Prophylactic and Curative Surgery (MC)

• Alexander Reyzelman DPM is an Associate Professor in the Dept of Medicine at the California School of Podiatric Medicine at Samuel Merritt University.

The Causal Pathway

• Neuropathy can lead to the absence of protective sensation.
• Deformity can result in structural abnormalities, limited joint mobility, and excessive plantar pressure.
• Trauma can be caused by short duration/high impact or repetitive/low impact forces.

Critical Questions for Diabetic Foot Surgery

• Considerations include whether surgery is dangerous for the diabetic population.
• Selection criteria must be established to determine who to operate on.
• It is important to determine if there is literature to support successful outcomes.

Diabetic Foot Surgery Classification

• Class I (Elective): Includes elective procedures.
• Class II (Prophylactic): Includes proactive procedures.
• Class III (Curative): Includes curative procedures.
• Class IV (Emergent): Includes reactive procedures.
• Proactive surgeries address previous or current ulcers and prophylactic needs.
• Reactive surgeries address acute soft tissue or bone infections and non-reversible ischemia.
• Armstrong and Frykberg (Diabetic Medicine 2003) and Kravitz, McGuire, and Sharma (Adv Skin & Wound Care 2007) classify diabetic foot surgeries.

Class I: Elective

• These surgeries aim to alleviate pain and limited motion with an intact neurologic status.
• An example is bunionectomy.

Class II: Prophylactic

• These surgeries are done for loss of protective sensation without an open wound.
• The goal is to reduce the risk of ulceration or re-ulceration.
• Examples include metatarsal head resection and Achilles tendon lengthening.

Class III: Curative

• Characteristic is the presence of an open wound.
• There is a greater risk of complications compared to Class II surgeries.
• An Example: Keller arthroplasty for hallux IPJ ulcer or hammertoe repair for toe lesion.

Class IV: Emergent/Ablative

• Surgeries limit progression of infection and involve the resection of necrotic or infected tissue.
• Amputation surgery is an example.

Prophylactic Surgery in the Diabetic Foot - Gudas, CJ Clin Pod Med 1987

• A 5-year retrospective study was conducted and many complications were associated.
• Consideration of nutritional, vascular, and neurologic status is key.
• Bacteriology, deformity, radiology and surgical predictive index are factors.

Goals of Diabetic Foot Surgery

• Reduction of pressure on the foot is crucial.
• Prevention of ulceration and potential amputation is a goal.
• Surgery aims to increase foot function, relieve pain, and allow for proper accommodation.

Patient Selection Considerations

• Failure of conservative treatment is a factor in surgical recommendations.
• Deformity, whether rigid or flexible, increases risk to the limb.
• Patient compliance and education are key.
• Overall general medical status must be considered during selection.

Patient Evaluation - History and Systems Approach

• History taking includes HPI (History of Present Illness), PMH (Past Medical History), medications/allergies, social history, previous surgeries, family history and a review of systems.
• Physical exam includes vascular, neurologic, orthopedic, dermatologic and shoe gear assessment.

Flexible vs. Rigid Deformities

• Rigid deformities cannot be offloaded.

Deformities Commonly Treated

• Ingrown toenails can be a common factor
• Digital deformities can occur
• Hallux Valgus is factor
• Tailor’s Bunion may occur
• Plantar Hallux Lesions are possible
• Metatarsal Head Lesions may form
• Charcot Deformity can become apparent
• Tendo-Achilles Contracture can develop
• Deformity after Partial Amputation is possible

Prophylactic Surgery - Definitions

• Frykberg (1994) defines prophylactic surgery as surgery to prevent serious associated disease or pathology.
• Armstrong (1996) defines it as surgery on intact integument to reduce bony prominence and thus the risk of future ulceration, infection, and amputation.

UTHSCSA Experience with Foot Surgery in Diabetics

• A 5-year retrospective study included 64 patients with 182 procedures.
• 81% of the procedures were for hammertoes or HAV (Hallux Abducto Valgus).
• The follow-up averaged 24 months
• 90.5% healed, 6.4% had a Grade O lesion, and 3.1% were lost to follow-up.
• There was a 15.6% complication rate.
• Prophylactic foot surgery in the vascularly intact, insensate foot to alleviate bony deformities produces satisfying results and aids in reducing the risk for further breakdown and amputation.

Phenol Matricectomy in Patients with Diabetes - VF, J Foot Ankle Surg 1997

• A study with 66 consecutive patients with diabetes mellitus who underwent phenol matrixectomy, found that 5% experienced regrowth.
• There were no significant complications and the risk in the DM population was limited.

Prophylactic Diabetic Foot Surgery - Armstrong et al, J Foot Ankle Surg, 1996

• A retrospective study of single digital arthroplasties with 31 patients with diabetes and 33 non-diabetic patients was performed.
• The purpose was to compare morbidity and outcomes of prophylactic surgery between the two groups.
• The average follow-up of 3 years had no significant difference and 96.3% remained ulcer-free.

