Digital Deformity Assessment Prior to Percutaneous Flexor Tenotomy for Managing Diabetic Foot Ulcers on the Toes

Long Term Outcomes After Flexor Tendon Tenotomy of the Diabetic Foot

Background

Hammertoes is one if not the most common deformity that afflicts the diabetic foot and leads to increased risk of diabetic foot ulcers. Flexor tendon tenotomy treatment of the diabetic hammertoe has gained increased interest and is now recommended in international guidelines as a treatment of hammertoes to prevent diabetic foot ulcers. There is however no published data on the long term outcomes following tenotomy treatment.

Introduction

The objectives of this study was to describe the demographics and long-term outcomes following tenotomy treatment of individuals with diabetes who had flexor tendon tenotomies of hammertoes performed between 2006 and 2009.

Methods

This was an observational study of a cohort from a prior study. The study was performed at Steno Diabetes Center Copenhagen between 1st of January 2020 and 31st of June 2020. Participants from the prior study were invited to join the study, consisting of one visit where foot examination was performed by orthopedic surgeon. Information on medical history was obtained from medical records.

Results

Of the original 38 operated participants, 21 (55.3%) had died during the follow-up period, one (2.6%) had moved away, and one (2.6%) had incorrect procedure performed originally. At follow-up (mean 149.7 months (±17)), age of the remaining 15 participants (86.7% male) was 66.6 years (±11.4), diabetes duration was 32.2 years (±13.3), all had neuropathy and 14 (93.3%) had palpable foot pulses. The 15 Included participants had 22 toes tenotomized in the original study, of which five toes (22.7%) in four participants (26.7%) had recurrent hammertoe deformities. Of the 15 participants, 14 (93.3%) had incurred at least one ulcer during the observation period, and eight (53.3%) had incurred an amputation.

Conclusion

This study reports an undescribed risk of recurrence of deformities after tenotomies and supports that this population is at high risk of new ulcers, amputations, and have a high mortality rate.

An overview of current developments and methods for identifying diabetic foot ulcers: A survey

Diabetic foot ulcers (DFUs) present a substantial health risk across diverse age groups, creating challenges for healthcare professionals in the accurate classification and grading. DFU plays a crucial role in automated health monitoring and diagnosis systems, where the integration of medical imaging, computer vision, statistical analysis, and gait information is essential for comprehensive understanding and effective management. Diagnosing DFU is imperative, as it plays a major role in the processes of diagnosis, treatment planning, and neuropathy research within automated health monitoring and diagnosis systems. To address this, various machine learning and deep learning‐based methodologies have emerged in the literature to support healthcare practitioners in achieving improved diagnostic analyses for DFU. This survey paper investigates various diagnostic methodologies for DFU, spanning traditional statistical approaches to cutting‐edge deep learning techniques. It systematically reviews key stages involved in diabetic foot ulcer classification (DFUC) methods, including preprocessing, feature extraction, and classification, explaining their benefits and drawbacks. The investigation extends to exploring state‐of‐the‐art convolutional neural network models tailored for DFUC, involving extensive experiments with data augmentation and transfer learning methods. The overview also outlines datasets commonly employed for evaluating DFUC methodologies. Recognizing that neuropathy and reduced blood flow in the lower limbs might be caused by atherosclerotic blood vessels, this paper provides recommendations to researchers and practitioners involved in routine medical therapy to prevent substantial complications. Apart from reviewing prior literature, this survey aims to influence the future of DFU diagnostics by outlining prospective research directions, particularly in the domains of personalized and intelligent healthcare. Finally, this overview is to contribute to the continual evolution of DFU diagnosis in order to provide more effective and customized medical care.

This article is categorized under:

Risk Factors for Ulcer Recurrence in Diabetic Patients Managed by an Integrated Foot Care Protocol

The aim of our study was to identify risk factors for the recurrence of diabetic foot ulcers (DFUs) in a selected population of patients in secondary prevention treated, according to International Guidelines, with an integrated foot care protocol by a referral diabetic foot clinic. A retrospective study was performed with the inclusion of selected outpatients with diabetes at higher risk for ulceration with a history of previous ulcer and/or amputation followed in our diabetic foot clinic between January 2015 and December 2021. According to the presence or absence of recurrence, patients were divided into 2 groups: ulcer recurrence and without ulcer recurrence. One hundred twenty-seven (127) patients were included, 47 patients (37%) developed an ulcer recurrence while 80 patients (63%) did not. The mean age was 71.7 years; 65% were male; 97% were affected by type 2 diabetes with a mean duration of 21.1 years, the mean HbA1c was 63 + 21 mmol/mol. Both groups of patients had foot deformities, such as claw and hammertoes; hallux valgus, and prominent metatarsal heads (MTHs). The presence of deformity was significantly associated with ulceration. The group with ulcer recurrence showed a higher rate of prominence MTHs in comparison to a group without ulcer recurrence. The MTHs resulted as the only independent predictor for recurrence. This study shows that the presence of the prominent MTH is a significant risk factor for ulcer recurrence in a selected population of diabetic foot patients treated in the best way with integrated foot care.

