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• W2031454547 abstract "Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. These patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers. Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. These patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers. Foot deformities, including contracture of the gastrocnemius-soleus complex, are clinically significant risk factors that commonly lead to diabetic foot ulceration.1Boulton A.J. Kirsner R.S. Vileikyte L. Clinical practice Neuropathic diabetic foot ulcers.N Engl J Med. 2004; 351: 48-55Crossref PubMed Scopus (120) Google Scholar, 2Boulton A.J. Armstrong D.G. Albert S.F. et al.Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (37) Google Scholar, 3Reiber G.E. Vileikyte L. Boyko E.J. et al.Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.Diabetes Care. 1999; 22: 157-162Crossref PubMed Scopus (738) Google Scholar In fact, deformity in association with peripheral neuropathy and trauma were the three most common component causes in the pathway leading to foot ulceration.3Reiber G.E. Vileikyte L. Boyko E.J. et al.Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.Diabetes Care. 1999; 22: 157-162Crossref PubMed Scopus (738) Google Scholar Structural alterations in the architecture of the foot often lead to abnormally high plantar foot pressures, as well as increased dorsal, medial, or lateral pressures when snugly fitting footwear is worn.4Frykberg R.G. Biomechanical considerations of the diabetic foot.Lower Extremity. 1995; 2: 207-214Google Scholar, 5Cavanagh P.R. Therapeutic footwear for people with diabetes.Diabetes Metab Res Rev. 2004; 20: S51-S55Crossref PubMed Scopus (44) Google Scholar These high pedal pressures consequently place the foot at risk for ulceration.6Veves A. Murray H.J. Young M.J. Boulton A.J. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study.Diabetologia. 1992; 35: 660-663Crossref PubMed Scopus (528) Google Scholar, 7Frykberg R.G. Lavery L.A. Pham H. Harvey C. Harkless L. Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration.Diabetes Care. 1998; 21: 1714-1719Crossref PubMed Scopus (325) Google Scholar, 8van Schie C.H. A review of the biomechanics of the diabetic foot.Int J Low Extrem Wounds. 2005; 4: 160-170Crossref PubMed Scopus (105) Google Scholar Although deformities such as hammer toes and bunions are quite common in the nondiabetic population, they also frequently develop in persons with diabetes but without significant consequence. It is the presence of peripheral neuropathy, however, that confers the attendant risk for ulceration in diabetic individuals. A recent study of patients undergoing foot and ankle surgery has shown that diabetes without complications imparts no greater risk for postoperative infection than that for persons without diabetes. However, when diabetic patients with complications (including neuropathy) were compared with those without diabetes, there was a tenfold risk for developing postoperative infection.9Wukich D.K. Lowery N.J. McMillen R.L. Frykberg R.G. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus.J Bone Joint Surg Am. 2010; 92: 287-295Crossref PubMed Scopus (145) Google Scholar Although this study's focus was on postoperative infection in the foot and ankle, many previous studies have demonstrated the importance of neuropathy as a significant predictor of foot ulceration.3Reiber G.E. Vileikyte L. Boyko E.J. et al.Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.Diabetes Care. 1999; 22: 157-162Crossref PubMed Scopus (738) Google Scholar, 7Frykberg R.G. Lavery L.A. Pham H. Harvey C. Harkless L. Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration.Diabetes Care. 1998; 21: 1714-1719Crossref PubMed Scopus (325) Google Scholar, 10Fernando D.J. Masson E.A. Veves A. Boulton A.J. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration.Diabetes Care. 1991; 14: 8-11Crossref PubMed Scopus (278) Google Scholar, 11Abbott C.A. Carrington A.L. Ashe H. Bath S. Every L.C. Griffiths J. et al.The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort.Diabet Med. 2002; 19: 377-384Crossref PubMed Scopus (694) Google Scholar, 12Boyko E.J. Ahroni J.H. Stensel V. Forsberg R.C. Davignon D.R. Smith D.G. A prospective study of risk factors for diabetic foot ulcer The Seattle Diabetic Foot Study.Diabetes Care. 1999; 22: 1036-1042Crossref PubMed Scopus (473) Google Scholar Neuropathy not only predisposes to foot ulcer in the presence of deformity and trauma but can also lead to the development of deformity in the diabetic foot.4Frykberg R.G. Biomechanical considerations of the diabetic foot.Lower Extremity. 