Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing

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.

The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy

BACKGROUND

Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability.

METHODS

Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession "Baumann" procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry.

RESULTS

Medial gastrocnemius recession and Baumann procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. Thirty-five percent of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus.

CONCLUSION

The MGR procedure produced comparable dorsiflexion improvement results to the Baumann procedure in our cadaver model. Surgeons must account for certain conjoint tendon anatomical variants when surgically treating IGC as traditional recession methods risk tendo-Achilles overlengthening.

LEVELS OF EVIDENCE

Level V: Cadaver Study.

Internal Offloading or Surgical Offloading Adjuvant Techniques in the Reconstruction of Diabetic Plantar First Metatarsal Head Ulcer For Lasting Results

Introduction  Management of diabetic foot ulcers (DFUs) is subverted by recurrences. The main cause for the recurrence of DFUs is the failure to recognize and address all the faulty biomechanics precipitating and perpetuating the ulcer. So, we have devised a protocol for treating the diabetic plantar first metatarsal head ulcer (DPFMHUs) incorporating structured internal offloading procedures in conjunction with reconstruction. Aim  The aim of this study was to evaluate our protocol in the management of DPFMHUs. Materials and Methods  Fifty-one patients (31 males and 20 females) with DPFMHUs were managed with our protocol in this prospective cohort study conducted from March 2015 to March 2020. All the faulty biomechanics were addressed by tailored internal offloading procedure as per the protocol. Results  All patients were followed up for an average period of 23.7 months. Early complications were in the form of wound infection (3 patients, 5.9%) and seroma/hematoma (2 patients, 3.9%). Late complication in the form of recurrence was seen only in one patient (1.9%); rest of the patients had no recurrence (98%). Transfer lesions were noted in six patients (11.8%). Conclusion  Our tailored protocol, which addresses all the faulty biomechanics associated with the DPFMHU, may be very helpful in preventing the recurrence and to give lasting results. It is imperative to design a tailored internal/surgical offloading procedure for all deforming forces that are responsible for precipitation and perpetuation of DPFMHUs, in addition to like tissue reconstruction.

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.

A Surgical Approach to Location-specific Neuropathic Foot Ulceration

The management of pedal ulcerations is often challenging because of a failure to correct underlying biomechanical deformities. Without correcting the biomechanical driving force creating the increased plantar pressures, it is unlikely for routine wound care to provide lasting solutions to pedal ulcerations. Patients with diabetes often experience glycosylation of their tendons, leading to contracture and pursuant deformity, creating imbalanced pressure distributions and eventual plantar ulceration. This article evaluates the efficacy of various lower extremity tendon transfers to balance the foot and redistribute plantar pressures to prevent or heal ulceration.

Mini Invasive Floating Metatarsal Osteotomy for Diabetic Foot Ulcers Under the First Metatarsal Head: A Case Series

Diabetic foot ulcers under the first metatarsal head are difficult to treat and prevent recurrence. The aim of this study is to summarize the results of a distal first metatarsal minimally invasive floating osteotomy for ulcers under the first metatarsal head in patients with diabetic neuropathy. We reviewed files of patients with diabetic neuropathy undergoing a floating first metatarsal osteotomy. Demographic and clinical data were collected and analyzed to determine success and complications. We found records for 21 patients (mean age 64) with University of Texas 1A ulcers. The ulcer's mean age was 11.2 months. Following surgery, the ulcer completely resolved after a mean of 3.7 (2 to 11) weeks in 19 patients. During the first year, there were 4 complications related to the surgery (including 3 infections). At latest follow-up, 17/21 (81%) patients had healed with satisfactory results. Minimal invasive floating distal osteotomy of the first metatarsal can cure and prevent recurrence of diabetic foot ulcers under the first metatarsal head in 80% of the patients, but the ability to provide close follow-up and prompt response are prerequisites.

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.

Healing ulcers and preventing their recurrences in the diabetic foot

Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 – the foot at risk, Class 2 – superficial ulcers without infection, Class 3 – the crippled foot and Class 4 – the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot.

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.

Minimally Invasive Distal Metatarsal Diaphyseal Osteotomy (DMDO) for Chronic Plantar Diabetic Foot Ulcers

BACKGROUND

The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes.

METHODS

A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out ( P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%).

RESULTS

All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points ( P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time.

CONCLUSION

Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications.

LEVEL OF EVIDENCE

IV, case series.

