Pressure redistribution - role of surgery

Recommendations

Identify and Treat the Cause
1 Take a careful history (general history, diabetic control and complications). Level of Evidence
Not Assessed
2 Conduct a foot inspection and examine for decreased sensation. Correct (if possible) risk factors for ulcer formation/amputation:§ Vascular supply§ Infection§ Pressure (including bony deformity)Remember the mnemonic VIP Level of Evidence
Not Assessed


Address patient-centered Concerns
3 Provide individualized education to enhance Glycemic control, Adherence to treatment, Plantar pressure redistribution/daily foot inspection. (GAP) Level of Evidence
Not Assessed


Provide Local Wound Care
4 Consider prophylactic deformity correction in diabetic patients with neuropathy to prevent ulceration, especially if use of pressure downloading devices has been ineffective. Level of Evidence
Not Assessed
5 Consider surgical pressure redistribution in patients with acute Charcot joint to prevent further injury and ensure a stable foot. Level of Evidence
Not Assessed
6 Consider surgical correction of foot deformity in patients with acute ulcer to speed healing. Level of Evidence
Not Assessed
7 In patients with an infected ulcer, consider resection of infected bone or joints in conjunction with surgical correction of foot deformity as an alternative to partial foot amputation. Level of Evidence
Not Assessed


Provide Organizational Support
8 Establish and empower an interprofessional team to work with Persons With Diabetes (PWD). Level of Evidence
Not Assessed


Background

The various bony or structural foot deformities seen in patients with diabetes may result in abnormally increased pressure in specific areas, especially on the plantar surface of the foot. These deformities include hammer toe, claw toe, bunions, pes planus or cavus, reduction in joint mobility and Charcot neuroarthropathy. Pressure downloading devices are commonly used to redistribute this pressure, prevent or treat foot ulcers and prevent amputation. Ulceration, infection and amputation are diabetic foot complications that often result in extensive morbidity, frequent hospitalization and mortality. These complications are also associated with significant costs. An analysis of healthcare costs of diabetic neuropathy in the United States found that the mean annual cost of treating an uninfected ulcer was $9,306, whereas the cost of treating an infected ulcer with osteomyelitis was greater than $45,000.

Appropriate management and prevention strategies have the potential to substantially reduce the incidence of diabetic foot complications. Prophylactic surgical correction of tendon, bone or joint deformity in diabetic patients with neuropathy redistributes increased pressure and may reduce the risk of ulceration. In patients with ineffective pressure downloading, surgical correction of foot deformity may prevent ulcer recurrence.

Surgical pressure redistribution in patients with uninfected ulcer may be an important part of the treatment strategy, and effective surgical management of acute Charcot joint may prevent further foot damage. For patients with an infected limb-threatening ulcer, resection of infected bone or joints in conjunction with procedures to remove areas of chronically increased pressure may be an alternative to partial foot amputation. Skin grafting may also be combined with correction of deformity to speed healing. The presence of critical ischemia should prompt referral for possible revascularization surgery prior to deformity correction.

After surgical correction of foot deformity, appropriate foot care should be implemented according to risk category.

