Suhad A Hadi, DPM discusses the risks and benefits of surgically offloading the diabetic foot and methods to determine that risk. Dr Hadi reviews the JFAS clinical practice guidelines and offers case studies to support her statements.
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Suhad Hadi, DPM
Louis Stokes Veterans Administration
Akron Community Based Outpatient Clinic
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Female Speaker: A little bit nonchalant in regards to we get ulcers healed, we get them healed fast and then when they recur, we tend to resort back to what we did to heal it. I think sometimes we’re starting to forget that there is a place for surgically offloading the diabetic foot. I have no financial relationships or disclosures to give. Some of the learning objectives or points that I wanted you to take home from this talk in giving it today was the actual global impact of diabetes that came up yesterday even in the rumble. But the impact of diabetes is really important. I want us to understand that it’s not something that’s going away in the near future. It’s something that’s going to always be there with us. There are surgical classifications for operating on a diabetic foot. Indications that can help predict your outcomes and help you guide your therapy more effectively. The risks and benefits. Is the surgery safe? What is the psychosocial aspects of doing surgery and the impact on both you and the patient, short and long term? How to identify the proper surgical candidate and how to assess the deformity appropriately? When we talk about the impact of diabetes, just from 2005 to 2011, we’ve seen an over 5 million increase in the number of people with diabetes. We still have a significant number of patients who carry the diagnosis of pre-diabetes or who remain undiagnosed in regards to knowing whether or not they have diabetes. Unfortunately, it’s that population that usually comes into the emergency room with a complication and their diagnosis is made at that time. The total costs are inching towards $200 billion in regards to direct and indirect cost so it is an expensive disease in overall care. When we look at the indirect cost, we have to throw in there the disability, work loss, not just associated to the disease process itself in regards to dialysis needs, retinopathy but also us immobilizing patients and keeping them off of work and keeping them inactive for any prolonged period of time. I really like this statement that Mayer Davidson made in 2007 that there’s a new diabetic patient diagnosed every 21 seconds and ultimately, over 1.5 million patients per year, if you do the math. How does that impact us in our profession in regards to the lower extremity and the risk of amputation and getting these patients healed? We know that 75% of lower extremity amputations are diabetes related, and 85% of those amputations are usually preceded by an ulceration. Again, 82,000 amputations, over 225 a day just in 2005. I received a phone call from a second cousin of mine just before coming to the conference, coincidently appropriate for this talk, that her father was going to have an amputation on Friday. She lives in Toledo. When I asked her what’s going on, she told me that, “Well, he’s been fighting an ulcer for a year. It would heal and open up, heal and open up.” Eventually, he got osteomyelitis and they had to amputate and do a ray amputation. She called to get my opinion. Again, I haven’t seen the ulcer or anything but in the back of my mind, I have to wonder, could something have been done because this patient clearly demonstrated a level of healing potential, could something more aggressively been done to prevent him from moving forward to an amputation. There are surgical classifications for surgery in diabetic patients. Oftentimes, I hear people say, “Oh, we’re doing it prophylactically.” I want us to remember that when we talk about prophylactic surgery, we’re really talking about a patient who has intact integument. The ulceration, if present, has already healed. The wound has already healed. These patients are insensate. When we’re doing surgery, we’re either really doing it in a proactive fashion such as in prophylactic surgery or even curative surgery where there is an ulcer and we know surgical component to the treatment will help ultimately heal it. Or reactive, so these patients come in, they have an abscess. They have infection or gangrene and you have really little choice other than to move forward with surgery. But there is a classification system for surgery and operating in the patients described by Frykberg in the past and Armstrong and it is part of the JFAS guidelines and also will help guide your therapy and give you some concept in regards to what expected outcomes and complications could occur with each class. When we talk about class I surgeries, these are elective surgeries. Oftentimes, I’ll hear residents say, “Oh, I want to fix their bunion prophylactically.” I look into the patient and yeah, the patient is complaining about a painful bunion but it’s a misnomer to say that it’s prophylactic surgery especially if these patients are sensate and they never had ulcer history, never had a problem. It really is your elective case with the painful deformity. There is a population of diabetic patients that will fall strictly under elective surgery. When we’re talking prophylactic surgery, these patients have either had a wound and healed and it’s recurring.
