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Roberts RHR, Davies-Jones GR, Brock J, Satheesh V, Robertson GAJ. Surgical management of the diabetic foot: The current evidence. World J Orthop 2024; 15:404-417. [PMID: 38835689 PMCID: PMC11145970 DOI: 10.5312/wjo.v15.i5.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/12/2024] [Accepted: 04/24/2024] [Indexed: 05/15/2024] Open
Abstract
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.
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Affiliation(s)
| | - Gareth Rhys Davies-Jones
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
| | - James Brock
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Vaishnav Satheesh
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Greg AJ Robertson
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
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Lazzarini PA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Bus SA. Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2024; 40:e3650. [PMID: 37292021 DOI: 10.1002/dmrr.3650] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU. METHODS We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed. RESULTS From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers. CONCLUSIONS Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.
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Affiliation(s)
- P A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - D G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA
| | - R T Crews
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University, North Chicago, Illinois, USA
| | - C Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
| | - G Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - K Kirketerp-Moller
- Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen, Denmark
- Steno Diabetes Center, Copenhagen, Denmark
| | | | - S A Bus
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Tiruveedhula M, Graham A, Thapar A, Dindyal S, Mulcahy M. A 2-Stage Approach in Managing Diabetic Forefoot Ulcers. Foot Ankle Int 2023; 44:1085-1094. [PMID: 37937719 DOI: 10.1177/10711007231191132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer. METHODS A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations. RESULTS Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion. CONCLUSION TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Madhu Tiruveedhula
- Basildon Hospital, Mid and South Essex University Foundation Trust, Basildon, United Kingdom
| | - Anna Graham
- Basildon Hospital, Mid and South Essex University Foundation Trust, Basildon, United Kingdom
| | - Ankur Thapar
- Basildon Hospital, Mid and South Essex University Foundation Trust, Basildon, United Kingdom
| | - Shiva Dindyal
- Basildon Hospital, Mid and South Essex University Foundation Trust, Basildon, United Kingdom
| | - Michael Mulcahy
- Basildon Hospital, Mid and South Essex University Foundation Trust, Basildon, United Kingdom
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Melnychuk I, Thompson C. Treatment of Recurrent Pressure Injury Using an Allograft Adipose Matrix. Adv Skin Wound Care 2023; 36:328-331. [PMID: 36924421 DOI: 10.1097/01.asw.0000923316.00142.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
ABSTRACT A 77-year-old man with a more than 10-year history of a spinal cord injury developed bilateral trochanteric stage 3 pressure injuries (PIs) several years ago. They initially healed. The right trochanteric PI opened again and continued to reopen every 2 to 3 months, likely because of deficient adipose layer in the area of the healed PI.To treat the recurrent PI, providers injected a total of 3 mL of allograft adipose matrix into the ulcerated area of the right trochanter PI in a fanning fashion to increase subcutaneous cushioning over the bony prominence. Silicone foam was used to assist with pressure reduction for the first month. When the ulcerations healed at 1 month, the silicone foam was discontinued, and an emollient ointment was applied bilaterally to provide both the currently affected site and healed scar tissue with moisture and enhanced barrier function. Follow-up examinations were completed at 1, 3, 7, 11, 14, 16, 19, 22, and 24 months; the ulcerations remained closed, and no new PIs developed.The authors propose that allograft adipose matrix is a potential treatment modality for recurrent PIs needing a supplemented subcutaneous layer that other modalities cannot provide. Further use is ongoing in clinical scenarios when there is deficient adipose layer such as recurrent PIs or to prevent PI deterioration in early stages.
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Affiliation(s)
- Igor Melnychuk
- Igor Melnychuk, MD, is Chief, Wound Care Department, Charles George VA Medical Center, Asheville, North Carolina, USA. Cecily Thompson, BS, OMS-IV, is Medical Student, Edward Via College of Osteopathic Medicine Carolinas Campus, Spartanburg, South Carolina
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Vermigli C, Ceppitelli C, Lupattelli R, Eugeni E, Murdolo G. A recalcitrant post-amputative diabetic foot ulcer treated with a new mechanical debridement system during COVID-19 lockdown. Minerva Med 2020; 113:343-346. [PMID: 33337126 DOI: 10.23736/s0026-4806.20.07282-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Cristiana Vermigli
- Department of Internal Medicine, Endocrinology and Metabolism, Perugia Hospital, Perugia, Italy -
| | - Celeste Ceppitelli
- Department of Internal Medicine, Endocrinology and Metabolism, Perugia Hospital, Perugia, Italy
| | - Raffaella Lupattelli
- Department of Internal Medicine, Endocrinology and Metabolism, Perugia Hospital, Perugia, Italy
| | - Elena Eugeni
- Department of Internal Medicine, Endocrinology and Metabolism, Perugia Hospital, Perugia, Italy
| | - Giuseppe Murdolo
- Department of Internal Medicine, Endocrinology and Metabolism, Perugia Hospital, Perugia, Italy
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Lázaro-Martínez JL, García-Madrid M, García-Álvarez Y, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Morales E. Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations. J Clin Orthop Trauma 2020; 16:86-98. [PMID: 33680830 PMCID: PMC7919928 DOI: 10.1016/j.jcot.2020.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/14/2020] [Accepted: 12/13/2020] [Indexed: 02/07/2023] Open
Abstract
Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU. Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications. A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot. Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection. When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures. Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.
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Elbarbary AH, Sallam EM, Ismail AM. Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer. INT J LOW EXTR WOUND 2020; 21:535-543. [PMID: 33225777 DOI: 10.1177/1534734620971106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although surgical offloading seems a more permanent solution for prevention and treatment of neuropathic plantar diabetic forefoot ulcers (DFUs), the evidence for this assumption is weak and needs further studies to be established. The aim of this retrospective study is to compare the healing efficacy, associated morbidity, and recurrence rates of surgical versus removable knee-high offloading for neuropathic plantar (DFUs) healing. From January 2016 to January 2018, 70 neuropathic plantar forefoot DFUs were nonrandomly assigned to either removable knee-high cam-walker (n = 35), or metatarsal head, or accessory bone resection (n = 35). The primary endpoints were the frequency and rate of complete healing, and the rate of ulcer area reduction within 4 months. The secondary endpoints were 4 months morbidity and ulcer recurrence within 12 months. After 4 months, complete healing was significantly inferior with cam-walker compared with surgical offloading; 24 (67.6%) versus 31 patients (88.6%), respectively, P = .015. Ulcer area reduction was 2.4 cm2 (66.7%) versus 2.6 cm2 (83.9%), P = .001, in the mechanical versus the surgical groups, respectively. The mean healing time was 3.6 ± 2.1 versus 2.8 ± 0.6 months in the mechanical versus the surgical groups, respectively, P = .012. Morbidity and recurrence show nonsignificant differences between both groups. Ulcer recurrence was noted in 5/35 (14.3%) versus 2/35 (5.7%), in mechanical versus surgical groups, respectively, P = .23. Therefore, metatarsal head/accessory bone resection offered improved healing efficacy but similar morbidity and recurrence to the removable cam-walker.
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Affiliation(s)
- Ahmed H Elbarbary
- Department of Vascular Surgery, Faculty of Medicine, Tanta University, Tanta, Gharbiah Governorate, Egypt
| | - Emad M Sallam
- Department of Vascular Surgery, Faculty of Medicine, Tanta University, Tanta, Gharbiah Governorate, Egypt
| | - Ahmed M Ismail
- Department of Vascular Surgery, Faculty of Medicine, Tanta University, Tanta, Gharbiah Governorate, Egypt
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