Nicholas J. Bevilacqua, DPM details the role of "pressure" in diabetic foot pathology. Dr Bevilacqua reviews the importance of identifying pathological mechanisms and offers conservative vs surgical treatment options. He provides evidence based medicine articles to substantiate decision making and ends the lecture with podiatric specific case scenarios.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Nicholas Bevilacqua, DPM
North Jersey Orthopaedic Specialists
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Male Speaker 1: While we’re converting now over from our basic sciences and our conservative methods, I think it’s very important to give you an overview of surgical principles and indications, cautions, precautions in the diabetic foot. I’ve asked none other than Nick Bevilacqua from beautiful downtown Teaneck, New Jersey to come and speak to you on a subject that’s near and dear to his heart. I’ve known Nick for 4 or 5 years. I guess Nick trained over here at the New York School, did a fellowship with the Rosalind Franklin School, practiced for a brief while in Des Moines, then in Los Angeles, and then his wife dragged him back to Teaneck. Here he is. He’s a podiatrist with the North Jersey Foot and Ankle Associates, and well versed in diabetic foot surgery. So, let’s welcome Nick Bevilacqua. Okay, Nick, 15 minutes.
Nick Bevilacqua: Alright, good evening. Thank you all for having me. Give yourselves a pat on the back for being here this late in the evening on a beautiful July day. My topic this evening is going to be Diabetic Foot Surgery. Let me see if this clicker works here. There we go. I’ll start off with a quote from Charles Horton Cooley who said, “Position yourself well enough, and circumstances will do the rest”. I really think this rings true when dealing with the diabetic foot ulcer. Dr. Hark [Phonetic], he spoke about the VIPs of wound healing. V is vascular. I is infection. P is pressure. Pressure management and pressure mitigation is going to be the topic of this talk. But if you properly identify patients that have compromised limb perfusion, and if you take the pros away from Dr. Joseph’s [Phonetic] talk yesterday in identifying treat infection, then we’re left with a simple neuropathic wound. Then, it becomes the situation where we just have to identify deformities, accommodate or treat them. We don’t want to end up like this guy. As you can see in the video here, he obviously didn’t follow the VIPs. We don’t want to get stuck in the face like this.
Male Speaker 3: Keep [Indecipherable] [02:26].
Nick Bevilacqua: That’s right. Dr. Frykberg talked about the etiology of diabetic foot ulceration and get right where he described the critical triad. Basically, we’re looking at all the component causes of an ulcer, the three most common that lead to a pathway in the evolution of an ulceration or deformity. Repetitive stress, that could be ill-fitting shoes, that could be just the repetitive trauma of walking and then neuropathy. I’ll get the hang of this. It stands for reason that as the number of deformities increase the pressures on the plantar aspect of the foot will increase as a result. Here, you can see, this is just a simple static image of a spike in pressure beneath the fifth metatarsophalangeal joint. You can see how that correlates clinically. That’s exactly where that patient has skin breakdown, right at that peak plantar pressure. It’s important to, first, identify any deformities and understand where the Ps in pressure are. Here’s a picture. This is actually a weightbearing radiograph. I sent this patient down for x-rays and at first glance, I thought the x-ray tech made a mistake. It’s not a weightbearing film. But if you look, he has such a severe equinus deformity that pulling on Achilles, where his heel never touches the ground. We see that when we look at a dynamic pressure analysis. This is looking at him, walking on a gait plate. You can see that spike in pressure. At first glance, it looks normal. You think where that heel contact, that’s where that spike in pressure is. But if we look at it closely and one more time, you see here, he rocks back. His heel never touches the ground. That spike in pressure is actually beneath his cuboid. It makes sense. That’s exactly where he has that lesion, right underneath that spike in pressure. Once we’ve identified the deformity, then we have to institute a pressure reduction plan. We can do that extrinsically or externally with different types of padding, bracing and shoes. Or intrinsically, and that’s going to be the focus of this talk, the internal or intrinsic offloading diabetic foot surgery. Just one quick slide, the methods to offload, we have a whole list of them. Dr. Frykberg mentioned the gold standard by far is the total contact cast. Total contact cast does not address the underlying deformity, so it’s not uncommon that these wounds heal. Patients go back into their shoes and then they reulcerate. The reulceration rate after two years approaches 75 or 80 % even with a total contact cast.