But they ultimately do have their integument intact, the ulceration is healed and you’re planning to move forward with surgery because you want to reduce this risk of recurrence. When we’re talking recurrence and moving forward with surgery, oftentimes, I tell the residents if the patient has to come in every two weeks to debride a postulcerative callus or a hemorrhagic callus that is resulting despite us healing the ulcer, we really need to start moving along the lines about thinking surgically to correct the deformity and that’s when we find patients falling into this prophylactic category. Curative surgery, we do tend to see more surgery done in regards of this category. Patients who have an active ulcer and it really is a deformity that’s still inhibiting the healing, if you check the vascular status and everything is in order for healing, everything points towards the deformity, the caution you need to take with this patient population is that they do have a higher risk in regards to complications compared to the class II category or the prophylactic category. Because they have an active wound, you want to make sure you brought down your bacterial bioburden, want to make sure there’s not underlying infection that’s playing a role in healing or some other factor before you proceed with a procedure that would be curative for this patient and hopefully, ultimately maintaining them in a healed state. The class IV, these are your emergent patients. These are the patients that come in. They’re either pussed out abscess, infection or ischemic component or gangrene and there really is no option other than surgical management. The two I’m focusing on in giving this talk are really your prophylactic and your curative patients, the ones who are falling to category 2 and category 3. But regardless of talking about surgery, you definitely want to understand what the risks and benefits of operating on these patients are going to be, not just for the patient but for yourself as well. Are you approaching this correctly? You want to know how certain the danger is. Again, assess the ulcer fully. Make sure there’s not some underlying component like infection or ischemia that’s keeping the ulcer from healing so that you don’t set yourself up for a failed procedure. Will the patient stay healed after surgery? That’s key. You’re going to propose this surgical correction. Is it really going to keep the patient healed long term, is it going to provide that much benefit for the patient? What is the likelihood the patient is even going to heal this surgery? Again, that goes back to the basic tenets of wound care that were discussed yesterday which apply towards healing of wound. They apply towards healing any anticipated surgery. What’s the level of urgency? Again, that’s important in knowing your surgical classes. Again, a bunion, no neuropathy, painful, it’s not something you have to take to the OR the next day or the following week. I do have a couple of cases in the end that hopefully I’ll be able to get to but that help describe how I triage the urgency of patients. Are there conservative measures that are going to give you the same outcome? The key component to this statement in my opinion is without compromising the patient’s quality of life. If you can conservatively, after healing an ulcer or wound, get a patient into a shoe or in a modified insole or padding technique that’s going to keep them maintained and not ulcerating and allow them return to a lifestyle that is reasonable in terms of keeping them as a community ambulator, returning them to the work if they are in the workforce then you don’t need to be operating on these patients. Now if you heal these sores and they recur, then you want to start thinking surgically. Then are there necessary interventions prior to the foot surgery optimizing their overall blood glucose control, optimizing their vascular status for healing, all that becomes really critical before you move forward. Identifying the surgical candidate, again, all the tenets that were discussed yesterday are what you want to do if you’re going to plan on taking these patients to surgery. Obtaining a thorough history and getting a really good physical exam, doing ancillary studies when necessary. I put radiology up there, it seems like a no-brainer but how many times I’ve seen somebody who want to correct the deformity in the presence of an ulcer and they’ve never gotten an x-ray because they assume they’re doing a “simple procedure”, a simple lump and bump surgery. They don’t get an x-ray but because these patients have had pathology, you really want to assess and make sure that there’s not something underlying going on that’s going to be a problem for you. It’s really just good practice to have that as a baseline. Plus, should you have a complication later, you have an x-ray to fall back on to monitor any changes. Again, remember that multidisciplinary approach really is essential in optimizing these patients prior to moving forward with surgery. You want to work with your primary care doctors to control all the conditions. We heard him talk about the VIPs yesterday, so my VIPs are a little bit different, because we’re, hopefully, of the understanding that we’re talking about the pressure component which was the piece of yesterday.
