Surgical Insights On Neuropathic Ulcers

Clinical Editor: Lawrence Karlock, DPM

Neuropathic ulcers can be extremely problematic for diabetes patients and podiatrists alike. Exploring the ins and outs of surgical treatment, our expert panelists take a closer look at specific ulcers, helpful techniques, the merits of preoperative vascular testing and postoperative protocols.

Q: Do you perform prophylactic diabetic foot surgery? If yes, what are the common types of situations in which you would use this treatment option?
All of the panelists consider prophylactic surgery in diabetes patients when conservative treatment options have failed to resolve an ulcer. John Steinberg, DPM, says these patients generally have a more rigid deformity that you can no longer sufficiently offload with corrective shoes or other devices.

Alan Catanzariti, DPM, also considers prophylactic surgery to treat a deformity with a significant sensory deficit in order to prevent ulceration. Dr. Steinberg concurs, emphasizing that ideally you want to perform this procedure prior to the patient ever ulcerating or requiring an amputation. After all, patients with a prior history of ulceration or amputation generally have higher rates of dehiscence and infection after prophylactic surgery than those who do not have that history, according to Dr. Steinberg.

Q: How do you surgically approach the plantar first metatarsal head neuropathic ulcer?
Dr. Catanzariti says your approach depends upon the structural deformity causing the ulcer or the foot type. All the panelists agree you should perform a sesamoidectomy if that’s the cause of the ulcer. When he’s dealing with more rigid foot types, Dr. Steinberg says he also considers a dorsiflexory osteotomy with fixation. Lawrence Karlock, DPM, prefers to concentrate on the metatarsal itself, employing a dorsiflexory wedge at the first metatarsal base with large bone staple fixation and/or screw fixation. Dr. Karlock adds that if there’s also an equinus deformity, he will address this at the same time.
If the patient has a pes cavus foot type and a plantarflexed first metatarsal, Dr. Catanzariti says he may consider a dorsal approach to performing a metatarsal osteotomy. If the deformity is somewhat flexible, Dr. Steinberg notes he’ll generally perform a Jones tenosuspension with hallux interphalangeal joint fusion and percutaneous tendo Achilles lengthening. Dr. Catanzariti adds he will sometimes perform primary closure of these wounds.

Q: Do you use tourniquets in diabetic patients who have palpable foot pulses?
While Dr. Catanzariti doesn’t use tourniquets for diabetes patients, he says it’s OK to use tourniquets for patients who have normal lower arterial perfusion. Dr. Karlock says he has no problem doing this for those who have a palpable pulse. If you adhere to accepted guidelines, Dr. Steinberg says using a tourniquet can enhance your surgical view and help facilitate better outcomes.
He says it is sometimes necessary to use a thigh tourniquet when patients have arterial calcification at the ankle. However, Dr. Steinberg cautions he would never use a tourniquet when the patient has a history of peripheral arterial bypass or other contraindications. Dr. Karlock adds diabetic patients can be treated with elective surgery just the same as non-diabetic patients “as long as their diabetic glycemic control is within the normal range” and they don’t have vascular disease.

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