Understanding The Osseous Contribution To Chronic Wounds

Author(s): 
Thomas S. Roukis, DPM, PhD, FACFAS

Structural deformities often contribute to the development of chronic wounds in the lower extremity but post-op offloading protocols with traditional surgical techniques can be difficult in high-risk populations. Accordingly, this author offers a closer look at soft tissue and osseous techniques that can address global forefoot deformities associated with chronic wounds, and allow early, guarded weightbearing.

The costs of chronic foot ulceration, secondary infection and subsequent amputation as a result of diabetes are staggering.1-4 Despite advances in limb salvage techniques and medical management, diabetes will continue to rise as the world’s population continues to become more obese and less active.5-9 It is understood that the primary event preceding amputation is infection.10-15

   It therefore is intuitive that preventing ulcerations from becoming chronic will limit the potential for infection to develop. This should logically lower the incidence of amputations. There continues to be an emphasis on relieving pressure and shear about forefoot ulcerations through conservative measures such as the use of various offloading devices.16-18 While literature does support this approach as an effective means of healing acute forefoot ulcerations, it does not support the continued use of these techniques for chronic forefoot ulcerations. Accordingly, their role in the treatment of chronic ulcerations is unclear at best.19-23

   This stands to reason as 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 may be combined with varying degrees of peripheral sensory neuropathy.20-27 Studies have demonstrated 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 Unfortunately, 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

   Therefore, it intuitively makes sense that one would desire either to minimize the extent of surgical intervention through the use of minimum incision surgical techniques or, if traditional open procedures are required, utilize fixation techniques that permit early protected weightbearing. I have previously discussed the application of various minimum incision surgical techniques for limb salvage surgery in detail.35-38 Accordingly, I will focus this discussion on structural realignment of global forefoot deformities associated with chronic ulceration and the use of soft tissue and osseous techniques that permit early, guarded weightbearing.

How To Address Flexion Contracture Of The Toes And Concurrent Chronic Wounds

Flexion contracture of the hallux and lesser toes is a common occurrence in patients with chronic ulcerations at the toe level. This is especially true of the plantar hallux interphalangeal joint ulceration and distal tuft ulcerations of the lesser toes.39-47

   In these situations, there is an effective method that can correct the global structural deformities responsible for development of the chronic ulceration yet allow early protected weightbearing. This method consists of percutaneous tenotomy of the long flexor tendons to the hallux and each lesser toe followed by manipulation of the toes in a dorsal direction (a.k.a. phalangeal set procedure). This is accompanied by debridement and coverage of the ulceration.46,47 I have found that an acellular dermal matrix (MemoDerm, Memometal), which employs a sterile sheet of pre-fenestrated cadaveric skin, is capable of providing durable coverage to chronic ulcerations.

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