Can Curative Foot Surgery Facilitate The Healing Of Diabetic Foot Ulcers?
What The Research Reveals About Metatarsal Head Resections
Neuropathic ulcerations under the metatarsal heads are a challenging problem and may lead to infection and amputation.16 Armstrong and co-workers evaluated the outcomes of an isolated fifth metatarsal head resection for ulcerations beneath the fifth metatarsal head and compared it to non-surgical care. The authors reported a faster healing rate and lower recurrence rate in the surgical group.17
Hamilton and colleagues proposed combining lesser metatarsal head resection with gastrocnemius recession and a peroneus longus to brevis tendon transfer in patients with chronic, neuropathic forefoot ulcerations.16 With all the ulcers being located beneath lesser metatarsal heads, the authors were able to preserve the first MPJ. The authors adjunctively addressed the equinus deformity with a gastrocnemius recession and alleviated pressure under the first metatarsal with the peroneus longus to brevis transfer. The authors retrospectively reviewed 10 patients who underwent the proposed surgery and all of the patients achieved ulcer healing with no ulcer recurrence at a mean 14.2 months of follow-up.
In a prospective cohort study involving 26 patients with chronic ulcerations under the first metatarsal head, Dayer and Assal performed a modified Jones extensor hallucis longus and a flexor hallucis longus transfer.18 If the first metatarsal was still plantarflexed, the surgeons performed a peroneus longus to brevis tendon transfer. The authors also addressed an equinus deformity with a gastrocnemius recession.
Twenty-three patients were available for follow-up and all but one achieved complete ulcer healing and no ulcer recurrence at a mean 39.6 months.18
Identifying and adequately offloading an underlying fixed deformity is essential for both healing an ulceration and preventing ulcer recurrence. Offloading with casts or specialized boots may be effective. However, there may be instances in which surgical intervention is required to augment healing and reduce the chance of ulcer recurrence. The results of the aforementioned studies suggest that certain “curative”-type procedures are safe and effective in the treatment of the neuropathic ulcerations.
Dr. Bevilacqua is an Associate Medical Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Rogers is an Associate Medical Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. He is a Fellow of the American College of Foot and Ankle Orthopaedics and Medicine.
Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.