformities and Ulcers of the Toes: A Systematic Review and Meta-analysis

Background

Diabetic foot ulcers (DFUs) are serious complications that induce a high risk of lower extremity amputations and mortality. Compared with the standard of care, few reports analyzed the outcome of surgical treatment mainly for diabetic toe deformities and ulcers. The aim of this study is to collate evidence on the outcomes of interphalangeal resection arthroplasty (IP-RA) in preventing and treating diabetic toe ulcers distal to the metatarsophalangeal joint.

Methods

A search strategy has been developed including electronic databases from inception. Only ulcers distal to the metatarsophalangeal joints were included. Noninfected and infected ulcers were also included at any toe location (dorsal/side/plantar). Outcomes were defined as healing rate, time to heal, ulcer recurrence, ulcer transfer, postintervention infection, wound dehiscence, and additional surgeries including amputation. Proportional meta-analysis was conducted for frequency outcomes.

Results

Six observational studies comprising 217 patients with 244 IP-RA procedures were included. The mean follow-up period was 23.4 ± 8.2 months. Weighted frequencies were as follows: healing rate (93.6%), ulcer recurrence frequency (4.3%), ulcer transfer frequency (15.4%), postoperative infection (10.5%), wound dehiscence (17.8%), revision surgery (5%), and amputation rate (3.4%). The mean healing time was 4.3 ± 1.8 weeks.

Conclusion

This review suggests that IP-RA is effective in preventing and treating diabetic toe deformities and ulcers with a modest rate of complications for this specific and often challenging clinical presentation.

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.

Basic haematological tests as inflammatory performance markers of patients treated either by conservative surgery or minor amputation for infected diabetic foot ulcers

Basic inflammatory markers have been extensively studied to differentiate between non-infected and infected diabetic foot ulcers (DFUs). Very rarely, basic haematological tests such as white cell count (WCC) and platelet counts were used as performance markers for DFU infection severity. The aim is to investigate these biomarkers in patients with DFU treated exclusively with surgery. In this retrospective comparative study, we included 154 procedures comparing a conservative surgery group (n = 66 for infected DFU) and a minor amputation group (n = 88 for infected DFU with osteomyelitis). Outcomes were set as the preoperative values of: WCC, neutrophils (N), lymphocytes (L), Monocytes (M), Platelets (P), red cell distribution width (RDW) and the ratios N/L, L/M and P/L. Area under curve (AUC) of the receiver operating characteristic (ROC) was calculated based on the diagnosis of minor amputation as a positive result. Cutoff point values with the highest sensitivity and specificity were obtained for each outcome. The highest AUC values were for WCC (0.68), neutrophils (0.68), platelets (0.7) and P/L ratio (0.69) with corresponding cut-off values of 10,650/mm3 , 76%, 234,000/mcL and 265, respectively. The highest sensitivity was for the platelet count (81.5%) while the highest specificity was for L/M (89%) and P/L ratios (87%). Postoperative values showed similar results. Simple routine blood tests could serve as inflammatory performance markers to help predict the severity of infection in patients treated surgically for infected DFU.

Are Digital Arthroplasty and Arthrodesis Useful and Safe Surgical Techniques for the Management of Patients with Diabetic Foot?

OBJECTIVE

To analyze and compare the development of short- and long-term complications in patients with diabetic foot after digital arthroplasty or arthrodesis.

METHODS

The authors reviewed patient records from January 2017 to March 2020. Patients were treated by digital arthroplasty or arthrodesis to correct toe deformity (elective or prophylactic surgery), achieve ulcer healing in toes (curative surgery), or manage toe infection (emergent surgery). During 1-year follow-up, researchers registered short- and long-term complications. Researchers analyzed the association between the type of surgery and the development of short- and long-term complications.

RESULTS

Forty-four patients (83.0%) received arthroplasty, and nine (17.0%) received arthrodesis. The mean time to heal from ulcers was 5.2 ± 5.2 weeks. A significant association was observed between arthrodesis and the development of long-term complications (P = .044; odds ratio, 5.1; 95% confidence interval, 0.9-27.2). No differences were observed between type of surgery and short- or long-term complications. Moreover, both short- and long-term complications were related to longer time to heal (respectively, 7.6 ± 6.0 vs 2.1 ± 0.5 weeks, P < .001; and 6.3 ± 6.2 vs 4.2 ± 4.0 weeks, P = .039).

CONCLUSIONS

Digital arthroplasty or arthrodesis are good options for managing patients with diabetic foot who require digital deformity correction to achieve digital ulcer healing or management of diabetic foot infection in phalanges.