Prophylactic and Curative Surgery (T/F)

Causal Pathway of Diabetic Foot Issues

• Neuropathy can cause absence of protective sensation
• Deformities can include structural abnormalities, limited joint mobility, and excessive plantar pressure
• Trauma can be short duration with high impact, or repetitive with low impact

Critical Questions for Diabetic Foot Surgery

• Is surgery dangerous for the diabetic population?
• What are the selection criteria for patient operation?
• Is there sufficient literature to support successful outcomes?

Diabetic Foot Surgery Classification

• Class I (Elective): Alleviation of pain and/or limited motion with intact neurologic status, example; bunionectomy
• Class II (Prophylactic): Loss of protective sensation without an open wound, goal of reducing ulceration risk, examples include metatarsal head resection and Achilles tendon lengthening
• Class III (Curative): Presence of an open wound, greater risk of complications than Class II, example involves Keller arthroplasty for hallux IPJ ulcer or hammertoe repair for toe lesion
• Class IV (Emergent/Ablative): Limits progression of infection via resection of necrotic or infected tissue, example; amputation surgery
• Proactive surgery involves previous or current ulcers, and prophylactic measures
• Reactive surgery addresses acute soft tissue or bone infections, and non-reversible ischemia

Prophylactic Surgery in Diabetic Foot

• A 5-year retrospective study revealed many associated complications
• Key factors to consider include nutritional, vascular and neurologic statuses, bacteriology, deformity, radiology, and a surgical predictive index
• One definition of prophylactic surgery is surgery performed to prevent the occurrence of serious associated disease or pathology
• Another definition is surgery performed on intact integument to reduce bony prominence and thus, decrease the risk of future ulceration, infection, and amputation

Goals of Diabetic Foot Surgery

• Reduction of pressure
• Prevention of ulceration and amputation
• Increased function
• Relief of pain
• Allow proper accommodation

Patient Selection Considerations

• Failure of conservative treatment
• Deformity placing the limb at risk (rigid or flexible)
• Patient compliance and education concerns
• General medical status

Patient Evaluation Approach

• History taking includes HPI, PMH, meds/allergies, social history, previous surgeries, family history, and review of systems
• Physical exam should assess vascular, neurologic, orthopedic, dermatologic, and shoe gear aspects

Flexible vs Rigid Deformities

• Rigid deformities cannot be offloaded

Common Deformities Treated in Diabetic Foot Surgery

• Ingrown toenails
• Digital deformities
• Hallux valgus
• Tailor's bunion
• Plantar hallux lesions
• Metatarsal head lesions
• Charcot deformity
• Tendo-Achilles contracture
• Deformity post partial amputation

UTHSCSA Experience with Surgery in Diabetics

• A 5-year retrospective study involved 64 patients with 182 procedures
• 81% of procedures were for hammertoes or HAV
• The average follow-up was 24 months
• 90.5% healed, 6.4% had a grade O lesion, and 3.1% were lost to follow-up
• The complication rate was 15.6%
• Prophylactic foot surgery in a vascularly intact, insensate foot can alleviate bony deformities, produce satisfying results, and reduce the risk of further breakdown and amputation

Phenol Matricectomy for Diabetics

• A study of 66 consecutive patients with diabetes mellitus, 57 underwent phenol matricectomy
• Procedures saw a 5% regrowth rate with no significant complications and limited risk

Prophylactic Diabetic Foot Surgery Safety

• A retrospective study of single digital arthroplasties in 31 diabetic and 33 non-diabetic patients aimed to compare morbidity and outcomes
• Average follow-up of 3 years showed no significant difference between the two groups
• 96.3% of participants remained ulcer-free

Outpatient Percutaneous Flexor Tenotomies

• A retrospective review assessed management of diabetic claw toe deformities with ulcers
• Inclusion criteria included mild to moderate rigidity and distal ulceration
• Exclusion criteria included absence of pulses and cellulitis
• Surgical technique involves digital block, DF ankle, pressure to plantar met head, puncture under middle phalanx, tendon cut, osteoclasis for rigid deformity, pressure dressing, WBAT in regular shoes
• Ulcers without osteo healed within 3 weeks, and ulcers with osteo, within 8 weeks
• Procedures had no complications, recurrence or hyperextension deformities

Prophylactic First Ray Surgery

• Keller Arthroplasty
• McBride Bunionectomy
• Osteotomy with fixation
• MTPJ Sesamoid Planing/Excision
• Met Head Resection
• Dorsiflexory Osteotomy
• Condylectomy
• HIPJ Arthroplasty/Arthrodesis
• HIPJ Sesamoid Excision