I’m going to talk about vascular status, infection and the psychosocial factors in these patients. When we talk about vascular status, if I’m taking a patient to the operating room and they are neurologically compromised or insensate, to me, they’re already at a high risk because they have an ulcer, they’re insensate, I need to fully assess their vascular status. I will Doppler them in the clinic and I will get a baseline noninvasive arterial study on all of the patients. I think that too is good practice. It gives them a baseline, it gives you a little bit more confidence towards their healing potential long term. Should something happen in the future, you have this baseline to fall back on for more aggressive vascular workup. Infection, again, ideally, you want good wound hygiene. You want to reduce the bacterial load. If you’re going there in a curative sense, you want to reduce the bacterial load. Any cellulitic component, antibiotic management when appropriate. There is a failure rate associated with surgery in proximity to an ulcerative site. I tend to find that that is more so if I go directly through an ulcer without ellipsing it. I find that if I can fully ellipse the ulcer and get a good healthy skin margins then I have no problem doing that. But when I go through the ulcer, I not only compromise the granular wound bed that I’ve tried to get built up over time, I also have a greater risk of compromising wound or aggravating tissues that maybe I did not fully address initially in examining the patient. When I take a metatarsal head for example out for a fifth metatarsal ulcer, I will go through a dorsal incision, take out the metatarsal head, explore the area and debride, irrigate and close it and then I offload them. Oftentimes, they will proceed to healing if all the other parameters we’ve discussed are intact and optimized for healing. My piece of psychosocial issues. I’m really big on the quality of life perception. My big thing is do patients really want to come to my clinic every week or every two weeks for me to trim their callus so that they don’t ulcerate? Is there something I can do to help them optimize this? They’ve already got their quality of life perception on the flipside in terms of the medical management of their diabetes with their primary. Many see an increase in medications, many are frustrated with having to manage their diet and exercise and healthcare access and we actually send our patients in support group for this for diabetes management. Then we have separate support groups for the flipside of it with our amputation group and our rehab teams. All these things will help optimize everything for you. I like this cartoon because it’s going to help describe what’s going to happen on the next slide. Our patients are so frustrated. They have their primary care doctors on one end saying, “You need to exercise. You need to get in shape. This is the only you’re going to bring your blood sugars down.” Then they have us on the flipside saying, “We’re going to offload you forever. We’re going to limit your activity. You can’t walk, you really need to cut down your work. You really need to do this and that.” They’re caught in this catch-22 and they really do see their quality of life spiraling downwards. Anything I can do to help improve that for them, I’m definitely going to try and to me, that involves moving forward with surgery. Again, I’ve had great success healing ulcers with a lot of the different advances we’ve had in wound care that all were talked about yesterday. The surgical side is becoming a little bit of a lost science. I’m not trying to label everybody or blame anybody but I think it’s always on the backburner anymore. Sometimes, it needs to be a little bit more on the front end of care. Assessing the deformity. The deformities are no different than the deformities you see everyday, the hammertoes, the bunions, the hallux limitus. Maybe the Charcot is different because you don’t see that in every patient. Tendo-Achilles contractures and residual deformities from prior amputations. We should address them similarly, however, understanding that we should do the simplest surgery possible for these patients to obtain that outcome. When we talk about deformities, we really want to understand whether the deformity is flexible versus rigid. Flexible deformities usually can be offloaded. If you can get the ulcer heal, usually, I’d like to say that you can maintain it healed with the right shoeing insoles and activity modifications that are reasonable to still sustain what the patient wants to achieve within their lifestyle. It’s the rigid deformities which can’t be offloaded that we really need to start considering addressing surgically as simply as we can to optimize these patients’ care. We have to learn to decide when enough is enough. Again, when these patients are coming in weekly or every three weeks, just so I can keep them maintained, to me, that’s enough because I don’t feel I’m doing them a favor. Especially out in Washington State where there are so many remote areas and the vision is to large, we’re covering Alaska, Montana, some of the Portland stuff.
