Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis

Offloading systems for the treatment of neuropathic foot ulcers in patients with diabetes mellitus: a meta-analysis of randomized controlled trials for the development of the Italian guidelines for the treatment of diabetic foot syndrome

AIM

To compare the effectiveness of commonly used offloading devices for the treatment of neuropathic foot ulcers in patients with diabetes mellitus. This meta-analysis (MA) has been performed for giving an answer to clinical questions on this topic of the Italian guideline on diabetic foot syndrome.

METHODS

The present MA includes randomized controlled studies (duration > 12 weeks) comparing, in patients with diabetes mellitus and non-infected neuropathic foot ulcer: any offloading device vs either no offloading device or conventional footwear; removable versus non-removable offloading devices; surgical procedure vs other offloading approaches. The primary endpoint was ulcer healing.

RESULTS

A total of 184 studies were identified, and 18 were considered eligible for the analysis. We found that: any plantar off-loading, when compared to the absence of plantar offloading device, is associated with a higher ulcer healing (MH-OR: 3.13 [1.08, 9.11], p = 0.04, I2 = 0%); total contact cast or nonremovable knee-high walker, compared to other offloading devices, had a higher ulcer healing rate (MH-OR: 2.64 [1.43, 4.89], p = 0.002, I2 = 51%); surgical offloading for active ulcers in combination with post-surgery offloading achieves higher ulcer healing rate when compared to offloading devices alone (MH-OR: 6.77 [1.64, 27.93], p = 0.008, I2 = 0%).

CONCLUSIONS

Any plantar offloading, compared to the absence of plantar offloading device, is associated with a higher ulcer healing rate. Total contact cast or nonremovable knee-high walker, compared to other offloading devices, is preferable. Surgical offloading for active ulcers, in combination with post-surgery offloading devices, achieves a higher ulcer healing rate when compared to other offloading devices alone. Further studies with a larger cohort of patients with diabetic neuropathic foot ulcers and extended follow-up periods are necessary.

Surgical management of the diabetic foot: The current evidence

The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.

Complications of Percutaneous Tendo-Achilles Lengthening for Treatment and Prevention of Diabetic Foot Ulcers: A Systematic Review

Percutaneous Achilles tendon lengthening is an effective surgical procedure to treat and prevent forefoot and midfoot ulcerations in patients with diabetes. Patients with diabetes are prone to plantar ulcerations due to a combination of factors, such as peripheral neuropathy, decreased tendon elasticity, peripheral vascular disease, and hyperglycemia. Complications such as re-ulceration and transfer lesion to the heel, associated with a calcaneal gait secondary to over-lengthening, are possible with percutaneous Achilles tendon lengthening. Although percutaneous Achilles tendon lengthening is well accepted, the overall incidence of complication has not been well described. A systematic review of the reported data was performed to determine the incidence of complication for percutaneous tendo-Achilles lengthening when used for the treatment and prevention of diabetic plantar ulcerations. Nine studies involving 490 percutaneous lengthening procedures met the inclusion criteria. The overall complication rate was 27.8% (8% with transfer heel ulcerations). Given the high rate of complications associated with a percutaneous Achilles tendon lengthening, careful patient selection and consideration of these risks should be considered prior to proceeding with this procedure. Additional prospective comparative analyses with standardization of surgical technique, degrees of lengthening achieved, and post-operative weightbearing and immobilization modalities are needed to decrease incidence of complication and achieve higher healing rates.

Surgical management of Charcot foot - The advancements over the past decade

Charcot neuroarthropathy is a progressive, destructive condition leading to deformity, dysfunction and, in some cases, amputation. Much evolution has occurred over the last couple of decades in the management of Charcot foot with a focus on developing limb salvage and reconstructive techniques. The aim has been to achieve a stable plantigrade foot that remains pain and ulcer-free whilst reducing amputation rates. Soft tissue and bony reconstructions have been explored, and various modalities of fixation, including internal, external, and combined techniques, have been described and their outcomes published. Currently, no strong evidence exists which supports a particular modality of treatment, nor have there been any randomised studies to this effect, but the results are nevertheless promising. Recent studies have reported on minimally invasive techniques, the use of super construct fixation, computer-navigated deformity correction, the efficacy of techniques such as subtalar arthrodesis or tendon balancing procedures and staged deformity corrections. There is a need for more controlled and comparative studies with consistent reporting of intended outcomes to create a stronger portfolio of evidence on the surgical management of Charcot foot.

