Cath Lab Digest

For patients with diabetes and rigid forefoot deformities, traditional surgical procedures and prolonged offloading periods have a high risk of potential complications. Accordingly, these authors offer perspectives and step-by-step pearls on the use of percutaneous surgery and minimal incision surgery procedures.

   The direct and indirect costs of foot ulcerations, infections and amputations as a result of diabetes are staggering.^1-4 Despite advances in disease management, wound healing, infection control and limb salvage techniques, diabetes will continue to rise as the world’s population continues to become more obese and less active.^5-9 It is well known that the primary event preceding amputation is infection.^10-13 Furthermore, in the vast majority of instances, a preexisting ulceration serves as a direct portal for bacteria to invade the foot, which results in infection.^10-15

   It therefore is intuitive that preventing ulcerations from developing or closing them as rapidly as possible once they do occur will limit the potential for infection to develop. This should logically lower the incidence of amputations.

   Traditionally, there has been an emphasis on conservative measures to relieve pressure and shear about forefoot ulcerations through the use of various offloading devices.^16-18 While literature does support this approach as an effective means of healing forefoot ulcerations, it does not support the continued use of these techniques to maintain healing and prevent recurrence.^19-23

   This is because the most likely cause for developing the ulcer in the first place is a structural foot deformity, which is most commonly rigid in nature, and is almost always combined with varying degrees of peripheral sensory neuropathy.^20-27

Understanding The Challenges Of Addressing Forefoot Deformities In Patients With Diabetes

   Evidence exists to support the concept that realignment of the mechanical forefoot deformities associated with patients with diabetes decreases the need for chronic wound care and improves outcomes.^20,28-33 Conceptually, this makes sense. However, when it comes to patients with diabetes, they may have a rigid deformity that usually involves the entire forefoot, dense peripheral sensory neuropathy including the contralateral non-operative limb, erratic glycemic control, malnutrition and varying degrees of medical comorbidities (i.e., coronary artery disease, nephropathy, retinopathy, etc.).

   Accordingly, the application of traditional surgical approaches and techniques including periods of non-weightbearing can be difficult in this patient population as the potential for complications is inherently high.^33,34

Can Surgical Offloading Techniques Provide Viable Alternatives?

   In regard to diabetic patients with an ulceration or recurrent ulceration, it seems intuitive that percutaneous surgery techniques (i.e., performed within the smallest possible working incision without direct visualization of the deeper structures) and minimal incision surgery techniques (i.e., performed through the smallest incision necessary) would be beneficial as a means of limb preservation/salvage without extensive soft tissue and osseous trauma.³⁵ However, the use of these techniques in this patient population has only briefly been mentioned in the literature.^36-38

   We employ percutaneous soft tissue and minimal incision osseous techniques to perform forefoot realignment in patients who are unlikely to heal with traditional surgical approaches, and would otherwise undergo an amputation or develop repeated ulceration as a result of significant structural pathology that physicians cannot manage with conservative measures.