1995; 2: 207-214Google Scholar, 8van Schie C.H. A review of the biomechanics of the diabetic foot.Int J Low Extrem Wounds. 2005; 4: 160-170Crossref PubMed Scopus (105) Google Scholar, 13Frykberg R.G. Zgonis T. Armstrong D.G. Driver V.R. Giurini J.M. Kravitz S.R. et al.Diabetic foot disorders A clinical practice guideline (2006 revision).J Foot Ankle Surg. 2006; 45: S1-S66Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar The Charcot foot is the most classic example of a deformity primarily related to peripheral neuropathy of any cause.14Sanders L.J. Frykberg R.G. Diabetic neuropathic osteoarthropathy: The Charcot foot.in: Frykberg R.G. The high risk foot in diabetes mellitus. Churchill Livingstone, New York1991: 325-335Google Scholar, 15Wukich D.K. Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review.J Diabetes Complications. 2009; 23: 409-426Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar Neuropathy affects the sensory nerves of the lower extremities and the motor as well as autonomic fibers.16Boulton A.J. Diabetic neuropathy: classification, measurement and treatment.Curr Opin Endocrinol Diabetes Obes. 2007; 14: 141-145Crossref PubMed Scopus (63) Google Scholar, 17Vinik A.I. Maser R.E. Mitchell B.D. Freeman R. Diabetic autonomic neuropathy.Diabetes Care. 2003; 26: 1553-1579Crossref PubMed Scopus (1323) Google Scholar, 18Boulton A.J. Vinik A.I. Arezzo J.C. Bril V. Feldman E.L. Freeman R. et al.Diabetic neuropathies: a statement by the American Diabetes Association.Diabetes Care. 2005; 28: 956-962Crossref PubMed Scopus (1360) Google Scholar, 19Andersen H. Gjerstad M.D. Jakobsen J. Atrophy of foot muscles: a measure of diabetic neuropathy.Diabetes Care. 2004; 27: 2382-2385Crossref PubMed Scopus (138) Google Scholar Consequently, motor neuropathy leads to muscle dysfunction, dynamic contractures, and even paresis (ie, foot drop). Ankle equinus, caused by a contracture of the gastrocnemius-soleus muscle complex and Achilles' tendon, is often found in patients with diabetes and has been associated with high forefoot plantar pressures.20Lavery L.A. Armstrong D.G. Boulton A.J. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus.J Am Podiatr Med Assoc. 2002; 92: 479-482PubMed Google Scholar, 21Armstrong D.G. Stacpoole-Shea S. Nguyen H. Harkless L.B. 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: 535-538Crossref PubMed Scopus (37) Google Scholar, 22Mueller M.J. Sinacore D.R. Hastings M.K. Strube M.J. Johnson J.E. Effect of Achilles tendon lengthening on neuropathic plantar ulcers A randomized clinical trial.J Bone Joint Surg Am. 2003; 85: 1436-1445PubMed Google Scholar The clinical effects of motor neuropathy are also seen in the form of intrinsic muscle atrophy.23van Schie C.H. Vermigli C. Carrington A.L. Boulton A. Muscle weakness and foot deformities in diabetes: relationship to neuropathy and foot ulceration in Caucasian diabetic men.Diabetes Care. 2004; 27: 1668-1673Crossref PubMed Scopus (72) Google Scholar The “intrinsic minus” foot is typified by such atrophy on the dorsal forefoot in concert with the development of hammer toes or claw toes (Fig 1).8van Schie C.H. A review of the biomechanics of the diabetic foot.Int J Low Extrem Wounds. 2005; 4: 160-170Crossref PubMed Scopus (105) Google Scholar, 24Habershaw G.M. Chrzan J. Biomechanical considerations of the diabetic foot.in: Kozak G.P. Campbell D.R. Frykberg R.G. Habershaw G.M. Management of diabetic foot problems. 2nd ed. WB Saunders, Philadelphia1995: 53-65Google Scholar In severe cases, the intrinsic minus foot will develop a cavus appearance and associated high plantar pressures under the prominent metatarsal heads. Shoes are an important cause of trauma to the neuropathic foot, especially in individuals with structural deformity. Therefore, the provision of properly fitted therapeutic footwear is considered a key component of an ulcer and amputation prevention program.13Frykberg R.G. Zgonis T. Armstrong D.G. Driver V.R. Giurini J.M. Kravitz S.R. et al.Diabetic foot disorders A clinical practice guideline (2006 revision).J Foot Ankle Surg. 2006; 45: S1-S66Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar, 25International Working Group on the Diabetic Foot. International Consensus on the Diabetic Foot. Paper presented at: International Working Group on the Diabetic Foot 2003; Noordwijkerhout, Netherlands.Google Scholar, 26Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999, Boston, Massachusetts