What The Evidence Reveals About Midfoot Ulcers In Patients With Diabetes

Author(s): 
Valerie Schade, DPM, AACFAS

   Rosenblum and coworkers reported on the results of exostectomy on 31 patients (32 ulcerations) with an average age of 50.6 years.9 The mean duration of the ulcerations was 12.9 months. The ulceration depths were superficial, probing to bone and deep but not probing to bone. One recurrent ulceration healed at the time of surgery. Surgeons ellipsed ulcerations less than 3 cm in diameter and covered ulcerations greater than 3 cm in diameter by utilizing a local fasciocutaneous flap overlying a flexor digitorium brevis muscle flap. For the recurrent ulceration that healed at the time of surgery, surgeons performed excision via a direct approach.

   The follow-up time was 20.8 months. Of the 32 ulcerations, 21 remained healed and 11 were subject to wound dehiscence and ulceration recurrence, which the authors attributed to inadequate bone resection.

   Catanzariti and colleagues reported on the use of ostectomy in 20 patients with 28 ulcerations.10 The authors used a direct approach for 21 ulcerations (13 medial and eight lateral) and an indirect approach for six ulcerations (five medial and one lateral). Complications consisted of midfoot instability in one patient, hindfoot/ankle Charcot in one patient, one recurrent ulceration requiring medial plantar artery flap coverage, one soft tissue infection, osteomyelitis in two patients, one non-healing wound, and one below-the-knee amputation (BKA). Complications occurred more often with plantar lateral midfoot ulcerations. The only complication related to a plantar medial midfoot ulceration was the BKA. Twelve (60 percent) patients had successful healing of their ulceration.

   Laurinaviciene and coworkers also found a higher incidence of complications related to plantar lateral midfoot ulcerations following exostectomy.6 In their study of 20 patients with 27 ulcerations (18 medial and nine lateral), they found that 17 (94.4 percent) medial ulcerations went on to complete healing in comparison to three (33.3 percent) lateral ulcerations at the average follow-up time of 21.6 months.

Is Realignment Arthrodesis An Effective Option For Midfoot Ulcers?

Due to the potential for unsatisfactory long-term results with exostectomy as well as the instability and significant deformity that can be associated with midfoot Charcot, the recent trend has been toward reconstruction of the foot with realignment arthrodesis.2

   Realignment arthrodesis involves the use of a “superconstruct” design as Sammarco described.12 This involves osseous resection for deformity correction and arthrodesis extending beyond the affected joints, utilizing hardware deemed to be the strongest that the soft tissues will allow and that will provide rigid stabilization of the foot.12 Indications for this procedure are a grossly unstable foot, recurrent ulceration, failed conservative treatment or failed surgical treatment consisting of a previous exostectomy. The advantage of realignment arthrodesis is the creation of a stable, plantigrade foot leading to a decreased risk of recurrent ulceration.4,12-14

   The primary disadvantages associated with realignment arthrodesis are the increased morbidity and mortality associated with the procedure given the longer operative times; the greater potential for complications related to hardware insertion and osseous healing; infection; and the prolonged restrictions on weightbearing. The most commonly reported complications are nonunion, infection, wound dehiscence, osteomyelitis, hardware failure or migration, and recurrent ulceration.

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