Always remember, obviously, that there’s a person attached to the foot and you have to take the whole clinical patient into scenario. If we look at the surgical options that we have, basically, the goals of diabetic foot surgery, first and foremost, you’re going to address the underlying deformity. If we perform it in phase of an open wound, we’re going to perform the surgery to help augment healing. Or, we may do it prophylactically, and we’re going to the different classifications of diabetic foot surgery to help prevent ulcer formation and ultimately want to increase function. I stole a quote from Sycum [Phonetic], plus he’s a biomechanist, and this was in a lecture at DEF CON in 2010 and I think this quote really sums up this talk, “Healing plantar ulcers is not considered most difficult, keeping ulcers healed is.” I think that’s where addressing and correcting the underlying deformity that’s causing the increased in pressure, that’s causing the skin breakdown is the biggest benefit of surgical management in this population. Again, you have a patient. This is a clinical scenario where they have this mild bunion deformity. They have this hammertoe. Often times, you see the callus, dorsal aspect, PIPJ, callus equals pressure. How do we address this? We can accommodate the deformity. You can use a specialized or noncustom shoe that has that forgivable material to help disperse the pressure. Severe deformity sometimes require custom shoes or we can intrinsically correct the deformity and internally offload the area. If we go back to that critical triad that was described earlier, the trauma unfortunately is still going to be there. They’re got to walk and they’re going to wear shoes. Neuropathy, at this point unfortunately is irreversible, but what we can do is we can address the deformity. Potentially, we are removing a very common component cause leading to the pathway of ulceration. I mentioned the diabetic foot surgery classification. This was described by Dr. Frykberg himself with Dr Armstrong, and they basically just broke it down into four different classes. You can see here, class I is elective surgery. This is performed in a patient that has diabetes, but they have intact sensation. Class II, very common, prophylactic surgery, these are patients with diabetes. Obviously, they have a deformity and they also have neuropathy. Class III is the same, but they actually have an open wound. Class IV is more of an emergent situation, requiring emergent incision and drainage which sometimes leads to amputation. This was a validated classification system. It makes sense that as we go higher up in the class, the risks increase, and the risk of infection, amputation and reulceration as you go higher up in the class. Just to point out, I’m going to talk about some of the most common deformities that we see with some of the procedures that we can use to address the deformities. But, a lot of these procedures can be used in different classes of the classification system. For example, we showed that hammertoe and the bunion. Let’s just take the hammertoe. For example, if you do an arthroplasty, patient has neuropathy, that’s prophylactic. If they have an ulceration, distal tip of the toe, you do an arthroplasty, that would be a curative class III surgery. The procedures can move throughout the different classes. I just want to bring up this study. This is a large retrospective review and of UPMC Dane Wukich who's a very busy foot and ankle surgeon, orthopedic surgeon, and he just looked at 1000 patients, looked at a whole host of different variables. I’ll just boil it down to the main crux of the study. Overall infection rate, 1000 cases, 4.8%. When he broke it down, he looked at half the infections occurred in the patients with diabetes and that only constituted of almost 20% of the total surgical population. When he further broke it down, he had a postop infection rate in those with diabetes, 13.2% versus those without, 2.8%. That’s pretty common in the clean elective orthopedic foot and ankle surgery, expect about a 2% postop infection rate. Then when he further broke down the results, we see that people or patients with uncomplicated diabetes, so complicated versus uncomplicated, in this case is going to be those with neuropathy and without. Those that had diabetes that did not have neuropathy, they were at no increased risk for postop infection as compared to those without diabetes. That’s in contrast to patients with complicated diabetes, in this case, neuropathy. They had a significantly higher rate of postop infection. It’s really the neuropathy that’s the strongest predictor of postop infection in this population. We’ll just go through some clinical examples here. This was a patient, had sort of like that pre-ulcerative lesion, dorsal aspect, proximal at the phalangeal joint.