American Diabetes Association.Diabetes Care. 1999; 22: 1354-1360Crossref PubMed Scopus (457) Google Scholar, 27American Diabetes AssociationPreventive foot care in diabetes.Diabetes Care. 2004; 27: S63-S64PubMed Google Scholar Unfortunately, over-the-counter shoes often cannot accommodate severe foot deformities, including high plantar pressures. In some situations, custom footwear is indicated to protect severely misshapen feet. Nonetheless, any footwear is only as good as the patients' adherence to wearing the shoes as prescribed. To this end, even in the ulcerated foot where strict adherence to off-loading modalities are critical, one study showed that patients had poor compliance and wore the prescribed off-loading devices only 28% of the time.28Armstrong D.G. Lavery L.A. Kimbriel H.R. Nixon B.P. Boulton A.J. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen.Diabetes Care. 2003; 26: 2595-2597Crossref PubMed Scopus (206) Google Scholar Nonetheless, several studies have shown that patients fitted with therapeutic footwear suffer significantly fewer primary or recurrent ulcerations compared with diabetic patients who were not given such footwear.29Uccioli L. Faglia E. Monticone G. Favales F. Durola L. Aldeghi A. et al.Manufactured shoes in the prevention of diabetic foot ulcers.Diabetes Care. 1995; 18: 1376-1378Crossref PubMed Scopus (257) Google Scholar, 30Chantelau E. Kushner T. Spraul M. How effective is cushioned therapeutic footwear in protecting diabetic feet? A clinical study.Diabet Med. 1990; 7: 335-339Crossref PubMed Scopus (88) Google Scholar, 31Chantelau E. Therapeutic footwear in patients with diabetes.JAMA. 2002; 288: 1231-1232Crossref PubMed Scopus (26) Google Scholar, 32Edmonds M.E. Blundell M.P. Morns M.E. Thomas E.M. Cotton L.T. Watkins P.J. Improved survival of the diabetic foot: the role of a specialized foot clinic.Q J Med. 1986; 60: 763-771PubMed Google Scholar Surgical intervention should be considered when recurrent ulceration or preulcerative lesions develop despite concerted efforts to prevent such lesions. Once considered ill-advised, corrective or reconstructive foot surgery has assumed an important role in the management of patients with chronic or recurrent foot ulcerations.13Frykberg R.G. Zgonis T. Armstrong D.G. Driver V.R. Giurini J.M. Kravitz S.R. et al.Diabetic foot disorders A clinical practice guideline (2006 revision).J Foot Ankle Surg. 2006; 45: S1-S66Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar, 33Piaggesi A. Schipani E. Campi F. Romanelli M. Baccetti F. Arvia C. et al.Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial.Diabet Med. 1998; 15: 412-417Crossref PubMed Scopus (122) Google Scholar, 34Armstrong D.G. Lavery L.A. Stern S. Harkless L.B. Is prophylactic diabetic foot surgery dangerous?.J Foot Ankle Surg. 1996; 35: 585-589Abstract Full Text PDF PubMed Scopus (68) Google Scholar, 35Catanzariti A.R. Blitch E.L. Karlock L.G. Elective foot and ankle surgery in the diabetic patient.J Foot Ankle Surg. 1995; 35: 23-41Google Scholar, 36Nicklas B.J. Prophylactic surgery in the diabetic foot.in: Frykberg R.G. The high risk foot in diabetes mellitus. Churchill Livingstone, New York City1991: 537-538Google Scholar, 37Frykberg R.G. Diabetic foot ulcers: pathogenesis and management.Am Fam Physician. 2002; 66: 1655-1662PubMed Google Scholar, 38Frykberg R. Giurini J. Habershaw G. Rosenblum B. Chrzan J. Prophylactic surgery in the diabetic foot.in: Kominsky S.J. Medical and surgical management of the diabetic foot. Mosby, Saint Louis1993: 399-439Google Scholar Of course, such patients need to be carefully selected and evaluated to ensure that adequate vascularity is present and that major comorbidities, including renal insufficiency, unstable cardiovascular disease, and congestive heart failure, are adequately controlled. Because peripheral arterial disease (PAD) is often asymptomatic in persons with diabetes, we follow the American Diabetes Association recommendation that an ankle-brachial index (ABI) be measured in such persons who are aged >50 years.2Boulton A.J. Armstrong D.G. Albert S.F. et al.Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (37) Google Scholar, 39American Diabetes AssociationPeripheral arterial disease in people with diabetes.Diabetes Care. 2003; 26: 3333-3341Crossref PubMed Scopus (143) Google Scholar Furthermore, we routinely recommend obtaining a preoperative ABI (with toe pressures and waveforms) in diabetic patients with foot ulcers in the absence of clearly bounding pulses. In 2003, Armstrong and Frykberg38Frykberg R. Giurini J. Habershaw G. Rosenblum B. Chrzan J. Prophylactic surgery in the diabetic foot.in: Kominsky S.J. Medical and surgical management of the diabetic foot. Mosby, Saint Louis1993: 399-439Google Scholar, 40Armstrong D.G. Frykberg R.G. Classifying diabetic foot surgery: toward a rational definition.Diabet Med. 2003; 20: 329-331Crossref PubMed Scopus (87) Google Scholar revised a risk-based scheme for classifying the types of foot surgery performed in diabetic patients largely depending on the presence of open wounds and their acuity. Fundamentally, the classes of foot surgery are distinguished by their progressive risks for subsequent proximal levels of amputation (Table):•Elective surgery (class I) represents reconstructive procedures performed to correct deformities or high plantar pressures in persons without neuropathy.•Prophylactic (class II) procedures are those performed in patients with neuropathy (loss of protective sensation) to reduce the risk of ulceration or recurrent ulceration when no open wounds are present.•Curative surgery (class III) is often performed when open wounds are present to effect a cure by removing underlying bony prominences (surgical decompression), osteomyelitis, or by draining underlying abscesses. Obviously, such procedures are at higher risk for nonhealing or infection than are the first two classes.•Emergent procedures (class IV) are performed for severe infections (wet gangrene, necrotizing fasciitis, etc) to control the progression of infection. As the name implies, these procedures are performed emergently and often consist of open amputations at the foot level combined with fasciotomies of the leg.TableClassification of diabetic foot surgery40Armstrong D.G. Frykberg R.G. Classifying diabetic foot surgery: toward a rational definition.Diabet Med. 2003; 20: 329-331Crossref PubMed Scopus (87) Google Scholar•Class I: Elective. Reconstructive procedures on patients who do not have loss of protective sensation (LOPS)•Class II: Prophylactic. Reconstructive procedures performed to reduce the risk of ulceration or reulceration in patients who have LOPS and do not have a wound present•Class III: Curative. Procedures performed to assist in healing of open wounds•Class IV: Emergent. Procedures performed to arrest or limit progression of infection Open table in a new tab Armstrong et al41Armstrong D.G. Lavery L.A. Frykberg R.G. Wu S.C. Boulton A.J. Validation of a diabetic foot surgery classification.Int Wound J. 2006; 3: 240-246Crossref PubMed Scopus (47) Google Scholar later validated this classification scheme in subsequent risk for proximal amputation and infection. They found a significant trend toward increasing risk of ulceration/reulceration, postoperative infection, all-level amputation, and major amputation with increasing class of foot surgery (P < .01 for all complications). As would be expected, the greatest frequency of major amputation was in class IV procedures. Specific types of operations or procedures are not restricted to single classes of surgery as described above. To the contrary, many procedures are used in operations performed across multiple foot surgery categories. For example, a hammer toe repair might be performed as an elective, prophylactic, or a curative procedure depending on the presence of neuropathy and the presence or absence of an open wound (Fig 2) A tendo-Achilles' lengthening (TAL) would be indicated under the same situations. A first ray amputation might be performed to cure chronic osteomyelitis even in the absence of an open wound (prophylactic), in the presence of a chronic draining ulcer (curative), or as an emergent procedure to control the spread of an acute necrotizing infection. A midfoot osteotomy or arthrodesis of an ulcerated Charcot deformity is commonly performed as a curative operation (class III), but is just as frequently performed to reconstruct a deformed nonulcerated foot and thereby offer surgical decompression to reduce plantar pressures (class II; Fig 3).15Wukich D.K. Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review.J Diabetes Complications. 