Equinus and Lengthening Techniques

Equinus is linked to most lower extremity biomechanically related disorders. Defining equinus as ankle joint dorsiflexion less than 5° of dorsiflexion with the knee extended is the basis for evaluation and management of the deformity. Consistent evaluation methodology using a goniometer with the subtalar joint in neutral position and midtarsal joint supinated while dorsiflexing the ankle with knee extended provides a consistent clinical examination. For equinus deformity with an associated disorder, comprehensive treatment mandates treatment of the equinus deformity. Surgical treatment of equinus offers multiple procedures but the Baumann gastrocnemius recession is preferred based on deformity correction without weakness.

Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review

BACKGROUND

Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment.

METHODS

We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006.

RESULTS

We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches.

CONCLUSIONS

Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.

Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot

BACKGROUND

Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity.

METHODS

We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications.

RESULTS

Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems.

CONCLUSIONS

Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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

Background

Diabetic foot ulcers have a devastating impact on an individual’s health-related quality of life and functional status. Additionally, diabetic foot ulcers impose a significant economic burden on our health care systems as a result of complications such as infection, hospitalisation and amputation. The current gold standard treatment for diabetic foot ulcers is total contact casting. However, the rate of ulcer recurrence is high, indicating the need for more effective long-term treatment options. Therefore, the aim of this study was to systematically identify, critique and evaluate all literature investigating the effectiveness of Achilles tendon lengthening, gastrocnemius recession and selective plantar fascia release in healing and preventing diabetic foot ulcers.

Review

Searches were conducted in MEDLINE, CINAHL, AMED, EMBASE and The Cochrane Library from the earliest available date to November 2014. Methodological quality of included studies was assessed using the Downs and Black checklist. Data from randomised-controlled trials were analysed using random effects meta-analysis. For all other studies, data were analysed descriptively.

Eleven studies (614 participants) were included in the review, with a median sample size of 29 participants. Meta-analysis of two randomised-controlled trials found that there was no statistically significant difference between Achilles tendon lengthening or gastrocnemius recession and total contact casting for time to healing of diabetic foot ulcers (mean difference, MD, 8.22 days; 95 % CI, −18.99 to 35.43; P = 0.55; I² = 34 %) and the rate of ulcers healed (risk ratio, RR, 1.06; 95 % CI, 0.94 to 1.20; P = 0.34; I² = 41 %). The rate of ulcer recurrence was significantly lower following Achilles tendon lengthening or gastrocnemius recession than total contact casting (RR, 0.45; 95 % CI, 0.28 to 0.72; P < 0.001; I² = 0 %).

Conclusions

Achilles tendon lengthening and gastrocnemius recession appear to be effective surgical treatments for healing diabetic foot ulcers. The rate of ulcer recurrence was lower following Achilles tendon lengthening or gastrocnemius recession procedures compared to total contact casting treatment alone. Therefore, these surgical procedures may provide viable treatment options for the management and prevention of diabetic foot ulcers. Further rigorous randomised-controlled trials with longer follow-up are required to determine the long-term effectiveness and safety of these procedures.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-015-0085-6) contains supplementary material, which is available to authorized users.

Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations

BACKGROUND

Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support-but less science-behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers.

METHODS

A systematic review of the literature was performed on December 21, 2013 using the PubMed, Scopus, and Cochrane databases along with the search term "(gastrocnemius OR gastrocsoleus) AND (recession OR release OR lengthening)." This search generated 1141 results; 12 articles found in the references of these papers were also screened for inclusion. In total, 18 articles met our inclusion criteria. These articles were reviewed and assigned a classification (I-V) of Level of Evidence, according to the criteria recommended by the Journal of Bone & Joint Surgery. Based on these classifications, a Grade of Recommendation was assigned for each of the indications of interest.

RESULTS

Grade B evidence-based literature ("fair") exists to support the use of gastrocnemius recession for the treatment of isolated foot pain due to midfoot/forefoot overload syndrome in adults. There are some data in support of utilizing gastrocnemius recession to treat midfoot or forefoot ulcers and non-insertional Achilles tendinopathy in adults, but to date this evidence remains Grade Cf. Insufficient evidence (Grade I) is currently available to make any recommendation either for or against this procedure for the treatment of insertional Achilles tendinopathy.

CONCLUSION

Scientific literature continues to grow in support of using isolated gastrocnemius recession as an effective treatment strategy for a variety of lower limb pathologies, although it remains clear that higher evidence levels and more carefully controlled investigations will be necessary to more convincingly define the true efficacy and ideal applications of gastrocnemius recession in the adult population.

LEVEL OF EVIDENCE

Level IV systematic review.

