Current Concepts In Surgical Offloading Of The Diabetic Foot
- Volume 25 - Issue 5 - May 2012
- 13242 reads
- 0 comments
Grant and colleagues popularized beaming to correct the Charcot deformity by recreating anatomical alignment.10 This beaming concept has become popular but requires large diameter screws.
We advocate a 7.3-mm cannulated screw or Synthes 6.5-mm fusion bolt. Another option for internal stabilization is locking plate fixation, which can stabilize and span the medial column. The one significant concern with this form of fixation is the need for good primary incision healing. Wound dehiscence results in exposed hardware. The endpoints for correction are restoring the talometatarsal axis and a stable fusion.
External fixation is another valuable option for cases in which internal fixation is not appropriate. One can combine tensioned fine wire fixation with intramedullary screw fixation to afford excellent stability during the healing process.11 However, surgeons must approach external fixation with caution in the diabetic foot due to a high risk of infection.
Properly designed surgical intervention will decrease healing time, reduce recurrence rates and remove or reduce deformities in the patient with diabetes. The foot and ankle surgeon must remember to approach surgical intervention in the patient with diabetes with thorough planning and caution. When surgeons use this approach, surgical offloading of the diabetic foot can save limbs and improve a patient’s lifestyle.
Dr. Todd is a Surgical Fellow with the Silicon Valley Foot and Ankle Fellowship at the Palo Alto Foundation Medical Group in Mountain View, Calif.
Dr. Jennings is affiliated with the Palo Alto Foundation Medical Group in Mountain View, Calif. She is the Chief of the Department of Podiatric Surgery at El Camino Hospital in Mountain View, Calif.
Dr. Rush is affiliated with the Palo Alto Foundation Medical Group in Mountain View, Calif. He is the Director of the Silicon Valley Foot and Ankle Fellowship.
1. Armstrong DG, Lavery LA, Vazquez JR, et al. Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes. Diabetes Care. 2003; 26(12):3284–3287.
2. Hansen ST. Tendon transfers and muscle-balancing techniques. In: Hansen ST (ed): Functional Reconstruction of the Foot and Ankle. Lippincott Williams & Wilkins, Philadelphia, 2000, pp. 439-441, 462-467.
3. Boulton AJ, Hardisty CA, Betts RP, Franks CI, Worth RC, Ward JD, Duckworth T. Dynamic foot pressure and other studies as diagnostic and management aids in diabetic neuropathy. Diabetes Care. 1983; 6(1):26-33.
4. Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am. 1999; 81(4):535–538. [published erratum appears in J Bone Joint Surg Am. 2000; 82-A(10):1510]
5. Griffiths GD, Wieman TJ. Metatarsal head resection for diabetic foot ulcers. Arch Surg. 1990; 125(7):832–835.
6. Cohen M, Roman A, Malcolm WG. Panmetatarsal head resection and transmetatarsal amputation versus solitary partial ray resection in the neuropathic foot. J Foot Surg. 1991; 30(1):29–33.
7. Hamilton GA, Ford LA, Perez H, Rush SM. Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients. J Foot Ankle Surg. 2005; 44(1):37–43.
8. Tamir E, McLaren AM, Gadgil A, Daniels TR. Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report. Can J Surg. 2008; 51(1):41–44.
9. Catanzariti AR, Mendicino R, Haverstock B. Ostectomy for diabetic neuroarthropathy involving the midfoot. J Foot Ankle Surg. 2000; 39(5):291–300.
10. Grant WP, Garcia-Lavin S, Sabo R. Beaming the columns for Charcot diabetic foot reconstruction: a retrospective analysis. J Foot Ankle Surg. 2011; 50(2):182-9.
11. Lamm B, Gottlieb H, Paley D. A two-stage percutaneous approach to charcot diabetic foot reconstruction. J Foot Ankle Surg. 2010; 49(6):517-22.