November 2013

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Study Finds Low Risk Of DFU Recurrence After Nerve Decompression

By Brian McCurdy, Senior Editor

While there has been controversy over the years about the use of nerve decompression for diabetic sensorimotor polyneuropathy, a recent study in the Journal of the American Podiatric Medical Association concludes that the risk of recurrent ulcers following the procedure is low.

   Researchers looked at follow-up data on 75 legs in 65 patients with diabetes who had neuropathic foot ulcers and underwent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels. The study notes that nine of 75 operated legs had developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, the study says 16 had ulcerated, of which three were amputated.

   The authors conclude that the study’s long-term decrease of the risk of diabetic foot ulcer recurrence after operative nerve decompression compares “very favorably” with the historical literature and the contralateral legs of the study cohort, which had no decompression.

   “I have been performing (decompression) since 2000 and the ulcer recurrence rate is extremely low,” says Stephen Barrett, DPM, FACFAS.

   Study co-author Andrew Rader, DPM, notes that decompression is most effective in patients with a positive Tinel’s sign at known sites of possible nerve entrapment and those with adequate vascularity (venous and arterial) and diabetes control. People without a positive Tinel’s sign at entrapment sites are poor candidates for this type of surgery, according to Dr. Rader, a Fellow of the Association of Extremity Nerve Surgeons who practices at Indiana Foot and Ankle.

   Dr. Barrett concurs, saying patients who have a positive Tinel’s sign have an approximately 85 percent chance for some improvement in sensation and reduction of pain. In contrast, he notes patients who have significant nerve damage and who cannot feel the Semmes Weinstein 5.07 monofilament will usually get the least benefit from decompression.

   “This is why I am so distraught that the use of the Semmes Weinstein 5.07 monofilament has become the ‘holy grail’ in the universe of providers treating diabetic ulcers because by the time the patient cannot feel this monofilament, his or her nerve damage is so bad that the patient’s chance of regeneration is very low,” says Dr. Barrett, an Adjunct Professor at the Arizona Podiatric Medical Program at the Midwestern University College of Health Sciences.

   Complications with decompression are rare but Dr. Rader says incisional dehiscence seems to be the greatest concern. “It was rare in our study cohort but can be frustrating when it happens,” he notes.

   Dr. Barrett adds that complications are very low if the surgeon is experienced in peripheral nerve surgery and the patient has a proper assessment. Excessive edema is a relative contraindication and he notes that absolute contraindications to the surgery would be any significant peripheral arterial disease or vascular problem that could compromise wound healing. He cites the efficacy of peripheral nerve decompression in patients with diabetes.

   “These patients, provided that selection criteria is proper, should have this surgery as it will reduce the chance of re-ulceration and subsequent amputation,” says Dr. Barrett, a Fellow and the incoming President of the Association of Extremity Nerve Surgeons. “This surgery is life changing and ultimately saves significant healthcare dollars.”

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