References

Essential Publications
1 Achilles Tendon Lengthening to heal plantar ulcers Quality Indicator
 Type: RCT
Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers: A randomized clinical trial. The Journal of Bone and Joint Surgery 2003;85A (8):1436-1445.
This study compared the healing of diabetic neuropathic ulcers of the forefoot and limited ankle dorsiflexion (less than or equal to 5 degrees) with TCC plus or minus Achilles tendon lengthening. Healing times were similar but recurrences were reduced with Achilles tendon lengthening.
2 Achilles Tendon Lengthening – ankle muscle performance Quality Indicator
 Type: RCT
Salsich et al. Effect of Achilles Tendon Lengthening on Ankle Muscle Performance in People With Diabetes Mellitus and a Neuropathic Plantar Ulcer. Physical Therapy 2005; 85(1): 34-43.
This is the first study of the effect of tendo-Archilles lengthening (TAL) on active and passive muscle performance in subjects with diabetes mellitus and a neuropathic plantar ulcer. (This is part of the Mueller et al, 2003 stduy.) The effects of TAL plus total-contact casting (TCC) (n=15) were compared with TCC alone (n=14) on ankle muscle performance (isokinetic dynamometer). Following surgery, subjects in the TAL group experienced 31% decrease in concentric plantar-flexion peak torque (initial 35±3 to pretest 24±3 N.m, P < 0.05); 64% reduction in passive torque at 0 degrees of dorsiflexion (initial posttest 18±2 to pretest 6±2 N.m, P < 0.05). Following TAL surgery, the angle of concentric plantar-flexor peak torque moved 16 degrees into dorsiflexion, comparing initial posttest with pretest (P< 0.05). There were no differences in dorsiflexion peak torque across groups or time. TAL led to a temporary decrease in active and passive plantar-flexor muscle performance. Since plantar flexor musculature is compromised following surgery, attention must be paid to the risk of plantar ulcer recurrence.
3 Surgical versus non-surgical approach for diabetic neuropathic foot ulcers Quality Indicator
 Type: RCT
Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, Navalesi R. Conservative Surgical Approach Versus Non-surgical Management for Diabetic Neuropathic Foot Ulcers: a Randomized Trial. Diabetic Medicine 1998;15:412-417.
This study was the first to compare surgical treatment (n=21) with non-surgical care i.e., weight-bearing pressure relief and regular dressings (n=20), in patients with diabetic neuropathic foot ulcers. Healing rate for the non-surgical group was less at 79% than for the surgical group (P < 0.05). Healing time was less for the surgical than the non-surgical group 46.73 + 38.94 vs. 128.91 + 86.60 days respectively. More infection was seen in the non-surgical group but the surgical group was treated with antibiotics for 5 days according to regular protocol. Recurrence rate was less for the surgical group, 14% vs. 41% (P < 0.01). Patient satisfaction and discomfort favoured the surgical group. This small study suggests that surgical intervention that involves excision of the ulcer, debridement or removal of involved bone, and suturing of the wound margins, is an effective treatment option.
4 Joint arthroplasty Quality Indicator
 Type: Case-control study (2 groups)
Armstrong DG, Lavery LA, Vazquez JR, Short B, Kimbriel HR, Nixon BP, Boulton AJ. Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes. Diabetes Care. 2003 Dec;26(12):3284-7.
The purpose of this study is to evaluate the effectiveness and safety of first metatarsophalangeal joint arthroplasty versus conventional non-surgical management of wounds in patients with diabetes. This was achieved by assigning a surgical and a non-surgical group, and comparing time to healing, amputation, reulceration and infection. The results showed that the surgical group experienced favourable outcomes in all four of the aforementioned categories, indicating that joint arthroplasty is a safe and effective option that can be implemented clinically.
5 Surgical treatment of diabetic foot wounds Quality Indicator
 Type: Narrative Review
Strauss MB. Surgical treatment of problem foot wounds in patients with diabetes. Clin Orthop Relat Res. 2005 Oct;439:91-6.
This article acts as a summary on surgical treatment of diabetic foot wounds. The publication discusses both diagnosis and surgical treatment of diabetic foot wounds.
6 Classification of diabetic foot surgery Quality Indicator
 Type: Scale Description
Armstrong DG, Frykberg RG. Classifying diabetic foot surgery: toward a rational definition. Diabet Med. 2003 Apr;20(4):329-31.
This publication describes a method of classifying diabetic foot surgery based on the presence or absence of neuropathy, open wounds and acute, limb-threatening infection. Based on these factors, a four-level classification is presented: elective, prophylactic, curative and emergent. This publication is useful because this classification can be implemented clinically to help facilitate communication among physicians.
7 Surgical versus non-surgical treatment of diabetic foot ulcers Quality Indicator
 Type: RCT
Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, Navalesi R. Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. Diabet Med. 1998 May;15(5):412-7.
This publication compares surgical versus non-surgical treatment in the management of diabetic, neuropathic foot ulcers. The results show that, based on complications, relapses and healing time, conservative surgical treatment is beneficial and can be safely and effectively used in outpatient settings.


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