We just addressed that with an arthroplasty, with a second metatarsal head resection. I bring this case up in example because this patient had undergone a contralateral below-knee amputation two years prior. It actually all started off with a digital ulceration that became infected. He had a transmetatarsal amputation that did not heal, and it went on to a below-knew amputation. He actually came into the clinic and was requesting surgical management to avoid the situation that he had dealt with two years prior. Another simple example of a prophylactic diabetic foot surgery, it’s just a simple bunion. This is a lady with diabetes neuropathy. Obviously now, she’s getting potential skin breakdown based on the types of the shoes that she wears. So simple Austin bunionectomy, in this case, corrected the underlying deformity. Curative foot surgery, this is class III. This is patients now that have a wound, so the goal of surgery is to identify, eliminate the deformity, help augment healing. Also, I think more importantly, prevent ulcer recurrence. This was just a paper out of Italy, Piaggesi and colleagues. He just compared the effectiveness of surgical versus nonsurgical management in noninfected neuropathic wounds. Surgery basically consisted of exostectomies versus just a regular wound healing. Modalities, healing rate was higher, healing time shorter. He actually had less infective complications because you think about these wounds that are just there being treated nonsurgically. The longer they are open, the longer they are present, the greater the risk of infection. Then, which is again, very important, fewer recurrences in the surgical group. So, they concluded that surgical treatment is a viable option in this patient population. Another common clinical scenario that we see, often times, patients present with this ulceration on the plantar aspect of the hallux. They have limited joint mobility during toe off. They’re getting extra pressure right at the distal tip of the toe. This patient, very often, we see this, he was put in a removal device, the ulcer actually healed. He went back to work in his normal shoes and it recurred, and this went on and on for a few years. Then finally, we decided to surgically address it. This was just a simple Keller arthroplasty, remove the base of the proximal phalanx. Then you can see here, we internally create greater range of motion nearby, offloading the distal tip of the hallux. Often times, these patients are put in a postop shoe when they come in for suture removal, often times the wound is healed. But more importantly, they go back to their normal footwear and they stay ulcer free. Again, just to remind us with that critical triad. We have the potential to eliminate one of the essential components or an important component of an ulcer formation. This was looked at by David Armstrong. He looked at, basically, these hallux ulcerations and surgical versus nonsurgical treatment in the surgical group, more rapid healing, fewer reulcerations. Flexor tenotomy, that’s an option, a little bit less invasive. These are patients that have the rigid hammertoes or even a hallux limitus, maybe not the ideal surgical candidate. This was an example, 47-year-old female. She had this chronic nonhealing wound on the hallux. You can see here now the picture of health. We just did in the office, in the clinic, she had obviously dense peripheral neuropathy, didn’t have any pain sensation, we just did a flexor tenotomy. This was looked at, recently published actually about six or seven years ago now, Foot and Ankle International. They looked at 28 toe ulcerations in 18 patients and this was lesser toes and great toes, and all the ulcers healed with no infections. There were three recurrences and they just repeated the tenotomy, so it is a viable option. You can see here, this was performed on just a second digit. This hammertoe, we’re not doing this for cosmesis. We’re just releasing the flexor tendon, internally offloading it, removing pressure away from that ulceration, allowing it to heal. Equinus deformity, now, we talked about some of the deformities that are pretty obvious, bunions, hammertoes, we’ll get into a little bit of Charcot. But, equinus is often overlooked, so it’s important whenever you evaluate these patients always assess range of motion, primarily at the ankle. We know that patients with diabetes, there’s a greater risk of equinus. You can see here, just the radiographic, this is the case I showed earlier, the endstage results of equinus. He had a Charcot deformity with that midfoot breakdown. The way we can address this, this is a simple triple hemisection originally described by Hoke. Basically, what we’re doing, three percutaneous incisions and we’re getting an accordion style lengthening. Here’s just a quick video. If it’s done by itself, usually the patient prone, it takes about two or three minutes. Most often, it’s performed in combination with either an exostectomy or a larger reconstructive case. You can do it supine, have the assistant hold the leg up. It’s basically 50% transection and a slow dorsiflexion, shouldn’t have the foot hit the anterior leg. Then will protect them for about a month or so, either. Often times, when we use this removable device, we render it irremovable with Coban. It’s been shown to reduce the plantar forefoot pressures and increase range of motion. Really, what it’s also doing is just weakening the posterior muscle group, so when they’re in the propulsive phase or gait there’s less pressure under the forefoot there. This is just an example, pre and post. Good wound care, understanding they have good blood flow, there’s no infection, and then you address the underlying deformity. This is kind of the landmark paper that really, again, tells us the importance of addressing the underlying deformity. This was Mike Mueller. He looked at 64 patients. This was a prospective randomized trial looking at patients with this chronic nonhealing forefoot wounds plantarly. Basically, it was randomized. One group was treated with just internal contact cast. The other group was treated with a total contact cast with a tendon Achilles lengthening. Initially, I don’t think the results were surprising. This is really just the benefits of the total contact cast. You can see that you got 100% and even almost 90% in just the total contact cast. I think the take home point of this study was the