Surgical Insights On Neuropathic Ulcers

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Here is a close-up view of a neuropathic ulcer under the second metatarsal.
Here is a macerated neuropathic ulcer with a hallux valgus deformity.
 Here is a view of an s/p distal Symes amputation for an elongated claw toe with ulceration.
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Author(s): 
Clinical Editor: Lawrence Karlock, DPM

Dr. Steinberg, who sees this deformity “very often” in these patients, generally uses the same approach as Dr. Catanzariti. Dr. Steinberg adds that the “simple procedure” can be performed outpatient with a local block of lido with epi to the incision sites along the posterior leg. Specifically, he says he performs the distal site medially, the central site laterally and the proximal site medially, and closes each with single prolene suture.
Dr. Karlock also opts for the Achilles tendon lengthening procedure to address an equinus deformity. He prefers the open technique unless there is an isolated gastrocnemius equinus. In those cases, Dr. Karlock will perform a strayer-type gastrocnemius recession.
He says this is an important deformity to address surgically for even forefoot ulceration, as it basically “makes these patients less propulsive and decreases the forefoot pressure and sheer forces.” For patients who have a transmetatarsal amputation or a Chopart’s amputation with recurrent plantar ulceration, Dr. Karlock says he will perform an Achilles tenectomy through a small incision and make a through and through cut through the Achilles tendon.

Dr. Catanzariti is the Director of Residency Training within the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Steinberg is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center in San Antonio. He is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Karlock (pictured at the right) is a Fellow of the American College of Foot and Ankle Surgeons and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, A Compendium of Clinical Research and Practice.

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