A Meta-analysis of the Types and Outcomes of Conservative Excisional Surgery for Recalcitrant or Infected Diabetic Toe Ulcers

Biomechanical Problems Related to Lesser Toes Dysfunction and Amputation

Should we care about the biomechanics of the foot or the full locomotor system? Anatomic changes are the main concerns of an orthopedic surgeon; however, the main objectives of treatment for lesser toe dysfunctions are to relieve the patient's symptoms to preserve or improve function. It is imperative to understand that the foot is part a three-dimensional biokinetic system that needs to function combined so that loads are harmoniously distributed throughout the body without harmful effects, especially for one of the most frequent voluntary neuromotor tasks in humans: walking.

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.

Conservative surgery in the management of diabetic foot complications (excluding Charcot). The role of the orthopedic surgeon

Diabetic foot complications (DFC) such as ulcers and infection are the leading cause for non-traumatic non-oncologic amputations worldwide with a 5-year mortality reaching 70 %. Every attempt is warranted to preserve the limb for physical and psychological integrity of these patients. When possible to perform, conservative surgeries could save the foot and its function. This review will focus on those procedures that do not require in-depth surgical or microsurgical skills and that could be performed by general orthopedic surgeons. Along with the technical description and specific indication, a literature search was performed to locate the evidence in relation with the efficacy of these procedures. The procedures could be described in 3 categories: bony surgeries, soft tissue procedures and orthoplastic techniques. The bones surgeries include resection arthroplasty, metatarsal osteotomy, internal pedal amputation, distal Symes amputation, cement augmentation and partial or total calcanectomy. Soft tissue procedures include Achilles tendon lengthening, gastrocnemius recession, toe flexor tenotomy and tendon transfer. The reconstructive/orthoplastic techniques include skin grafting, local flaps, fillet flap and regional flaps, mainly the reverse sural flap. Though most of these conservative surgeries have been shown to yield good to excellent results, the indication for each surgery could be confusing. The role of the orthopedic surgeon is fundamental for the optimal treatment of DFC. Though most procedures are easy to learn and to perform without the need of extra surgical skills, mastering indications is key for successful outcomes. In addition, the knowledge of these limb preserving techniques could be paramount in rural areas or if no foot and ankle surgeons are available.

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.

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.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm

BACKGROUND

The treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes.

METHODS

This is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation.

RESULTS

Outcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level.

CONCLUSIONS

Bone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

Percutaneous Partial Bone Excision in the Management of Diabetic Toe Osteomyelitis

BACKGROUND

Diabetic foot osteomyelitis affecting the toes is associated with several complications including amputation. Management is variable and include medical therapy alone or coupled with surgery. Removal of infected tissues is a common therapeutic option. However, limited source data are available. This study determines the outcome and complications of percutaneous partial bone excision (PPBE) of infected bone among diabetic patients with toe osteomyelitis.

METHODS

This is an uncontrolled experimental prospective study in diabetic patients who underwent PPBE of infected pieces of bone for toe osteomyelitis in the outpatient setting at a single foot clinic. All participants were followed up until the occurrence of wound healing or amputation.

RESULTS

Forty-seven patients (mean ± SD age was 62.8 ± 11.6 years) participated. Forty-four patients (93.6%) had complete healing and 3 (6.4%) required toe amputation. The mean (±SD) wound healing time was 11 (±4.6) (range, 7-22) weeks. Diabetes mellitus type 1 and younger age were significantly associated with increased risk for amputation.

CONCLUSION

PPBE of infected toes in diabetic patients can be performed successfully and safely in the outpatient clinic. It can also improve healing and avoids inpatient stay.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

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.

Analysis of systemic risk factors between diabetic/vascular patients having primary lower limb amputations and re-amputations

Background: Patients with diabetes mellitus (DM) are known to be predisposed to many complications in the lower extremities such as neuropathy, peripheral artery disease (PAD) and infection. Diabetic foot ulcers are complications of diabetes that can lead to lower extremity amputations, re-amputations and high mortality rates.Purpose: The aim of this study is to evaluate the risk factors associated with higher re-amputation rates in diabetic foot disease.Research Design: This is a mono-centric retrospective comparative study.Study Sample: the study included 136 patients, with a total of 193 procedures (111 primary amputations and 82 re-amputations) between 2011 and 2021.Data Analysis: The t-student test and Spearman correlation were used to look for mean differences and any relevant association, respectively. Multivariate logistic regression analysis was computed to look for independent variables.Results: Twenty-two (27%) and 60 (50%) of those who had major and minor amputations, respectively, had a re-amputation (p = 0.006). Besides diabetes (89%), the commonest risk factor associated with amputation was hypertension (86.7%), be it for primary amputation or re-amputation, followed by peripheral (PAD) and coronary artery diseases. Only three risk factors showed independent correlation with re-amputation; chronic kidney disease (r = 15%, p = 0.03), smoking (r = 15%, p = 0.03), and simultaneous presence of DM + PAD (r = 13.7%, p = 0.05).Conclusions: Factors that were significantly correlated with increased re-amputation rates have a clear pathologic pathway that affects vascularity and wound healing. Further studies should be aimed at developing a clear scoring system that can be used to stratify patient for re-amputation risk, and to better predict the results according to the severity of diabetes.

