Diabetic foot surgery: classifying patients to predict complications

The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer

Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.

The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer

Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.

The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer

Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.

Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association

Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.

The Safety and Effectiveness of the Percutaneous Flexor Tenotomy in Healing Neuropathic Apical Toe Ulcers in the Outpatient Setting

Percutaneous flexor tenotomy is a minimally invasive procedure that involves cutting one or both flexor digitorum tendons underneath the toe. It is an alternative to open surgical procedures performed in an operating theatre. This project is a prospective case series investigating the utility, effectiveness, and participant satisfaction of the percutaneous flexor tenotomy when performed in the outpatient setting. People with diabetes, digital flexion deformity, and loss of protective sensation with an apical ulcer or preulcerative lesion presenting to the Austin Health Foot Ulcer Specialist Outpatient Clinic were enrolled in the study. The procedure was performed under sterile technique with an 18-gauge needle or fine scalpel blade. Participants were reviewed weekly until the incision and/ or ulcer healed. Participants were then followed up at 3 and 6 months. Time to ulcer healing, reulceration rate, frequency of complications, and patient satisfaction were recorded. There were 11 toe ulcers and 41 preulcerative lesions. A total of 76 tenotomy procedures were performed on the 23 participants across 35 episodes of care. The mean time to ulcer healing following tenotomy was 10.2 ± 4.3 days. There were no recurrences of ulceration. The infection rate per episode of care was 2.8%. There were 11 toes (14.5%) that sustained a transfer lesion post the index procedure. The mean time to development of a transfer lesion was 95.5 ± 98.1 days. All participants strongly agreed that they were satisfied with the outcome of the procedure. The flexor tenotomy is an effective procedure to expedite the healing of apical toe ulcers in people with loss of protective sensation and flexion digital deformity. It has a low infection rate and high patient satisfaction rate when performed in the outpatient setting. There is a moderate risk of transfer preulcerative lesions to an adjacent digit. Levels of Evidence: Level IV: Prospective case series.

Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction

Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group.

Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score

Background

All diabetic neuroosteoarthropathy (Charcot arthropathy) treatment concepts are focused on a long-term infection-free, ulcer-free, and plantigrade sufficiently stable foot in order to avoid amputation. Reconstructive arthrodesis techniques for severe deformities are associated with high postoperative complication rates. This study reports a detailed complication analysis and provides a strategy that may help detect patients at risk for a complicated postoperative course.

Methods

The study comprised 43 feet in 37 patients with severe non-plantigrade or unstable Charcot deformity, Eichenholtz stages II/III (Sanders and Frykberg types II-V), who underwent reconstructive arthrodesis of the mid- and/or hindfoot. Patients were retrospectively enrolled 4.5 years postoperatively (range 1.8–11.2 years). All patients showed at least two out of five positive Pinzur high-risk criteria (immuno-compromising illnesses, large bone deformity, longstanding ulcer overlying infected bone, regional osteopenia, obesity). Follow-up included a detailed clinical analysis and radiologic assessment with emphasis on complication analysis and evaluation in accordance to the PEDIS classification system.

Results

Significantly lower overall complication rates, as well as re-operation, reulceration and amputation counts were found for patients with a cumulative PEDIS count below 7. For PEDIS single criteria, significantly lower overall complication rates were found for patients without signs of occlusive peripheral artery disease, an ulcer extent <0.9 cm², ulcer depth including erosion and inflammation of the skin and subcutaneous tissues only. Soft-tissue complications affected 49 % of patients, hardware breakage 33 %, hardware loosening 19 %, non-union 18 % and amputation 21 %. Radiographs revealed a correct reconstruction and restoration of all foot axes postoperatively with partial recollapse at the lateral foot column; however, fixation strength for the medial column was maintained.

Conclusions

Internal corrective arthrodesis for patients within the deformed stages of Charcot deformity can provide adequate reconstruction, as assessed by intraoperative radiographic measures, that exhibit superior long-term stability for the medial column. Despite a high risk patient population, a favourable outcome in terms of overall complication, re-ulceration, and amputation rates for patients/feet with a cumulative PEDIS count below 7 was found. The cut-off value of 7 may aid clinical decision-making during preoperative planning for Charcot deformity.

Resection Arthroplasty for Resistant Ulcers Underlying the Hallux in Insensate Diabetics

BACKGROUND

Foot ulcers carry considerable morbidity in patients with peripheral neuropathy and frequently lead to foot amputation. The purpose of this study was to present our experience treating recalcitrant ulcers underlying the hallux interphalangeal joint in patients with diabetes mellitus (DM)-related neuropathy with a first metatarsophalangeal (MTPJ1) resection arthroplasty.