Immediate Effects of Weight-Bearing Calf Stretching on Ankle Dorsiflexion Range of Motion and Plantar Pressure During Gait in Patients with Diabetes Mellitus

High plantar pressure is a risk factor for diabetic foot ulcers, and it is known that restriction of ankle dorsiflexion range of motion (ROM) causes high plantar pressure. Stretching is a non-invasive and general means to improve ROM; however, the effect of stretching on the ROM and plantar pressure has not been clarified in patients with diabetes mellitus. We aimed to study the effects of intermittent weight-bearing stretching on ankle dorsiflexion ROM and plantar pressure during gait in patients with diabetes mellitus. Seven patients with diabetes mellitus participated, and their triceps surae was stretched using weight-bearing stretching with a stretch board. Five minutes of stretching was performed 4 times with a rest interval of 30 s. Ankle dorsiflexion ROM was measured with the knee flexed and extended. Peak pressure and pressure-time integral during gait were measured and calculated for the rearfoot, midfoot, forefoot, and total plantar surface before and after stretching. Ankle dorsiflexion ROM with the knee extended or bent increased significantly after stretching (P < .05). Peak pressure and the pressure-time integral decreased significantly, especially in the forefoot (P < .01), and these also decreased significantly in the total plantar surface (P < .05). The duration of foot-flat decreased after stretching (P < .05). Weight-bearing stretching improved ankle dorsiflexion ROM and reduced plantar pressure during gait. These results suggest that weight-bearing calf stretching may be an effective means to prevent and treat diabetic foot ulcers.

A 12-Week Supervised Exercise Therapy Program for Patients with Diabetic Foot Ulcers: Program Development and Preliminary Feasibility

Exercise therapy helps improve glycaemic control and insulin sensitivity and may be relevant in treating patients with diabetic foot ulcers (DFUs). This study describes the development of a 12-week exercise therapy program for patients with DFUs and the preliminary feasibility of the program focusing on the program's inclusion, adherence, and safety. The development process is built on knowledge from a published systematic review on exercise for people with DFUs and a grounded theory study on the main concerns of people with DFUs regarding physical activity. The development involved doctors, wound care nurses, podiatrists, and feedback from patients and physical therapists using semi-structured interviews. The program was designed as a combination of aerobic and resistance training exercises. The aerobic exercise phase on the stationary bike of 30-minute duration was aimed at a moderate intensity. Resistance exercises were conducted with a 15-repetition maximum approach (four to five sets per trial) throughout the 12-week period. Three patients were included and received the exercise intervention. Except for recruitment and retention rates, acceptance levels were met for all other research progression criteria. Patients found the intervention relevant, wanted further guidance on continuing exercising, and would have liked the intervention closer to their home for example, a municipality setting. Although the exercise therapy program for patients with DFUs was developed in a thorough process with the inclusion of available evidence and the involvement of patients and other stakeholders conclusions on feasibility are limited due to the low recruitment rate. A reconsideration of the setting is needed in future exercise intervention studies.

A Novel Classification for Diabetic Foot Ulcers of the First Ray

OBJECTIVE

Diabetic foot ulcers of the first ray result from several distinct biomechanical mechanisms related to anatomical deformities, which must be addressed if surgical offloading is contemplated. The objective of this study was to create a classification of the anatomical deformities of first-ray ulcers that could lead to better standardization of treatment and reporting.

METHODS

The authors performed a file review of patients with diabetic neuropathy diagnosed with first-ray ulcers over a period of 3 years in an outpatient setting. Anatomical deformities were diagnosed clinically and reported with ulcer location. The primary classification was the metatarsophalangeal joint, the interphalangeal joint, and the distal phalanx.

RESULTS

Records for 59 patients (mean age, 62 years) with University of Texas A1 and A2 ulcers were reviewed. Mean ulcer duration was 2 months. The more common deformities were hallux valgus (41%), hallux valgus interphalangeus (14%), and hallux malleus (20%), and these were primarily associated with metatarsophalangeal, interphalangeal joint, and tip-of-toe ulcers, respectively (P < .0001).