Outcomes of Hallux Amputation Versus Partial First Ray Resection in People with Non-Healing Diabetic Foot Ulcers: A Pragmatic Observational Cohort Study

There are few data comparing outcomes after hallux amputation or partial first ray resection after diabetic foot ulcer (DFU). In a similar context, the choice to perform one of these two surgeries is attributable to clinician preference based on experience and characteristics of the patient and the DFU. Therefore, the purpose of this study was to determine the more definitive surgery between hallux amputation and partial first ray resection. We abstracted data from a cohort of 70 patients followed for a 1-year postoperative period to support clinical practice. We also attempted to identify patient characteristics leading to these outcomes. Our results suggested no statistical difference between the type of surgery and outcomes such as recurrence of DFU and amputation at 3, 6, and 12 months or death. However, there was a statistically significantly increased likelihood of re-ulceration for patients with CAD who underwent hallux amputation (p = 0.02). There was also a significantly increased likelihood of re-ulceration for people with depression or a history when the partial ray resection was performed (p = 0.02). Patients with prior amputation showed a higher probability of undergoing another re-amputation with partial ray resection (p = 0.01). Although the trends that emerge from this project are limited to what is observed in this statistical context, where the number of patients included and the number of total observations per outcome were limited, it highlights interesting data for future research to inform clinical decisions to support best practices for the benefit of patients.

Evidence-based conservative limb preserving surgery for the diabetic foot complications: A systematic review of systematic reviews

BACKGROUND

Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC.

METHODS

PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies' quality.

RESULTS

22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82.

CONCLUSIONS

There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.

The internal pedal amputation as a salvage procedure in diabetic and ischemic foot infection. A meta-analysis

BACKGROUND

Osteomyelitis of the diabetic foot is a very challenging condition and amputation is often indicated. In some cases where the infection is localized and the surrounding soft tissue is mildly involved, an internal pedal amputation (IPA) based on resection and limited excision of the infected bone have been suggested as a viable option. This systematic review aims to look for the effectiveness of this technique in treating selected cases of diabetic foot osteomyelitis.

METHODS

A systematic literature search was conducted using multiple electronic databases from inception. Eight studies met the inclusion criteria; one retrospective comparative study, six retrospective observational studies and one prospective observational study.

RESULTS

Based on a pooled sample of 545 patients followed over a mean period of 27.7 ± 15.2 months, the weighted results were as follows: (a) healing rate was 87.7% (95% CI = 0.757-0.959), (b) time for healing was 7.1 ± 2.9 weeks, (c) wound infection rate was 5.6% (95% CI = 0.030-0.089), (d) wound dehiscence rate was 8% (95% CI = 0.010-0.204), (e) ulcer recurrence rate was of 10% (95% CI = 0.037-0.188), and (f) amputation rate was 2.8% (95% CI = 0.001-0.085) whilst all were minor amputations.

CONCLUSION

The findings support the selection of toe/ray sparing surgery via IPA as a viable surgical option for selected cases of focal osteomyelitis secondary to diabetic foot infection. The results would indicate that when the ulcer size could be adequately reduced, removing the infected bone while preserving the soft tissue envelope could yield high chance of success with few serious complications.

A Systematic Review on the Outcomes of the Fillet Flap in Treating Diabetic and Ischemic Forefoot Ulcers

Background

Diabetic and ischemic foot ulcers are difficult to heal, and the mastering of numerous treatment methods is imperative to achieve healing. One of these methods is the fillet toe flap used to cover specific diabetic wounds of the forefoot associated with toe osteomyelitis. Instead of amputating the infected toe, phalanges are removed while keeping the viable surrounding soft tissue.

Methods

A systematic review was performed searching electronic databases up to October 2019 to identify relevant articles reporting the outcomes of the fillet flap in forefoot ulcers of patients with diabetes or peripheral artery disease. All study designs were included. The healing rate was the primary outcome. Secondary outcomes were the time to heal, ulcer recurrence, and complication rates of such infection, partial necrosis, and total necrosis.

Results

The 8 studies that met the inclusion criteria were all case series or case reports, with a total of 28 patients including 29 flaps. The mean healing rate was 92.8% (2/29); in both cases, total necrosis was due to infection (7.2%). No ulcer recurrence or partial necrosis was noted.

Conclusions

Though having limited indications, the fillet flap illustrates the full optimization of the available resources for wound coverage. The consistent presence of an axial vessel makes the fillet flap a reliable local flap to be used in specific circumstances where the loss of a toe is unavoidable. Further research is needed with large prospective controlled trials to support the findings of the review.

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.

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.

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.