METHODS

We retrospectively reviewed the computerized medical files of patients with diabetic neuropathy treated with a MTPJ1 resection arthroplasty. We performed 28 arthroplasties on 20 patients with a mean age of 59 years. The patients had a diagnosis of DM for a mean of 10.7 years. Of the ulcers, 26 were grade 1A ulcers, and 2 were grade 2A ulcers (University of Texas score); the ulcer's mean age was 5.4 months. The mean dorsiflexion of the hallux before surgery was 46 degrees.

RESULTS

The primary ulcer recovered in a mean of 3.1 weeks. Major complications (wound dehiscence and infection) occurred in 6 of 28 operations. Patients returned to normal activity 4 weeks after all procedures except in the 6 patients with dehiscence. In a subgroup of patients with follow-up longer than a year, the ulcer recurred after 4 of 18 arthroplasties (22%) between 3 and 12 months due to postoperative hallux rigidus. In the remaining 14 of 18 arthroplasties (78%), there was no recurrence during a mean follow-up of 26 months.

CONCLUSION

MTPJ1 resection arthroplasty may be considered in a patient with resistant plantar hallux ulcerations, even in the absence of hallux rigidus. As with all operations on neuropathic feet in patients with DM, the surgeon and the patient should be aware that there is a significant likelihood of complications, but most are treatable.

LEVEL OF EVIDENCE

Level IV, case series.

Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates

INTRODUCTION

Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates.

MATERIALS/METHODS

21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis.

RESULTS

A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially.

CONCLUSION

Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.

Intramedullary medial column support with the Midfoot Fusion Bolt (MFB) is not sufficient for osseous healing of arthrodesis in neuroosteoarthropathic feet

INTRODUCTION

To address midfoot instability of Charcot disease a promising intramedullary implant has recently been developed to allow for an arthrodesis of the bones of the medial foot column in an anatomic position. We report on a group of patients with Charcot arthropathy and instability at the midfoot where the Midfoot Fusion Bolt had been employed as an implant for the reconstruction of the collapsed medial foot column.

MATERIAL AND METHODS

A total of 7 patients (median age 56.3 years, range 47-68) were enrolled with severe Charcot deformation at Eichenholtz stages I-II (Sanders and Frykberg types II and III). The medial column was stabilised primarily with an intramedullary rod (Midfoot Fusion Bolt) in stand-alone technique in order to reconstruct the osseous foot geometry. The bolt was inserted in a retrograde mode via the head of MTI and forwarded into the talus. Follow-up time averaged 27 months (range 9-30).

RESULTS

Intraoperative plantigrade reconstruction and restoration of the anatomic foot axes of the medial column was achieved in all cases with the need for revision surgery in 6 out of 7 patients due to soft tissue problems (2 impaired wound healing, 1 postoperative haematoma, 3 early infection). Implant-associated problems were seen in one case intra-operatively with fracture of the first metatarsal shaft and two cases with implant loosening of the MFB and need for implant removal during long time follow-up. Two patients underwent lower leg amputation due to a progressive deep soft tissue infection. One patient healed uneventfully without need for revision surgery. Except for one case recurrent ulcerations were not observed, so far.

CONCLUSION

Medial column support in midfoot instability of Charcot arthropathy with a single intramedullary rod does not provide enough stability to achieve osseous fusion. MFB loosening was associated with deep infection in a majority of our cases. To prevent early loosening of the intramedullary rod and to increase rotational stability, additional implants as angular stable plates are needed at the medial column and eventually an additional stabilisation of the lateral foot column where manifest instability exists at the time of primary surgical intervention.

Prognostic difference between soft tissue abscess and osteomyelitis of the foot in patients with diabetes: data from a consecutive series of 452 hospitalized patients

From January 2008 to December 2010, 452 patients with diabetes were admitted to our diabetic foot unit because of deep soft tissue abscess (group A: n = 210) or chronic osteomyelitis (group B: n = 242). Patients from group A underwent emergency debridement in the operating room. Patients from group B underwent elective surgery. Twenty-six (5.8%) major amputations were performed: of these, 18 (8.57%) were performed in patients from group A and 8 (3.31%) were performed in patients from group B (p = .024). Multivariate analysis showed the independent role on amputation outcome of the abscess (odds ratio, 2.64; p = .029; confidence interval [CI] 1.11 to 6.28), dialysis treatment (odds ratio, 3.17; p = .039, CI 1.06-9.51), and C-reactive protein > 0.5 mg/dL (odds ratio, 3.75; p = .022, CI 1.21-11.64). In group A, 43 (22.6%) patients healed only with drainage, and 147 (70.0%) minor amputations were performed: 53 (36.1%) at the level of the forefoot and 94 (63.9%) at the level of the midfoot. In group B, 234 (96.7%) minor amputations were performed, 208 (88.9%) at the forefoot and 26 (11.1%) at the midfoot level (p < .001). Fourteen postoperative complications occurred in patients from group A and 2 in patients from group B (p < .001). In group A, 3 patients died during hospitalization, 1 from septic shock and 2 from sudden death. None of the group B patients died. This study demonstrates that the severity of a foot soft tissue abscess is not comparable with that of a chronic osteomyelitis not only because of a higher rate of major amputation, but also because of a much more proximal level of minor amputation.