Gastrocnemius recession or tendo-achilles lengthening for equinus deformity in the diabetic foot?

Contracture of the Achilles-gastrocnemius-soleus complex leading to ankle equinus has been linked to the development of various foot disorders. Decrease in ankle dorsiflexion results in an increase in plantar pressures and in diabetes and neuropathy, increased pressures can lead to ulceration and possibly the formation of Charcot foot. Surgical management of the equinus deformity corrects this abnormality and has the potential to avert the development of Charcot foot or ankle. Gastrocnemius recession, tendo-Achilles lengthening, and Achilles tenotomy have all been offered as surgical solutions to this condition. This article reviews ankle equinus and compares the treatment options available. A video of Hoke's triple hemisection has been included with this article and can be viewed at www.podiatric.theclinics.com.

Resection arthroplasty, external fixation, and negative pressure dressing for first metatarsophalangeal joint ulcers

BACKGROUND

A frequent complication for the diabetic patient is neuropathic ulceration on the plantar surface of the first metatarsophalangeal (MTP) joint which can be difficult to manage. Debridement and resection arthroplasty with temporary external fixation and VAC dressing (Kinetic Concepts Inc, San Antonio, TX) is an alternative operative treatment to amputation. This study examined the outcomes of one center's experience with patients who have undergone this procedure.

MATERIALS AND METHODS

This retrospective cohort study examined patients who underwent the procedure between March 2002 and March 2010. Information was obtained on relevant outcomes including: the initial procedure, secondary procedures on either foot, total time in external fixation, time until amputation, cause of ulceration and co-morbid conditions. During the study period, 16 patients underwent resection arthroplasty with external fixation for first MTP ulceration. Fourteen of these patients had underlying diabetes mellitus, one had Charcot-Marie-Tooth disease and one had neuropathy of unknown cause. All were available for followup at the end of the study period. Median followup was 38 (range, 3 to 96) months.

RESULTS

At latest followup, six patients required amputation, either transmetatarsal or transtibial, to treat their recurring ulceration.

CONCLUSION

Resection arthroplasty with temporary external fixation appears to be a safe, effective and possible alternative to amputation for the treatment of neuropathic ulceration of the first MTP.

Cutaneous anaesthesia of the lower leg can improve sensibility in the diabetic foot. A double-blind, randomized clinical trial

AIMS

Impaired sensory function in the sole of the foot in diabetic patients is a substantial problem caused by unknown mechanisms. Hand or foot sensibility can be improved by cutaneous anaesthesia of the forearm or lower leg, respectively, in healthy subjects. Hypothetically, cutaneous anaesthesia induces a silent area in the primary somatosensory cortex, allowing adjacent cortical areas to expand; thus, resulting in enhanced sensory processing. Our aim was to improve sensory function in the foot in Type 1 and Type 2 diabetic patients by application of an anaesthetic cream to the lower leg.

METHODS

In a double-blind study, 37 patients with Type 1 or Type 2 diabetes were randomly assigned to cutaneous application of either an anaesthetic cream (EMLA) or a placebo cream to the skin of the lower leg for 1.5 h. Sensibility at five points of the sole of the foot was assessed before and after 1.5 and 24 h. Vibrotactile sense was also assessed. Primary outcome was change of touch threshold at the first metatarsal head from pretreatment to 1.5 h assessment.

RESULTS

Anaesthetic cream on the lower leg resulted in a significant improvement of touch threshold at the first metatarsal head after 1.5 and 24 h. In addition, improvement of touch thresholds was also observed at the other four assessment sites, together with a decreased vibration threshold at 125 Hz.

CONCLUSIONS

The findings of improved touch thresholds open up new possibilities in treatment of sensibility disturbances in the diabetic foot, using a simple and non-invasive method.

Gastrocnemius recession as an alternative to tendoAchillis lengthening for relief of forefoot pressure in a patient with peripheral neuropathy: a case report and description of a technical modification

The gastrocnemius recession is a popular surgical procedure for the treatment of equinus contracture. Lengthening the gastrocnemius tendon has been show to be an effective means of reducing pressure to the plantar forefoot by weakening the triceps surae complex. The more traditional method of weakening the triceps surae is a modification of Hoke's triple hemisection through the tendoAchillis. This technique unfortunately carries a serious risk of the development of a calcaneal gait. The purpose of this case report is to demonstrate that the gastrocnemius recession is an effective and safe alternative to the traditional tendoAchillis lengthening. The authors also describe a minimally invasive technique that uses a pediatric speculum for a self-retrained retractor and portal for instrumentation and visualization.