These patients have to travel in so it’s not as realistic. This is probably when I’ve seen a bigger push in my practice to move towards this in my care. When to consider surgery? Essentially, you want to consider surgery when all your conservative therapy fails to maintain them in a healed state. Again, even therapeutic shoes, patients will come in and be frustrated that they had a recurrence. But I’m wearing my shoes, I’m wearing my insoles. There are actually studies that showed that there’s a 28% recurrence up to a year in these patients and anywhere up to 100% at 40 months in these patients. Your surgical outcomes should be geared towards reducing the pressure, increasing function, allowing for proper shoe gear and long-term prevention of ulceration and amputation. Your procedure should be chosen to correct the underlying problem in the most minimally invasive manner and that’s key for me. We’ll see some cases in the end and though the procedure seemed simplistic, it has actually achieved the greatest outcome for the patient. There are studies to support this. It was interesting for me to see that a lot of the prophylactic surgery studies were outdated so they are further back. A lot more of the studies towards healing ulcers and wound and stuff is really more advanced in regards to the advanced technologies that we’re seeing today. But there was a good study from Jacqueline [phonetic] and his group, a little biased towards the UT side of me but this was in my time. There was a five-year retrospective study, 64 patients and 90.5% patients maintained healing at an average of 24-month followup. They did have a 15% complication rate, meaning there were some people had like a postoperative infection, cellulitis that was managed. There were some that have progressed to maybe amputation or more aggressive debridement. But overall, they had a 90% success rate in maintaining a healed state once all surgical treatment was done. Essentially, what the studies do find when you read into a majority of them is that prophylactic foot surgery and I’d say curative also, so prophylactic and curative surgery is actually effective and will produce a good outcome in the insensate yet vascularly intact foot. It’s really key that you assess the vascular status and make sure that these patients have the tendency towards healing before you move forward to really get the outcomes that many of the studies are seeing with surgery in these patients. Again, the goals of the talk are to really understand the impact of diabetes, where surgically classifying your patients can come into play and where the risks and benefits can outweigh each other and how they can benefit your patient long term. How to identify which patients are your better surgical candidates and how to fully assess the deformity? I think in giving this talk, I felt like maybe I’m going to come off as sounding too aggressive and then when you all see the cases, you’re going to think I’m too simple with my patients. In the end, I think that’s kind of how I want it to come off. I think there is room for being more aggressive yet there is room when you become aggressive to selectively choose the simplest thing you have to do for that patient. It does not have to be in a big, aggressive, reconstructive procedure every time. Though there is a place for everything in the operating room. This patient is actually 60-year-old male with diabetes who kept getting a recurrent ulcer to the plantar aspect of his foot. He was new to me after I’ve transferred to Seattle. Essentially, he told me, “I come in every two to four weeks, they trim my callus, I still get an ulcer so now my primary care doctor felt it was better that I don’t walk on my foot and so now I’m confined to this motorized scooter. So I don’t have this recurrence anymore and when I do get active, this is what happens.” He blisters and he breaks down. The minute he tries to get active, take a walk with his wife, playing with his grandkids, so he’s real frustrated. He can’t do any of these things. He's failed, so first time with me, so if I’m not going to jump to surgery. We tried different shoe modifications, different shoe types, talk to the prosthetics department and he actually still continued to recur. I got an x-ray and he said, “Wow, nobody has ever x-rayed my foot before.” This is when I say, “It sounds counterintuitive but get an x-ray, fully assess your deformity.” When we got an x-ray, if you see on the bottom here, he's dorsally dislocated. It’s been chronic and ongoing forever and nobody has taken an x-ray and you can actually see the first metatarsal shaft and neck where the phalanx is hitting it has deformed the first metatarsal neck. That’s how long it’s been going on for. When you look at the rest of the x-rays, all the other digits are also dorsally dislocated at the MPJs. His deformity was severe enough that this gentleman was going to break down the minute he put his foot down on the ground. I asked him, had anybody ever talked to him about surgery. And he said, “No, because I’m diabetic. I might lose my foot.”