ulcer recurrence. Look at seven months, 59% versus 15, and two years, 81% versus 40%. This really brings home the importance of recognizing and treating the actual deformity that’s causing that pressure, that’s causing that skin breakdown. Complications, obviously, I said it was a simple procedure but it still has to be performed carefully. You don’t want to just recklessly lengthen the tendon where you can over lengthen it and get calcaneal gait or sometimes the patient’s are a little too active. Afterwards, they can rupture through it and they get the calcaneal gait which leads to an ulceration. Often times, this wound is a lot more difficult to heal than the plantar forefoot ulceration that you had. Sometimes, we’ll thrust this a little bit more proximal at the myotendinous junction. We’ll do a gastrocnemius recession. This was just an example of a patient who had this flexible plantarflexed first ray. Contemplated doing either a Jones tenosuspension to him and a dorsiflexory wedge osteotomy. Figure, let’s just do the gastroc recession. Here is at seven weeks or two weeks, seven weeks, and he actually remains ulcer free. This is the last photo in two years afterwards. Don’t forget, radiographs, sometimes you can have those anterior osteophytes, which cause that abrupt stop in range of motion. This was just treated with simple cleaning out the osteophytes. Often times, central ray or metatarsal head resections are valuable in addressing that sub-two or sub-three lesion. What happens, you can always have a complication of a transfer lesion because you’re disrupting that parabola. Usually, if you do, let’s say an isolated second metatarsal head resection and they breakdown underneath the third, rather than continue to chase the lesion and then run the risk of having an ulcer underneath the fourth, often times we’ll go straight to sort of like this panmetatarsal head resection, two through five there. You can combine that with some soft tissue work, whether it’d be addressing equinus with TAL or gastroc, and this has been shown to work well as well. I’m just going to finish up with some examples of Charcot. I’m going to give a little bit more of a detail talk on the Charcot foot later. For this talk, let’s just focus on it just being a severe deformity. This was a 43-year-old gentleman. He had diabetes for 15 years, unstable midfoot. He actually did have an ulceration, which healed and we decided to treat him surgically before the ulcer came back because this was we felt was unstable. Goals of Charcot reconstruction are the same as any type of diabetic foot surgery. You want to decrease the pressure. You want to get a plantar grade foot, augment healing, prevent ulcer formation, and ultimately, ulcer recurrence. Just a couple of quick slide showing the deformity. Again, this is the dynamic pressure analysis. We can see just like that previous patient I showed you, that spike in pressure underneath the cuboid, we addressed this basically at the apex of the deformity. Classic rocker bottom is the classic late stage deformity or the Charcot midfoot breakdown. Often times, a biplane or wedge is performed where we want to try to plantar flex and adduct that forefoot segment there. This is just comparing sort of that pre and post. Dr. Leport [Phonetic] is going to go into more of the pearls on Charcot reconstruction. I just want to show you, this is how we sort of internally offload. If we look here in six months remains ulcer free. But if we look at the pressure analysis, pre and post reconstruction, we can see how we have this spike in pressure here. Look how we completely offloaded that lateral plantar part of his foot, beneath the cuboid that had that ulceration in the past. Theoretically, we internally or intrinsically offloaded that foot.
Just one more example of Charcot, this is a 52-year-old and this lady actually had a wound. This is now class III. This is a curative foot surgery to help augment healing and also prevent ulcer recurrence. This lady had wounds on and off for seven years. She’s been in and out of the wound care center’s, hyperbaric oxygen, but she had this midfoot deformity there, that plantar prominence causing pressure. This is just to give you sort of a comparative normal foot x-ray. We can see that plantar prominence. When they walk, it breaks down usually beneath that cuboid laterally. Again, just like the last case, you addressed this at the apex of the deformity biplane or wedge. We used external fixation just because there was an open wound. Here, she’s at three years. Again, you’re not doing this for cosmetic reasons. The goal is plenary of foot free of any bony prominences. She is able to actually ride her bike 50 miles a week, so she’s been able to sort of restore some of her previous lifestyle. Then, we’ll just finish off with two examples of just Charcot ankle. Charcot ankle, there’s really not a place for conservative management. Very unstable deformities, your body doesn’t tolerate severe valgus or varus in this case. This lady actually had a history of that chronic on and off ulceration beneath the distal fibular. The weightbearing, you could see severe cavus deformity. In this case, we just did an ankle fusion and we were able to reduce that varus malalignment. That’s an example of a prophylactic surgery because she was also free at the time. We can very well have a curative surgery. This is a lady, same situation, varus ankle, had that chronic nonhealing wound, same thing. In this case, osteomyelitis distal fibula, we actually resected it and then just did a tibiotalocalcaneal fusion using now for this case. But again, you’re just addressing the underlying deformity to allow the ulcer to heal and then hopefully prevent ulcer recurrence. In summary, again, always step back, address the VIPs of wound healing, vascular infection, pressure. Identify the deformity, either accommodated, treat it aggressively. Dr. Frykberg said, never let them leave the office in the same shoe wear that they came in with. Often times, it’s either a total contact cast or an instant total contact cast, that’s a removable device rendered irremovable. Then consider the surgical options to augment healing. Also, be realistic with the goals of the surgery, realistic with yourself and also to the patient. Prepare for complications especially for patients with neuropathy have increased risk of postop infections and is always a team approach. Thanks.