Current Concepts In Surgical Offloading Of The Diabetic Foot

Nicholas Todd, DPM, Meagan Jennings, DPM, FACFAS, and Shannon Rush, DPM, FACFAS

   First, the gastroc recession offloads the forefoot as we previously described. With the first metatarsal head intact and the removal of the lesser metatarsal heads, there is increased pressure on the first metatarsal head. The peroneus longus to brevis transfer offsets this increased pressure, thus creating a stable and ulcer-free foot.

How To Address Digital Ulcerations

Digital deformities are common deformities even among healthy patients. Often, one can accommodate these deformities with padding or treat them surgically with arthrodesis or arthroplasty. Flexor clawing secondary to the intrinsic minus foot, flexor stabilization and poor balance can lead to distal tuft ulceration and osteomyelitis. It is one of the most common causes of digital amputation in the diabetic foot. When padding is not providing desired results, perform a flexor tenotomy. Surgeons can perform a flexor tenotomy with the patient under local anesthesia. The results are often satisfying and dramatic.

   Tamir and co-workers performed a retrospective study of percutaneous flexor tenotomies in patients with claw toes and ulcerations.8 The results showed that the tenotomy facilitated healed toes with ulcers in three weeks and there were no recurrences in ulceration. Interestingly there were no complications in the study.

   This surgical technique involves a stab incision under the intermediate phalanx. Cut the flexor and bandage the digit in its corrected position. One must remember that when evaluating patients with these digital deformities, it is difficult to achieve satisfactory results with a rigid digital deformity without performing an adjunctive procedure such as osteoclasis.

What You Should Know About Midfoot Ulcerations

Debate rages on the appropriate treatment of Charcot foot. The significant deformities that occur often lead to predictable ulceration with secondary infection and often result in loss of limb. Plantar ulceration can occur secondary to Charcot collapse and a resulting secondary deformity. One can perform an exostectomy to treat Charcot deformity, which is often characterized as a rocker bottom foot. Surgeons often perform the exostectomy in conjunction with surgical wound care.

   Catanzariti and colleagues reviewed 20 patients who underwent ostectomy for chronic or recurrent ulceration in the midfoot secondary to diabetic neuroarthropathy.9 Wounds resolved in 74 percent of the cases. The study authors noted failures with ulcerations of the lateral column. The authors concluded that the ostectomy is successful in addressing Charcot ulcerations of the medial column. When patients use post-op bracing, they can expect low recurrence in ulceration, according to the study authors.

   Patients with lateral wounds need education on the fact that there is a high chance of re-ulceration and a possible need for further reconstructive surgery. One can best approach exostectomies of the midfoot from either the lateral or medial aspect of the foot. Postoperative care usually aligns with the need for wound care and often results in offloading and immobilization in some form.

   In situations in which the joints of the midfoot are grossly unstable and exostectomy is not appropriate, a reconstruction with osteotomy or arthrodesis is required. The appropriate choice of fixation for Charcot reconstruction often employs a combination of internal and external fixation, intramedullary rods and locking plate techniques.

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