Outpatient Percutaneous Flexor Tenotomies for Management of Diabetic Claw Toe Deformities with Ulcers - Tamir et al, Can J Surg, 2008

• A retrospective review of outpatient percutaneous flexor tenotomies in diabetic patients with claw toes and ulceration was conducted.
• Inclusion criteria: Mild to moderate rigidity and distal ulceration
• Exclusion criteria: Absence of pulses and cellulitis.
• Surgical technique: a digital block, DF ankle, pressure to plantar met head, puncture under middle phalanx, tendon cut, osteoclasis for more rigid deformity, pressure dressing and WBAT in regular shoes.
• Results: 34 toes in 14 patients, 8 male and 6 female, 24 ulcers with 10 at risk, 3 osteomyelitis, average duration of ulceration 11 months, mean follow-up 13 months.
• Ulcers without osteo healed in 3 weeks and ulcers with osteo healed in 8 weeks.
• No complications or recurrence.
• No hyperextension deformities seen.

Prophylactic 1st Ray Surgery Options

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

Clinical Efficacy of the First Metatarsalphalangeal Joint Arthroplasty as a Curative Procedure - Armstrong et al, Diabetes Care, 2003

• A case control study evaluated the complications and outcomes of 1st MPJ arthroplasty compared to standard, non-surgical management of hallux IPJ wounds.
• 21 surgical patients underwent Keller type arthroplasty and 20 age/sex matched patients received standard non-surgical care with a 6 month follow up.
• Ulcer healing: 24 days vs 67 days.
• Ulcer recurrence: 5% vs 35%.
• Infection: 40% vs 38%.
• Amputation: 10% vs 5%.

Lesser Metatarsal Surgery Includes

• Pan or Solitary Metatarsal Head Resection
• Dorsiflexory / Shortening Osteotomies
• Condylectomy
• Tailor’s Bunionectomy

Conservative Surgical Approach Versus Non-surgical Management for Diabetic Neuropathic Foot Ulcers: a Randomized Trial - Piaggesi et al, Diab Med, 1998

• A prospective, randomized trial addressed healing rate in 6 months, duration of healing time, prevalence of recurrence and prevalence of infection.
• Group A (n=20) received non-operative therapy involving dressing changes and offloading.
• Group B (n=21) received operative therapy which consisted of removal of ulcer/bone and closure with sutures and a 5 day course of IV abx.
• Healing Rate was 19/24 (79%) for the non-operative group and 21/22 (95%) in the operative group.
• Duration of Healing was 129 days versus 47 days.
• Recurrence Rate was 8/19 (41%) versus 3/21 (14%)with transfer lesions.
• Infection Rate was 3/24 (12.5%) versus 1/22 (4.5%)
• The non-operative group resulted in less Well vascularized patients Lower complications ,Faster healing Short term follow-up Less recurrence.

Metatarsal Head Resection for Diabetic Foot Ulcers - Griffiths et al, Arch Surg 1990

• A retrospective review of diabetic patients who underwent metatarsal head resections for recalcitrant diabetic foot ulcerations
• Indications: Non healing ulcers (22), Infected ulcers (5), Transfer lesions (3), Ulcerations after amputations (2), and Painful callus (2).
• 34 met head resections on 25 patients in 32 operations.
• Mean age was 58 and 19 males and 6 females.
• Mean time of ulceration pre-op = 9.0 months.
• Mean follow up was 13.8 months.
• Mean time for ulcer healing post-op was 2.4 months.
• There was no recurrence in the same area and 3 transfer lesions were re-operated.

Efficacy of Fifth Metatarsal Head Resection for Treatment of Chronic Diabetic Foot Ulceration - Armstrong et al, JAPMA 2005

• A retrospective cohort study evaluated outcomes of operative versus non-operative treatment of ulcerations sub 5th metatarsal head in people with diabetes.
• Duration to healing was 5.8 weeks versus 8.7 weeks with the non-operative care.
• Reulceration rates were 4.5% versus 28%.
• Infection rates were 18% versus 22%.
• Amputation rates were 4.5% versus 12%.
• The follow up was 6 months.

Pan Metatarsal Head Resection - Giurini et al JAPMA 1993

• 34 panmetatarsal head resections occurred.
• Average follow-up was 20.9 months
• Overall success rate of was 97%
• The most common complication was regrowth of bone resulting in development of new ulceration

Partial Calcanectomy in the Treatment of Recalcitrant Heel Ulcerations - Randall et al, JAPMA 2005

• Literature Review: 148 cases since 1931 with 89% healing rates in patients DM and PVD using Incisional approaches.
• A retrospective review of 8 patients underwent partial calcanectomy for chronic non-healing ulcerations.
• 8 patients with 9 feet saw 7/9 (78%) healed without recurrence
• 2 failures resulted from PVD / Improper post-op offloading.
• Ambulatory status was unchanged post-op

Surgical Management of the Charcot Foot

• 1-4% of the diabetic population experiences charcot foot, with a a M=F prevalence.
• The average age of developing Charcot is 40.
• 30% may be bilateral and complications may occur
• Indications for Surgery: Unstable deformity not amenable to bracing, Deformity with current non healing ulceration and Deformity with potential for recurrent ulceration
• Surgical Procedures: Exostectomy and Arthrodesis to the Midfoot, Hindfoot, and Ankle .

Charcot Deformity study by Brodsky and Rouse Clin Ortho 1993

• A study showed 12 patients who underwent exostectomy
• Average follow-up was 25 months
• 11 of 12 patients had Type I midfoot involvement
• 11 of 12 patients remained healed

Achilles Tendon Lengthening - Armstrong et al JBJS 1999

• The study consisted of 10 Subjects with DM with All UT DM Foot Risk Category 3 and All with pre-operative AJ DF <10 degrees.
• TAL was Performed.
• Peak plantar forefoot pressure assessments were taken pre and 8-weeks postoperatively.