CONCLUSIONS

By classifying ulcer locations, the relevant corrective surgery may be chosen. Although some prophylactic procedures may be safe and effective, prophylactic hallux valgus correction in the diabetic foot requires further study.

Changes in physical function and ambulatory state after Achilles tendon lengthening for diabetic foot ulcers

[Purpose] The recurrence rate of diabetic foot ulcers is high and is related to kinematic factors. Achilles tendon lengthening has been shown to reduce the recurrence rate of foot ulcers by increasing the range of motion in the ankle joint and decreasing the plantar load. However, there are few reports on the effects of Achilles tendon lengthening in Japanese patients, but the results are yet to be clarified. This study aims to investigate the effects of Achilles tendon lengthening on physical function and ambulatory state in patients with diabetic foot ulcers. [Participants and Methods] This study initially included 10 patients with diabetic ulcers who had undergone Achilles tendon lengthening between April 2013 and March 2020. We retrospectively evaluated the factors available from the medical records. [Results] The dorsiflexion range of motion in the ankle joint increased by 10.5 degrees on average after surgery, while the plantar load decreased by 19.1 percent, while gait speed and stride length remained unchanged. [Conclusion] Achilles tendon lengthening for diabetic foot ulcers increased the range of motion in the ankle joint and decreased the plantar load without changing the ambulatory state.

High rate of complications after corrective midfoot/subtalar arthrodesis and Achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3

PURPOSE

Corrective midfoot resection arthrodesis is the standard treatment of Charcot arthropathy type Sanders 2 and 3 with severe dislocation. In order to critically evaluate the effect of surgical correction, a retrospective analysis of our patient cohort was performed. Hereby, special emphasis was set on the analysis of the pre- and post-operative equinus position of the hindfoot.

METHODS

Retrospectively, all patients (n = 82) after midfoot resection arthrodesis in Charcot type Sanders 2 or 3 were included. Complications were recorded, and the mean complication-free interval was calculated. Additionally, the calcaneal pitch as well as Meary's angle were measured pre- and post-operatively and in case of complications.

RESULTS

Overall complication rate was 89%. Revision surgery was necessary in 46% of all patients. The mean complication-free interval was 285 days (0-1560 days). Calcaneal pitch and Meary's angle significantly improved after operation but returned to pre-operative values after onset of complications. Achilles tendon lengthening showed no significant effects on the mean complication-free interval.

CONCLUSION

Operative treatment of Charcot arthropathy remains a surgical challenge with high complication rates. Surgical correction of equinus position has been highlighted for successful treatment but was not able to prevent complications in this study, which is demonstrated by the recurrent decrease of the calcaneal pitch in cases of reoperation. Therefore, as a conclusion of our results, our treatment algorithm changed towards primarily addressing the equinus malpositioning of the hindfoot by corrective arthrodesis of the hindfoot.

1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment

PURPOSE

The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics.

METHODS

The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control.

RESULTS

The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg.

CONCLUSION

The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain.

LEVEL OF EVIDENCE

II.

CLINICAL TRIALS IDENTIFIER

NCT02760784.

Distal Metatarsal Osteotomies for Chronic Plantar Diabetic Foot Ulcers

In more than 30 years of scientific literature (1986-2021), the few published studies on the management of CPDFUs by DMOs showed satisfactory clinical and radiographic outcomes. Although these reports were all case series, their data suggest that DMOs, performed at a different level of the distal metatarsal bones, are an effective surgical treatment option for achieving rapid healing of CPDFUs and preventing their recurrence after balancing the pressures in diabetic forefeet. Hence, DMOs can be a valid alternative treatment method also for CPDFUs with chronic infection, ulcers penetrating deep structures, and even ulcers with osteomyelitis at the metatarsophalangeal level.

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.

