Cath Lab Digest

When one ensures proper patient selection, surgical offloading may offer key benefits for patients with diabetic foot ulcerations. Accordingly, these authors offer insights and review study findings on the use of flexor tenotomies, metatarsal head resection, Achilles tendon lengthening and external fixation to help facilitate optimal outcomes.

   For decades, the treatment of diabetic foot ulcerations has presented a major challenge for patients and podiatric surgeons alike. Traditionally, much of the treatment of diabetic foot ulcerations has centered on conservative therapy with the primary treatment focusing on eliminating abnormal pressure on the foot.

   However, patients with diabetes typically possess many more comorbidities than the average patient. These comorbidities may include abnormal biomechanics, vascular/arterial compromise, diminished protective sensation, renal disease and altered nutritional status. These factors not only put the patient with diabetes at risk for the development of ulcerations but also delay the effectiveness, and often cause conservative treatments to fail.

   In 2007, the Centers for Disease Control and Prevention (CDC) estimated that 7.8 percent of the U.S. population (or approximately 23.6 million Americans) have diabetes with the disease population growing at alarming rates.¹ In 2007, the CDC also reported 1.6 million new cases of diabetes in individuals 20 years old or older.¹

   Among this population, researchers have estimated that the lifetime incidence of developing foot ulcerations is as high as 15 percent.² Despite the numerous treatments available, these ulcerations commonly become chronic wounds. These chronic wounds present a huge burden to patients with diabetes as well as to the healthcare system with costs estimated at nearly $13,200 per ulcer-related episode.³

   Some conventional modalities that physicians utilize in the treatment of diabetic foot ulcerations include padding, sharp debridement of calluses and ulcerations, orthotics, diabetic shoes, enzymatic debriders and bioengineered skin substitutes. While all of these treatments have been effective in some individuals, the “gold standard” for reducing abnormal pressure in diabetic foot ulcers, especially plantar ulcers, is a total contact cast (TCC).

   Total contact casts accomplish offloading by evenly distributing pressure across the plantar aspect of the foot. This modality therefore eliminates excessive pressure at one specific point and redistributes some of the forefoot pressure to the rear foot. Alternatives to the TCC include a removable cast boot. However, the TCC is often more effective since patient compliance is not usually an issue.

   Although total contact casts and these other non-surgical approaches can be effective, the surgical approach provides a more definitive result and tends to be more cost-effective.⁴ Even though it is controversial, non-emergent surgical treatment of diabetic foot ulcers has become an increasingly popular approach in comparison to conventional treatment.

Emphasizing Appropriate Patient Selection

   When should one consider surgery? This is often dependent upon the opinion of the surgeon but the general consensus is that one should consider surgery when flexible deformities have failed all conservative methods or when a rigid deformity exists.

   Due to the number of comorbidities that exist among the diabetic population, not all patients may be appropriate candidates for surgical intervention.

   Therefore, careful patient selection is of the utmost importance and one should assess several criteria. These criteria include but are not limited to: adequate circulation, absence of infection, general medical status, nutritional status and patient compliance. Physicians should ensure medical clearance and perform non-invasive vascular testing.