I told him that realistically, there is the chance that you might end up with an amputation but we worked him up. I’ve worked with his primary care doctor. His blood sugars were always in good control. We had arterial studies done. His pulses were faint to palpation but they were there and again, pulses alone are not an indicator of healing. We did obtain the arterial studies and he had good TBIs and his ABIs were good. We talked even longer and we talked about the risk of him potentially having a complication especially because he’s at a chronic ulcer but there was no sign of underlying deep infection. He wanted to move forward with it and so we did. What did I talk to him about doing surgically? I really did keep it simple. I talked about a Keller-Mayo type procedure where we took the base of the phalanx and the head of the first metatarsal out and a pan metatarsal head resection. I did talk to him about correcting the toe deformities and in his mind, he did not want that because he felt all my problem is plantar. If you look at the pictures, I don’t know if you can tell, but he has diffuse callusing across the ball of the foot. It was essential for me to push him towards taking out the lesser metatarsal head as well because if I would have only addressed this, this would have been the next problem. Though I couldn’t convince him toward doing arthroplasty to the toes, I did convince him or talk to him about taking the metatarsal heads out which he was agreeable to which is what we essentially did. This is his one week postop. You can see the erythema in the toe so I did become concerned. I wasn’t too alarmed. He does have venous insufficiency. He did have a bit more swelling. I did put him on antibiotics and he came back the week after to see me and it was resolved. My paranoid state, I took the wire out a little bit earlier than I normally would take it out and I’m going to apologize, I don’t have another follow-up x-ray and a picture of him but he’s about three months out right now. The plantar ulcer is healed. The toes do still have some contracture. They actually look a little bit straighter here with the met heads taken out but they do have some contracture left. But a few months overall, he has remained healed and again, I don’t think we did anything too aggressive or too crazy on this patient. Hopefully, the goal is that he’ll stay out of the motorized scooter. He’s happier, he’s walking right now in his sandal. He’s not quite in his shoe yet. But he’s happier. He doesn’t have the pain on the ball of foot because he was actually getting pain the ball of his foot and I think he felt it was being blown off because he’s neuropathic so why would he have pain. But it was painful for him. This is a second patient who is a dialysis patient who had actually an ulcer on the contralateral foot, plantar medial first MPJ that was severely macerated and get that verrucous-type appearance. He was also new to me after I transferred to Seattle and we talked. He wants to get on the renal transplant list and he is a good candidate to get on the renal transplant list but was fearful that he heard that the wound might keep him from staying on the list or even being able to receive a kidney, should one become available for him. I talked to him about becoming more aggressive in doing surgery. This is the foot we operated on. There was a big ulcer underneath here. It’s about 2.5 centimeters to 3 centimeters, always macerated, always verrucous. This gentleman would come in essentially once a week. After his Friday dialysis, he comes straight down to clinic to me and I would trim it up. We did a Keller-Mayo on him so that he could stay on the transplant list. He has remained healed and this is about seven months postop and he has not had a callus or anything. The only bad thing is he became more active. Despite using a walker for assisted gait, he became more active and what happened is he started to ulcerate on the other foot where he never had an ulcer before. He wants now, he’s very proactive and he knows that he was optimal for healing. His circulation studies and his vascular consult felt that he could heal anything done at the foot level. We are planning to go in surgically. He’s scheduled at the end of the month on this side to do just a simple bunionectomy, just simple lump and bump surgery. Again, this is going to improve his quality of life. He stays on the renal transplant list. If something should come up where he can get the transplant, he doesn’t have anything that is compromising his ability to move forward with that. Ideally, we want to understand the classifications and the urgency of diabetic foot surgery. You want to fully assess and evaluate the patient medically for the healing potential. Recognize when conservative measures have been fully exhausted. Really, don’t underestimate the impact you can have on the psychosocial aspect of these patients and how you can really improve their quality of life. They may not go out there and run a marathon a year later but they’re going to be out there and there are going to be community ambulators. They’re going to be able to stay on things like renal transplant lists and they’re going to become more active members of the community again. Keep surgical options simple when possible to achieve an acceptable long-term outcome and again, improve the patient’s quality of life. Thank you.