A Decade of Limb Salvage Surgery. learning lessons afterwards

Transcription

1 A Decade of Limb Salvage Surgery. learning lessons afterwards PROF. DR. JOSÉ LUIS LÁZARO-MARTÍNEZ DIABETIC FOOT UNIT UNIVERSIDAD COMPLUTENSE DE MADRID (SPAIN)

2 7 Minutes

3 Surgery in Diabetic Foot Recognized Benefits Unquestionable utility on management of DFU Main role in debridement, treating infection and reconstruction Limitations Performing by different specialities (Vascular, orthopaedic, plastic, general, podiatric surgeons and others) Absence of specific techniques Unclear indication, prognosis and associated complications

4 Different Surgeries: Different Prognoses Emergency Surgery Conservative Surgery

5 Frequency of location of DFUs 23% 14% 19% 22% 19% 80%-90% of the DFUs are located on the Forefoot 9% 1%

6 Misdiagnosis and banalization of some DFIs

7 Guía IDSA 2012 Infección Pie Diabético Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, Pinzur MS, Senneville E,.2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Infectious Diseases Society of America. Clin Infect Dis Jun;54(12):e doi: /cid/cis346.

8 Is Conservative Surgery a new concept? No, It isn t Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. 9: , 1911 Griffiths GD, Wieman TJ.Metatarsal head resection for diabetic foot ulcers. Arch Surg Jul;125(7):832-5.

9 Main Issue regarding surgery: Recurrence and/or reulceration Rates for ulcer recurrence, we estimate that roughly 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years

10 Conservative Surgery If you've never swum, don t dive into the pool

11 Lesser Toes Dorsal Distal/Plantar Arthroplasty (Primary Closure) Distal Phanlangectomy / Tenotomies (Primary Closure) Dorsal Arthroplasty (Primary Closure) DFUs Location First Toe Plantar/Distal Sesamoidectomy Arthroplasty/Phalangectomy (Primary Closure) Exostectomy/Phalangectomy (Secondary Closure) Beneath First Metatarsal Queilectomy of first metatarsal head Metatarsal head resection Beneath Lesser Metatarsal Fistulous Track Open wound Dorsal Head Resection Plantar Head Resection

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13 Conservative Surgery: Toe Lesions Tenotomy (Flexible toe deformities): Flexor tenotomy for distal ulcer and/or calluses Arthroplasty (Rigid toe deformities ): Removal interphalangeal joint for hammer or claw toes.

14 Consideration before Flexor Tenotomies Pathophysiology of lesser toes deformities Flexor stabilization Flexor digitorum longus or brevis gains advantage over the interossei Pronated foot Flexor substitution Flexors gain an advantage over the interossei Supinated foot Extensor substitution EDL gains an advantage over the lumbricales Cavus foot Coughlin MJ, Mann RA, Saltzman C (eds.) Surgery of the Foot and Ankle. Eighth edition. Mosby, St. Louis, 2011.

15 When you are performing toe tenotomies caused by a extensor substitution Sanz-Corbalán I, Lázaro-Martínez JL, García-Álvarez Y, García-Morales E, Álvaro-Afonso FJ, Molines-Barroso R. Digital deformity assessment prior to percutaneous flexor tenotomy for managing diabetic foot ulcers on the toes. Journal of Foot & Ankle Surgery. Acceptep paper. August 2018.

16 Conservative Surgery : Metatarsal Bones Resection More frequent procedure for managing Osteomyelitis beneath Metatarsal Head Considered as Offloading surgery in patients with rigid foot deformities or low compliance of offloading treatment High risk of developing a new ulcer

17 Risk for Recurrences and Reulceration Recurrences rates range from 30% to 50% according to time of follow-up Ghanassia E, Villon L, Thuan Dit Dieudonne JF, Boegner C, Avignon A, Sultan A. Long-term outcome and disability of diabetic patients hospitalized for diabetic foot ulcers: a 6.5- year follow-up study. Diabetes Care. 2008;31: Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26: Cavanagh PR, Boulton AJ, Sheehan P, Ulbrecht JS, Caputo GM, Armstrong DG. Therapeutic footwear in patients with diabetes. JAMA. 2002;288:1231

18 69 % HR 3,307

19 The optimal cutoff point between +11 mm (sensitivity = 84.6%, specificity = 86.7%) and 7mm (sensitivity = 81.8%, specificity = 65.4%) is associated with higher risk for reulceration

20 Resection rate of metatarsal (RRM) of less than 25% is associated with the development of a recurrence

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22 Participants with first segment amputation and one other amputation showed an association with the probability of reulceration in comparison with any other specific type of minor amputation.

23 Prognostics factors Level Number Location Molines-Barroso RJ, Lázaro-Martínez JL, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Klepzig JL, Aragón-Sánchez J. Validation of an algorithm to predict reulceration in amputation patients with diabetes.int Wound J Aug 9. doi: /iwj [Epub ahead of print]

24 Metatarsal Head Resection Metatarsal Head Resection is a very common procedure Not without consequences High risk of recurrence Important Biomechanical knowlegde An other osteotomy.? A transmetatarsal amputation.? What is more effective in the long term?

25 Outcomes of TMA 77% functional at 1 year Follow-up

26 Pre-surgery Post-surgery

27 Conservative Surgery: Panresection Lázaro-Martínez JL, Aragón-Sánchez J, Alvaro-Afonso FJ, García-Morales E, García-Álvarez Y, Molines-Barroso RJ. The best way to reduce reulcerations: if yo understand biomechaniscs of the diabetic foot, yo can do it. Int J Low Extrem Wounds Dec;13(4):

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29 A solution?: Filling out the gap..

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32 Conclusions Biomechanical mandatory assessment before surgery is Planning a proper technic, do not think in ulcer closure, do think in the risk of recurrence and re-ulceration Metatarsal Head Resection has got the higher risk for recurrences in forefoot diabetic surgery Needing for specific training in diabetic foot surgery

33 13 times Champions League Winners THANKS FOR YOUR ATTENTION