Can Curative Foot Surgery Facilitate The Healing Of Diabetic Foot Ulcers?

Author(s): 
Nicholas J. Bevilacqua, DPM, and Lee C. Rogers, DPM

   Unfortunately, one cannot control the amount of tendon lengthening with this procedure and over-lengthening can result in a calcaneal gait. In patients with an insensate heel, this can result in heel ulceration. This complication occurs in up to 10 percent of patients and often requires a partial calcanectomy and local muscle flaps.12 There is also a risk of tendon rupture with a percutaneous lengthening and this will result in heel ulceration if the surgeon does not address this. These complications may result in a difficult to heal ulceration and may lead to a high-level amputation if one does not manage this appropriately.

   A gastrocnemius recession may be a safer alternative to a percutaneous TAL. One may be able to have better control of the amount of lengthening and the gastrocnemius recession preserves the plantarflexion muscle strength. However, a gastrocnemius recession carries a higher recurrence rate of late plantar forefoot reulceration.12 To avoid over-lengthening, we routinely perform a gastrocnemius recession to assist in the healing of plantar forefoot wounds.

   In addition to addressing the equinus deformity, the podiatric surgeon must also address other biomechanical deformities that may be contributing to the ulceration. Failure to include these adjunctive procedures with a TAL may prevent healing or accelerate ulcer recurrence.12

What You Should Know About The Percutaneous Flexor Tenotomy

   Common forefoot deformities that are known to increase pressures and are associated with skin breakdown include hammertoe, clawtoe and first metatarsophalangeal (MPJ) deformities (hallux limitus/rigidus).3 One may perform a simple digital arthroplasty to address the contracture deformity of a hammertoe and relieve pressure at the ulceration. Percutaneous flexor tenotomy is an option for the treatment of neuropathic toe ulcerations secondary to contracture deformity.

   In a systematic review of electronic databases and all relevant sources, Roukis and Schade identified two studies that fit their inclusion criteria (which involved consecutively enrolled patients undergoing the same procedure and follow-up of at least 12 months’ duration).15 Both studies were retrospective case series and involved percutaneous flexor tenotomy of the hallux and/or lesser toes. All patients experienced healing with the incision and the index ulceration. Although the methodological quality of both studies was poor, the studies support the ability of a percutaneous flexor tenotomy of the hallux and lesser toes to heal neuropathic toe ulceration secondary to toe contracture in people with diabetes.15

Key Insights On First MPJ Arthroplasties

   Limited joint mobility at the first MPJ increases pressure plantarly at the distal hallux during ambulation. This can lead to ulceration under the hallux. This is a clear indication for curative surgery to address the underlying deformity and thereby reduce the distal pressure and assist in wound healing.

   Armstrong and colleagues compared the safety and efficacy of a first MPJ arthroplasty (Keller-type procedure) with non-surgical management for wounds at the plantar aspect of the hallux interphalangeal joint (IPJ).8 The surgery group healed significantly faster than patients in the non-surgical group. Care after healing was identical in both groups and the surgical group had fewer ulcer recurrences during the six-month follow-up.

   There was a very high prevalence of postoperative infections in the surgical group but this was in comparison to the proportion of patients in the control group who required treatment for infection during the period of therapy. The results of this study suggest that a first MPJ arthroplasty is a safe and effective procedure in the treatment of non-infected, non-ischemic wounds beneath the hallux.8

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