2009; 23: 409-426Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 42Zgonis T. Roukis T.S. Frykberg R.G. Landsman A.S. Unstable acute and chronic Charcot's deformity: staged skeletal and soft-tissue reconstruction.J Wound Care. 2006; 15: 276-280PubMed Google Scholar, 43Zgonis T. Roukis T.S. Lamm B.M. Charcot foot and ankle reconstruction: current thinking and surgical approaches.Clin Podiatr Med Surg. 2007; 24 (ix): 505-517Abstract Full Text Full Text PDF PubMed Scopus (37) Google ScholarFig 3Reconstruction for correction of unstable Charcot ankle. A, Preoperative clinical view demonstrates ankle deformity. B, A preoperative radiograph shows osteolysis of the talar dome. C, Circular external fixator in place after talectomy and fusion. D, Postoperative radiograph.View Large Image Figure ViewerDownload Hi-res image Download (PPT) This review will focus on those procedures commonly used by foot and ankle surgeons to address deformities that are causing abnormal pressure gradients. As already noted, many of these procedures can be used in elective, prophylactic, or curative situations depending on the presence (or absence) of neuropathy or ulceration. Although we will not discuss amputations or specific management of infection, a brief discussion of those procedures used to correct the Charcot foot will be presented. Common digital deformities, such as hammer toe, claw toe, and mallet toe, are known to increase pressures and are associated with neuropathic ulceration. Correcting the structural deformity with a resection arthroplasty may augment healing and reduce the risk of ulcer recurrence.44Kim J.Y. Kim T.W. Park Y.E. Lee Y.J. Modified resection arthroplasty for infected non-healing ulcers with toe deformity in diabetic patients.Foot Ankle Int. 2008; 29: 493-497Crossref PubMed Scopus (25) Google Scholar Alternatively, a percutaneous flexor tenotomy offers a less invasive approach and may afford the necessary intrinsic pressure modulation to augment healing. Distal tip ulcers, in a flexible hammer toe, may be managed with a flexor digitorum longus tenotomy. A blade or 18-gauge needle is introduced 1 cm proximal to the proximal plantar flexural crease of the toe (Fig 4). The ankle is held in a dorsiflexed position with the patient actively holding all toes in a flexed position. The toe is manually straightened, and the blade is moved across the taught tendon, making ease of the tenotomy. The long extensor tendon will now hold the toe straight. A postoperative shoe can be used for limited ambulation. Overextension of the toe can be managed with an extensor longus tenotomy at a later date. Laborde45Laborde J.M. Neuropathic toe ulcers treated with toe flexor tenotomies.Foot Ankle Int. 2007; 28: 1160-1164Crossref PubMed Scopus (53) Google Scholar retrospectively reviewed 18 patients presenting with plantar toe ulcers treated with a flexor tenotomy. All patients had a flexible claw toe deformity with ulcers on the distal plantar aspect of the hallux or lesser toes. The incision and the ulcer healed in all patients. Two patients underwent a repeat procedure for ulcer recurrence and remained ulcer free at 17 and 34 months. Tamir et al46Tamir E. McLaren A.M. Gadgil A. Daniels T.R. Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report.Can J Surg. 2008; 51: 41-44PubMed Google Scholar retrospectively reviewed the outcomes of 14 patients (24 toes) treated with percutaneous flexor tenotomies for a claw toe deformity to off-load the tip of the toe for ulcer healing. The authors performed an osteoclasis in select patients to correct rigid contractures at the proximal interphalangeal joint. All patients healed with no significant complications noted. Although the methodologic quality of both studies was poor, their results support the ability of a percutaneous flexor tenotomy of the hallux and lesser toes to heal neuropathic toe ulceration secondary to toe contracture in persons with diabetes.47Roukis T.S. Schade V.L. Percutaneous flexor tenotomy for treatment of neuropathic toe ulceration secondary to toe contracture in persons with diabetes: a systematic review.J Foot Ankle Surg. 2009; 48: 684-689Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar A rigid hammer toe is best treated with an arthroplasty at the level of the distal or proximal interphalangeal joint. However, a percutaneous flexor tenotomy may be attempted in the nonflexible deformity before resorting to an open arthroplasty. On those occasions where a hallux ulcer is not due to a limitation of motion at the metatarsophalangeal joint (MTPJ), this same procedure can be used on this digit (Fig 5). Neuropathic ulcerations under the metatarsal heads are a challenging problem and may lead to infection and amputation.48Hamilton G.A. Ford L.A. Perez H. Rush S.M. Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients.J Foot Ankle Surg. 2005; 44: 37-43Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Various metatarsal procedures have been described, including metatarsal head osteotomies and resections.38Frykberg R. Giurini J. Habershaw G. Rosenblum B. Chrzan J. Prophylactic surgery in the diabetic foot.in: Kominsky S.J. Medical and surgical management of the diabetic foot. Mosby, Saint Louis1993: 399-439Google Scholar, 49Sayner L.R. Rosenblum B.I. Giurini J.M. Elective surgery of the diabetic foot.Clin Podiatr Med Surg. 2003; 20: 783-792Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 50Tillo T.H. Giurini J.M. Habershaw G.M. Chrzan J.S. Rowbotham J.L. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations.J Am Podiatr Med Assoc. 1990; 80: 211-217PubMed Google Scholar An isolated metatarsal osteotomy should be considered for a chronic, nonundermining, nontunneling, ulcer below a specific metatarsal head. It can be performed through a dorsal incision with a double-action bone cutter or an oscillating saw. The osteotomy can be done at the surgical or anatomic neck of the metatarsal (Fig 6). A collar of bone may be removed if shortening of the metatarsal is desired. Such procedures are generally performed when the plantar ulceration does not penetrate to bone. A tunneling ulcer should be appropriately débrided to remove all undermining. A metatarsal head resection may be performed to assist in healing by internally off-loading the ulcer (Fig 7). Armstrong et al51Armstrong D.G. Rosales M.A. Gashi A. Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration.J Am Podiatr Med Assoc. 2005; 95: 353-356PubMed Google Scholar evaluated the outcomes of an isolated fifth metatarsal head resection for ulcerations beneath the fifth metatarsal head and compared it with nonsurgical care. They reported more rapid healing and a lower recurrence rate in the surgical group. The surgeon must be cognizant of maintaining a nearly normal metatarsal parabola. The second, third, and fourth metatarsals function as a single unit and any disruption in metatarsal length or height may result in a transfer callus or ulceration. If an ulcer occurs, further metatarsal osteotomy may be necessary. Osteotomies should be performed on the remaining two metatarsals, and if not, additional ulceration is likely to develop over the remaining metatarsal, necessitating a third procedure. This scenario is especially likely to occur after one of the metatarsal heads has been removed due to infection. Multiple metatarsal head resections or a panmetatarsal head resection may be considered for nonhealing ulcers in the presence of an abnormal metatarsal parabola (Fig 8).52Giurini J.M. Habershaw G.M. Chrzan J.S. Panmetatarsal head resection in chronic neuropathic ulceration.J Foot Surg. 1987; 26: 249-252PubMed Google Scholar Hamilton et al48Hamilton G.A. Ford L.A. Perez H. Rush S.M. Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients.J Foot Ankle Surg. 2005; 44: 37-43Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar proposed combining lesser metatarsal head resections with gastrocnemius recession and a peroneus longus-to-brevis tendon transfer in patients with chronic, neuropathic forefoot ulcerations. All ulcers were located beneath lesser metatarsal heads, allowing the authors to preserve the first MTPJ. They adjunctively managed the equinus deformity with a gastrocnemius recession and alleviated pressure beneath the first metatarsal with the peroneus longus-to-brevis transfer. The authors reported ulcer healing in 10 patients (100%), with no ulcer recurrence at a mean 14.2 months of follow-up.48Hamilton G.A. Ford L.A. Perez H. Rush S.M. Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients.J Foot Ankle Surg. 2005; 44: 37-43Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Limited range of motion at the MTPJ is a common forefoot deformity that contributes to ulcer formation beneath the hallux. This limitation in joint range of motion leads to increased pressure on the hallux during ambulation. Pressure reduction is essential and usually consists of an external device to off-load the area.53Wu S.C. Crews R.T. Armstrong D.G. The pivotal role of offloading in the management of neuropathic foot ulceration.Curr Diab Rep. 2005; 5: 423-429Crossref PubMed Scopus (65) Google Scholar This does not correct the underlying defo" @default.
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• W2031454547 title "Surgical off-loading of the diabetic foot" @default.
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• W2031454547 doi "https://doi.org/10.1016/j.jvs.2010.06.008" @default.
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