Forefoot Procedures to Heal and Prevent Recurrence. Watermark. Diabetic Foot Update 2015 San Antonio, Texas

Transcription

1 Forefoot Procedures to Heal and Prevent Recurrence Diabetic Foot Update 2015 San Antonio, Texas J. Randolph Clements, DPM Assistant Professor of Orthopaedics Virginia Tech- Carilion School of Medicine Roanoke, Vriginia

2 Goals of Surgery Goals: Surgically Offload the wound Is prophylactic diabetic foot surgery dangerous. Armstrong et al 31 patients, 96% ulcers healed, no recurrences within first year, 14% postoperative infections By ulcer location Distal tip of toe Dorsal toe IPJ Plantar lesser met head Plantar 1 st met head Plantar midfoot Plantar heel

3 Goals of Surgery Increase joint motion where it is limited Reducing abnormal pressure points Repairing structural foot deformities when they are an underlying cause of ulceration Preventing the First of Recurrent Ulcers, Lavery et al

4 Why Patients Ulcerate, Where they Ulcerate Distal Tip Dorsal IPJ Distal Tip Dorsal IPJ Plantar IPJ Lesser Toe Hallux What Are the Options? Flexor Tenotomy Resection Arthroplasty HIPJ Fusion vs?fhl tenotomy IPJ Fusion Keller Resection Arthroplasty

5 Causes Hammertoe, Clawtoe Treatment Flexor Tenotomy Distal Tip Ulcer Safety and effectiveness of flexor tenotomies to heal toe ulcers in persons with diabetes. Kearney et al 48 patients with 58 tenotomies, 98.3% healed with mean time 40 +/- 52 days, 12.1% recurrence, 5% post-operative soft tissue infections, Mean follow up 28 months

6 Flexor Tenotomy Technique The flexor digitorum longus is placed under tension ( bowstringing ) by positioning the affected toe in hyperextension. A 3mm incision is made at the middle of the proximal phalanx, and the tendon is cut. All stab wounds are sutured and a pressure bandage is applied for the first days. The patient is examined at 1- week, and subsequently followed-up at regular intervals.

7 Week 1 Week 2

8 Is IPJ Fusion better?

9 Dorsal Toe IPJ Ulcer Causes flexible and rigid hammertoe Treatment flexor tenotomy, digital arthroplasty

10 Plantar Hallux IPJ Ulcer Causes - hallux limitus/rigidus, equinus Treatment - Keller arthroplasty Clinical efficacy of the first MTPJ arthroplasty as a curative procedure for hallux IPJ wounds in persons with diabetes. Armstrong et al 41 patients 21 surgical tx faster healing and fewer ulcer recurrence at 6 month follow up surgery group healed faster than pts in the standard therapy group (standard / versus surgery /- 9.9 days), had fewer recurrent ulcers (standard 35.0 versus surgery 4.8%)

11 DPH Hallux 65 degrees PHP Ground

12 Hallux Limitus/Rigidus 1 st MPJ cannot range 65 degrees of DF DHP PHP Ground

13 Hallux Limitus/Rigidus 1 st MPJ cannot range 65 degrees of DF DHP PHP Ground

14 Plantar Lesser Metatarsal Head Ulcer Cause prominent metatarsal, equinus, abnormal parabola Treatment TAL, metatarsal head resection

15 Plantar Lesser Metatarsal Head Ulcer TAL - Silfverskiold exam, Root defines 10 degrees ankle dorsiflexion as normal Effect of Achilles tendon lengthening on neuropathic plantar ulcers. Mueller et all 64 pts, immobilization in a TCC alone or combined with TAL 88% of ulcers in the TCC group and 100% in the TAL group healed after 41 +/- 28 days and 58 +/- 47 days, respectively Risk for ulcer recurrence was 75% less at seven months and 52% less at two years than that in the TCC group

16 Plantar Lesser Metatarsal Head Ulcer Clinical efficacy of the pan metatarsal head resection as a curative procedure in pts with DM and neuropathic forefoot wounds. Armstrong et al 92 pts with diabetes (66.3% male), with ulcers classified as University of Texas grade 1A or 2A at the plantar aspect of the forefoot Surgery group healed faster than those in the standard therapy group (60.1 ± 27.9 days versus 84.2 ± 39.9 days, respectively Surgery group had fewer recurrent ulcers (15.2% for surgery group and 39.1% for conservative therapy)

17 Plantar Lesser Metatarsal Head Ulcer Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration. Armstrong et al Retrospective cohort model, 40 pts (22 cases and 18 controls). Surgical group healed faster (mean +/- SD, 5.8 +/- 2.9 versus 8.7 +/- 4.3 weeks). Less likely to reulcerate (4.5% versus 27.8%).

18 Plantar Heel Ulcers Causes Over Achilles lengthening, Pressure Treatment Partial Calcanectomy, Achilles repair Tendon transfer A retrospective assessment of partial calcanectomies and factors influencing postoperative course. Cook J et al Reviewed 50 cases of pts treated with partial calcanectomy for chronic plantar heel ulcer. Total closure was 51% to 83% at one year.

19 Plantar Heel Ulcers FHL tendon transfer in diabetics for treatment of non-healing plantar heel ulcers. Kim JY et al Evaluate results of FHL tendon transfer for management of a plantar heel ulcer as a sequelae of insufficiency of the Achilles tendon in nine diabetic patients. Duration of a plantar heel ulcer was /- 3.8 months. Following sx all healed within 8 weeks.

20 Thank you