Furnishing Wound Repair by the Subcutaneous Fascia

Mammals rapidly heal wounds through fibrous connective tissue build up and tissue contraction. Recent findings from mouse attribute wound healing to physical mobilization of a fibroelastic connective tissue layer that resides beneath the skin, termed subcutaneous fascia or superficial fascia, into sites of injury. Fascial mobilization assembles diverse cell types and matrix components needed for rapid wound repair. These observations suggest that the factors directly affecting fascial mobility are responsible for chronic skin wounds and excessive skin scarring. In this review, we discuss the link between the fascia's unique tissue anatomy, composition, biomechanical, and rheologic properties to its ability to mobilize its tissue assemblage. Fascia is thus at the forefront of tissue pathology and a better understanding of how it is mobilized may crystallize our view of wound healing alterations during aging, diabetes, and fibrous disease and create novel therapeutic strategies for wound repair.

Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.

The Association of Gastrocnemius Tightness, Genu Valgum and Hallux Valgus: A Prospective Case-Control Study

There has been much debate regarding the aetiology and pathogenesis of hallux valgus and it appears to be multifactorial with contracture or tightness of the Achilles tendon and more specifically the gastrocnemius being implicated as an intrinsic factor. The purpose of this study was to look at the association of gastrocnemius tightness, genu valgum and hallux valgus. A prospective case-control study with 25 patients in each group was carried out over a 12-month period. The case group observed adult patients who were referred primarily because of symptomatic hallux valgus and were assessed for the following: hallux valgus stage; presence or absence of isolated gastrocnemius tightness; presence or absence of genu valgum. The control group excluded those with pre-existing hallux valgus, genu valgum and rheumatoid arthritis and were assessed for isolated gastrocnemius tightness. There was a statistically significant association between the presence of genu valgum and hallux valgus when comparing both groups with a p < .001. There was also a statistically significant association between the Silfverskiöld test and the presence of hallux valgus, as well as the Silfverskiöld test and the presence of genu valgum with a p < .001. This study is the first to describe the association of gastrocnemius tightness, genu valgum and hallux valgus. Further studies are required to assess this relationship but knowledge and awareness of it can be applied by clinicians when considering the most appropriate management options with patients.

Effect of Mini-invasive Floating Metatarsal Osteotomy on Plantar Pressure in Patients With Diabetic Plantar Metatarsal Head Ulcers

BACKGROUND

Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study's purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers.

METHODS

We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year.

RESULTS

Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa (P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s (P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics.

CONCLUSION

This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence.

LEVEL OF EVIDENCE

Level III, retrospective case series of prospectively collected data.

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.

Comparison of neurosensory devices in detecting cutaneous thresholds related to protective sensibility: A cross-sectional study in São Paulo, Brazil

AIMS

To quantify the static and moving cutaneous sensibility threshold of diabetic patients using a neurosensory device for quantitative pressure detection.

METHODS

Three hundred thirty-four (n = 334) patients with type 2 diabetes and no previous history of wounds on the feet were studied using the one- and two-point static (1SP;2 SP) and one- and two-point moving (1MP;2 MP) tests through the pressure-specified sensory device (PSSD) on the cutaneous territory of the dorsal first web, hallux pulp, and medial calcaneal. In addition, patients were evaluated using the Semmes-Weinstein monofilament (SWM) No. 5.07 and tuning fork (128 Hz), which were used as normality parameters to detect the loss of protective sensibility. The same examinations were used to assess the control group (228 nondiabetic).

RESULTS

Altered values were observed for the static and moving tests over the three studied nerve territories. In comparing the sensibility threshold between diabetic patients who were sensitive and nonsensitive to SWM 5.07, we observed that this filament is not the most indicated for identifying the loss of sensibility in these patients. The prevalence of patients at risk varied between 85 and 89%. The biochemical marker associated with these high rates was HbA1c (p = 0.02).

CONCLUSIONS

Numeric quantification of the pressure threshold allowed us to determine the functional deficit of nerve fibers. Our findings suggest that the neurosensory device should be used as an adjuvant tool to evaluate the degree of loss of sensation on the skin.

Calf muscle stretching is ineffective in increasing ankle range of motion or reducing plantar pressures in people with diabetes and ankle equinus: A randomised controlled trial

BACKGROUND

Limited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may increase ankle dorsiflexion and reduce plantar pressures in people with diabetes.

METHODS

Two arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention.

FINDINGS

68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:-0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:-2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:-10.0 to 12.9, p = 0.803) or barefoot peak pressures (-19.1 kPa, 95% CI:-96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up.

INTERPRETATION

Our data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus.

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.

Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength and improved dorsal extension in forefoot overload syndrome

BACKGROUND

Gastrocnemius recession (GR) has been introduced for treatment of forefoot overload syndrome (FOS). We questioned if GR leads to an altered forefoot load and weakness of plantarflexors in those patients.

METHODS

26 patients suffering from FOS and gastrocnemius tightness underwent GR. A strength power analysis of plantar flexors and a pedobarography was performed. Clinical outcome was measured by Foot Function Index (FFI).

RESULTS

Plantarflexors are impaired about 40% six weeks and around 10% 24 weeks following GR compared to the contralateral side. Patients experienced a pain relief and an improvement of ankle dorsiflexion from 2° to 15°. An increased contact time of the heel (15%) and a shift of metatarsal plantar pressure from lateral to medial could be demonstrated.

CONCLUSIONS

This study suggests that GR leads to pain reduction by an increase in heel contact time and a shift of gait line to medial in patients with a FOS. Despite, a temporary impairment of muscle strength has to be considered.

Osteoclasis for the Treatment of Recalcitrant Diabetic Forefoot Ulceration: A Case Study

Recurrence after diabetic foot ulceration is a common occurrence after healing. Curative surgery has been suggested to reduce the incidence of recurrent ulcerations. Osteoclasis is a simple procedure used to fracture the metatarsal head in attempt to reduce pressure under the affected metatarsal without transferring excessive pressure to adjacent metatarsals. We present a case study of a 65-year-old diabetic male with multiple attempts to heal and maintain a healed ulceration who underwent an osteoclasis procedure. Following this patient for 3 years (until time of death), no recurrent or new ulcerations had occurred. Further studies should be conducted to identify if this result is reproducible prior to widespread use.

Flexor Tenotomy Improves Healing and Prevention of Diabetes-Related Toe Ulcers: A Systematic Review

Toe deformities are common in people with diabetes and are often associated with toe ulcers. Operative procedures have been used to reduce toe deformities, because these were proposed to be beneficial in the management of toe ulcers. The present systematic review investigated the effect of flexor tenotomy to address toe deformity for healing and preventing diabetes-related toe ulcers. Four electronic databases were searched in January 2016. Studies were included if they had reported the effects of flexor tenotomy for healing and/or preventing diabetes-related toe ulcers. Six studies with a total of 264 flexor tenotomies performed on toes with ulcers and 57 performed as a prophylactic procedure were included. The mean duration of preoperative ulceration was 207.9 (range 7 to 1825) days. The mean duration to postoperative ulcer healing was 29.5 days, with an overall healing rate of 97%. The rate of ulcer recurrence was 6%. All the toes that had undergone prophylactic flexor tenotomy remained free of ulceration. Overall, the rate of complications was low. Flexor tenotomy to address toe deformity is relatively safe and effective in healing and preventing diabetes-related toe ulcers. Flexor tenotomy should be considered in the management of diabetes-related toe ulcers in the presence of toe deformities.

Surgical Correction of the Achilles Tendon for Diabetic Foot Ulcerations and Charcot Neuroarthropathy

Achilles tendon pathologic conditions are implicated in contributing to the development of many diabetic foot complications including diabetic foot ulceration and Charcot neuroarthropathy. Surgical correction of the diabetic equinus deformity has been studied as an isolated or adjunctive treatment when dealing with difficult-to-close diabetic foot ulcerations or when surgically addressing the diabetic Charcot neuroarthropathy foot or ankle. This article reviews the most common indications, complications, and surgical procedures for equinus correction by either a tendo-Achilles lengthening or gastrocnemius recession for the management of diabetic foot conditions.

Surgical Treatment Options for the Diabetic Charcot Midfoot Deformity

Management of diabetic Charcot midfoot deformity is one of the most demanding aspects of foot and ankle surgery. Its treatment should aim at reducing the rate of complications, including foot and ankle amputations or limb loss. Attempting reconstruction at Eichenholtz stages I and II carries the risk of infection and loss of fixation. It is advisable to limit surgical reconstruction to Eichenholtz stage III in the absence of any evidence of infection or vascular insufficiency. Achilles lengthening or gastrocnemius-soleus release is an essential initial step in surgery. Addressing the medial foot column first is a key to a successful reconstruction.