First MPJ Arthroplasty for Hallux IPJ Wounds

• A case control study evaluated complications and outcomes of the procedure, compared to standard, non-surgical management
• The study showed that 21 surgical patients underwent Keller type arthroplasty
• 20 age, sex-matched patients receiving standard non-surgical care served as controls
• A 6-month follow-up was conducted
• Ulcer healing was achieved in 24 days compared to 67 days
• Ulcer recurrence: 5% vs 35%
• Infection: 40% vs 38%
• Amputation: 10% vs 5%

Lesser Metatarsal Surgery Options

• Pan or solitary metatarsal head resection
• Dorsiflexory/shortening osteotomies
• Condylectomy
• Tailor's bunionectomy

Conservative vs Surgical Management of Diabetic Neuropathic Foot Ulcers

• Randomized trial addressed healing rate in 6 months and duration of healing time, prevalence of recurrence and infection
• Group A (n=20) received non-operative therapy, dressing changes and offloading
• Group B (n=21) received operative therapy involving removal of ulcer/bone, closure with sutures, and 5 days of IV antibiotics
• Group A healing rate was 79% vs 95% in Group B
• Group A duration of healing: 129 days vs 47 days in Group B
• Group A recurrence rate: 41% vs 14% in Group B
• Group A infection rate: 12.5% vs 4.5% in Group B
• Group B patients are well vascularized, and experience lower complications, faster healing with less recurrence
• Studies had a short-term follow-up

Metatarsal Head Resection for Diabetic Foot Ulcers

• A retrospective review assessed diabetic patients who underwent metatarsal head resections for recalcitrant diabetic foot ulcerations
• Indications for metatarsal head resection include non-healing ulcers (22), infected ulcers (5), transfer lesions (3), ulcerations after amputations (2), and painful callus (2)
• A sample study involved 34 met head resections on 25 patients in 32 operations
• Mean age of the sample was 58, consisting of 19 males and 6 females
• Mean time of ulceration pre-op = 9.0 months with mean follow up of 13.8 months
• Mean time for ulcer healing post-op = 2.4 months with no recurrence in the same area
• Three transfer lesions were re-operated

Fifth Metatarsal Head Resection for Diabetic Foot Ulceration

• A retrospective cohort study was done to evaluate outcomes of operative versus non-operative treatment of ulcerations sub 5th metatarsal head in people with diabetes
• Duration to healing was 5.8 weeks vs 8.7 weeks
• Reulceration rates were 4.5% vs 28%
• Infection rates were 18% vs 22%
• Amputation rates were 4.5% vs 12%
• 22 patients underwent 5th met head excision
• 18 patients received standard operative care
• 6-month follow up

Pan Metatarsal Head Resection

• Study shows 34 panmetatarsal head resections had average follow-up of 20.9 months
• The overall success rate was recorded at 97%
• The most common complication involved regrowth of bone resulting in the development of new ulceration

Partial Calcanectomy

• Involves 8 patients who underwent partial calcanectomy for chronic non-healing ulcerations, in a retrospective review
• 148 cases since 1931 have seen 89% healing rates in DM and PVD patients using incisional approaches
• Results showed 7 of 9 feet (78%) had healing without recurrence
• 2 failures involved PVD/improper post-op offloading
• Ambulatory status was unchanged post-op

Surgical Management of Charcot Foot

• This affects 1-4% of the diabetic population, M=F population
• Average age of developing Charcot is 40, with 30% potentially developing bilaterally
• Possible complications include: Unstable deformity not amenable to bracing, deformity with current non-healing ulceration, or a deformity with potential for recurrent ulceration
• Arthrodesis of the midfoot, hindfoot or ankle may be required
• Surgical procedures consist of exostectomy and arthrodesis

Charcot Deformity Results

• Involved cases report Brodsky and Rouse Clin Ortho 296 Nov, 1993 found results for 12 patients who underwent exostectomy
• In this study, the average follow-up was 25 months
• 11 of 12 patients had Type I midfoot involvement
• 11 of 12 patients remained healed

Achilles Tendon Lengthening

• Involves 10 Subjects with DM who were all UT DM Foot Risk Category 3
• All subjects had pre-operative AJ DF <10 degrees
• TAL Performed
• Peak plantar forefoot pressure assessments pre and 8-weeks postoperatively
• Postoperative results showed reduction in peak plantar pressure (86.1 ± 9.4 vs. 63.3 ± 13.2 N/cm², p < 0.001) and in ankle joint range of motion at 8 weeks postop (0.4 ± 3.1 vs. 8.7 ± 2.3, p < 0.001)