Safety and Efficacy of Several Versus Isolated Prophylactic Flexor Tenotomies in Diabetes Patients: A 1-Year Prospective Study

Background: To assess long-term clinical outcomes of patients who underwent isolated versus several percutaneous flexor tenotomies for the treatment of toe deformities and previous diabetic foot ulcers; Methods: Twenty-three patients (mean age 66.26 ± 11.20, years) who underwent prophylactic percutaneous flexor tenotomies secondary to tip-toe ulcers participated in this 1-year prospective study. The study was stratified into two groups for analyses: (1) isolated tenotomies patients, and (2) several tenotomies patients (two or more tenotomies). Outcome measures were toe reulceration and recurrence, minor lesions, digital deformities, and peak plantar pressure (PPP—N/cm2) and pressure/time Integral (PTI—N/cm2/s) in the hallux and minor toes after a 1-year follow-up period; Results: Patients with isolated tenotomies (n = 11, 35.48%) showed a higher rate of reulceration (n = 8, 72.7%, p < 0.001) in the adjacent toes, additionally, we found more prevalence of hyperkeratosis (n = 11, 100%), minor lesions (n = 9, 81%), and claw toes (n = 11, 100%) (p < 0.001). In several tenotomies patients (n = 20, 64.52%), we found a higher rate of floating toes (n = 16, 80%) in comparison with isolated tenotomies patients (p < 0.001). PPP and PTI in the non-tenotomy toes were higher in the group of patients who underwent isolated tenotomies (p < 0.001); Conclusions: Patients who underwent several tenotomies had better clinical outcomes after a 1-year follow-up period compared to isolated tenotomies.

Are Digital Arthroplasty and Arthrodesis Useful and Safe Surgical Techniques for the Management of Patients with Diabetic Foot?

OBJECTIVE

To analyze and compare the development of short- and long-term complications in patients with diabetic foot after digital arthroplasty or arthrodesis.

METHODS

The authors reviewed patient records from January 2017 to March 2020. Patients were treated by digital arthroplasty or arthrodesis to correct toe deformity (elective or prophylactic surgery), achieve ulcer healing in toes (curative surgery), or manage toe infection (emergent surgery). During 1-year follow-up, researchers registered short- and long-term complications. Researchers analyzed the association between the type of surgery and the development of short- and long-term complications.

RESULTS

Forty-four patients (83.0%) received arthroplasty, and nine (17.0%) received arthrodesis. The mean time to heal from ulcers was 5.2 ± 5.2 weeks. A significant association was observed between arthrodesis and the development of long-term complications (P = .044; odds ratio, 5.1; 95% confidence interval, 0.9-27.2). No differences were observed between type of surgery and short- or long-term complications. Moreover, both short- and long-term complications were related to longer time to heal (respectively, 7.6 ± 6.0 vs 2.1 ± 0.5 weeks, P < .001; and 6.3 ± 6.2 vs 4.2 ± 4.0 weeks, P = .039).

CONCLUSIONS

Digital arthroplasty or arthrodesis are good options for managing patients with diabetic foot who require digital deformity correction to achieve digital ulcer healing or management of diabetic foot infection in phalanges.

Lesser toe deformity classification: A simplified approach with treatment influence

Deformities of the lesser toes are one of the most commonly treated conditions by foot and ankle surgeons. Despite their frequency, a standardized classification has yet to take hold among providers. Generic nomenclature with the addition of multiple adjunctive descriptors continues to be the standard leading to international confusion. A literature review was conducted to analyze any literature and/or textbooks pertaining to lesser toe deformity classification systems. Seven sources met the inclusion criteria and were analyzed consisting of novel, modified, and previously published systems. A simplified and treatment driven lesser toe deformity classification utilized at the University of Louisville is introduced, which categorizes these deformities into one of two groups. Type 1 deformities are those isolated to the toe only and Type 2 deformities are toe deformities that include metatarsal phalangeal joint involvement. The intent of the University of Louisville Lesser Toe Deformity Classification (LTDC) is to improve communication and documentation, as well as assist surgical planning. LEVEL OF CLINICAL EVIDENCE: 5.

Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations

Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU. Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications. A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot. Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection. When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures. Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.

The effect of needle tenotomy on hammer, mallet and claw toe deformities in patients with diabetes, a retrospective study

Aim

The aim of this study was to evaluate outcomes of needle tenotomies as a treatment option for hammer, mallet and claw toes in patients with diabetes.

Methods

This was a retrospective study where all patients receiving flexor tendon tenotomy by needle at our outpatient clinic were identified through the electronic patient record system.

Results

A total of 81 patients that had 106 tenotomy procedures performed were identified. The 81 included (68% male) had an average age of 65.4 years, and 27 (33%) had Type 1 diabetes. Of the 106 procedures 36 were performed due to an ulcer on the feet. Of the 36 treated ulcers, 34 (94%) healed in an average time of 28 days. Tenotomies performed to prevent impending ulcers from progressing to active ulcers, were performed 84 times in total. Of the 84 procedures 6 patients progressed to an active ulcer. No serious complications i.e. infections or amputations in relation to the procedure were registered.

Conclusion

Needle flexor tenotomies are a relatively safe and effective treatment compared to tenotomies done by scalpel, both as treatment for ulcers and to prevent formation of new ulcers associated with hammer, mallet and claw toe deformities. As a side note, transfer lesions are avoidable if all toes on one or both feet are tenotomized in one procedure.