“As long as the foot is balanced to resolve any soft tissue ankle equinus or varus/valgus residual forefoot frontal plane deformities, the disadvantages are limited,” says Dr. Roukis of transmetatarsal amputations. “Excellent soft tissue handling, proper contouring of the residual metatarsal parabola and electrocautery of the residual metatarsals will limit wound healing problems, mechanical, pressure-induced wounding and ectopic bone growth respectively.”
Dr. Roukis, the President-Elect of the American College of Foot and Ankle Surgeons, has not had a patient refuse an initial transmetatarsal, Chopart or Lisfranc amputation instead of a partial first ray amputation. Patients have told him the cost of care is markedly lower following the successful healing of their transmetatarsal amputation in comparison with partial first ray amputation due to fewer office visits, debridements and in-shoe orthosis modifications.
“Most patients have been through endless rounds of wound care and the ulceration and associated care have disrupted their life to such an extent that they simply desire a foot that they can use again without the development of an ulcer every time they are active,” says Dr. Roukis, who is affiliated with the Department of Orthopedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center in La Crosse, Wis.
Study Skeptical Of HBOT For Diabetic Foot Ulcers
By Danielle Chicano, Editorial Associate
A recent study in Diabetes Care concludes that physicians need to reevaluate the usefulness of hyperbaric oxygen therapy (HBOT) in the treatment of diabetic foot ulcers (DFUs).
The retrospective analysis of data looked at 6,259 patients with diabetes, adequate lower limb arterial perfusion and foot ulcers extending through the dermis. Researchers found that HBOT neither improved the likelihood that a wound might heal nor decreased the likelihood of amputation in patients with DFUs. Researchers also reported that in the propensity score-adjusted models, patients who received HBOT were more likely to undergo amputation and less likely to have healing of their foot wound.
Caroline Fife, MD, argues against the validity of the findings in this study. She points out that the study did not report the selection criteria for HBOT, making it unclear whether researchers properly analyzed the therapy.
“The (study’s) retrospective analysis of practice in a single wound care organization does not indicate the effectiveness of HBOT when appropriate clinical practice guidelines are followed,” notes Dr. Fife, who is in private practice in The Woodlands, Texas.
Although prospective studies have shown that HBOT may increase the likelihood of minor amputations in exchange for decreasing major amputations, Dr. Fife says the Diabetes Care study was unclear about the degree of amputation.
“The study did not distinguish between minor and major amputations when evaluating outcomes,” notes Dr. Fife, the Chief Medical Officer at Intellicure, Inc.
Dr. Fife cites an abundance of randomized, controlled trial data that supports the efficacy of HBOT. She also notes that a recent meta-analysis concluded that HBOT improved healing and reduced the risk of major amputation in patients with DFUs. Dr. Fife adds that when it comes to advanced modalities for diabetic foot ulcers, HBOT “stands alone in having RCT evidence of efficacy in Wagner 3/4 grade ulcers and hypoxic wounds.”