Should one consider primary surgical reconstruction in charcot arthropathy of the feet?

Charcot neuroosteoarthropathy of the feet can induce severe instability and deformity with subsequent plantar ulceration leading to substantial disability or even amputation. Traditionally, nonoperative treatment is regarded as the primary option of treatment while surgery is restricted to treating complications or failure of nonoperative treatment. Failed nonoperative treatment essentially prolongs treatment period. We retrospectively reviewed 22 patients (26 feet) with midfoot (n = 9) or hindfoot (n = 17) neuropathy who underwent primary surgical reconstruction and reorientation arthrodesis due to manifest instability, nonplantigrade foot position, and deformity with overt (n = 8) or what we judged was impending ulceration (n = 9). The minimum followup was 0.5 years (mean, 2.7 years; range 0.5-7 years). All eight ulcers healed without recurrence of ulceration or manifestation of new ulcers during the followup period. We observed complications leading to further surgery in nine patients: five with perioperative hematoma and four with instability. AOFAS scores rose from a preoperative mean of 39 to 70 points (hindfoot cases) and from 51 points to 84 (midfoot cases). Early surgical reconstruction in high-risk patients can provide timely restoration of a plantigrade and stable foot and improved quality of life of the patient at complication rates comparable to those after secondary surgery following failed nonoperative treatment; however we emphasize we had no control group in this small case series for which we could compare nonoperative treatment.

LEVEL OF EVIDENCE

Level IV, therapeutic study (case series). See Guidelines for Authors for a complete description of levels of evidence.

Percutaneous flexor tenotomy for treatment of neuropathic toe ulceration secondary to toe contracture in persons with diabetes: a systematic review

Percutaneous flexor tenotomy has been proposed for treatment of neuropathic toe ulcerations secondary to toe contracture in persons with diabetes who have failed ongoing local wound care measures due to the perceived safety and efficacy. Because this patient population comprises a substantial proportion of the authors' practice, we undertook a systematic review of electronic databases and other relevant sources to identify material relating to the use of percutaneous flexor tenotomy for the treatment of neuropathic toe ulcerations secondary to toe contracture deformities in persons with diabetes. Information from peer-reviewed journals, as well as that from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was considered. In an effort to procure the highest-quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing the same percutaneous surgical treatment, evaluated patients at a mean follow-up of > or =12 months' duration, and included details of complications. Two studies were identified that met the inclusion criteria, both of which were retrospective case series of relatively poor methodological quality. Rather than providing strong evidence for or against the use of percutaneous flexor tenotomy for the treatment of neuropathic toe ulceration secondary to toe contracture in persons with diabetes, the results of this systematic review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.

LEVEL OF EVIDENCE

1.

A 1-piece shape-metal nitinol intramedullary internal fixation device for arthrodesis of the proximal interphalangeal joint in neuropathic patients with diabetes

A common complication associated with diabetes is the development of a rigid structural lesser toe contracture, which, when combined with peripheral sensory neuropathy, can lead to ulceration, infection, and amputation. Surgical correction of lesser toe contractures in persons with diabetes has been advocated to decrease the potential for ulceration and amputation. Lesser toe proximal interphalangeal joint arthrodesis employing myriad joint preparation and fixation methods is commonly performed to correct a rigid structural toe contracture. The author performed a retrospective, observational, cohort study involving 10 patients (30 toes) with diabetes, dense peripheral neuropathy, and rigid structural toe contracture treated with a 1-piece shape-memory Nitinol intramedullary internal fixation device for arthrodesis of the proximal interphalangeal joint. Successful fusion was achieved in 28 of 30 toes (93%), with a stable nonunion achieved in the remainder. Complications that arose occurred early in the author's experience with this implant and consisted of secondary contracture of the distal interphalangeal joint (23%), displaced fixation (13%), and malunion (7%). No patient developed ulceration, and no additional surgery has been required to date. When properly performed, the use of this implant for arthrodesis of the proximal interphalangeal joint in neuropathic patients with diabetes appears safe and reliable.