Javier Aragon-Sanchez, MD, PhD discusses clinical presentations for diabetic neuropathic foot ulcerations, reviews the conservative and surgical approaches for treatment, focusing on cases where the etiology is biomechanical.
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TAPE STARTS – [00:00]
Speaker: Next up conservative surgeries. Very important role in long-term wound management, conservative surgeries, and I couldn't think of anybody better to discuss what works and what doesn't work than Dr. Javier Aragon-Sanchez. Next, my friend.
Dr. Javier Aragon-Sanchez: Many references. Okay, the first time that the term conservative surgery for treating diabetic foot osteomyelitis appear in the medical literature was with the French group from Habaning [phonetic] in France and they performed a comparison between patient treated with medical treatment consisting of antibiotics, wound care and offloading compared with the conservative surgery. As you can see in the table, the healing rates were higher in the conservative surgical group. The healing was faster in the conservative surgical group, and the conservative surgery was able to shorten the duration of antibiotic therapy. The conservative surgery, the concept is the procedure in resolving defective bone and non-viable soft tissue are removed without amputation of any part of the foot. What does not work is the delay in referral. When you receive patient in such condition, it's very difficult to perform any conservative surgery because you can see the fistulous hole, severe soft tissue destruction, extensive cellulitis and this is a very common problem.
In the older diabetic study, more than one in four individuals have been treating for more than three months before referral to a diabetic foot clinic, and the patients with delay on referral had such condition and it's very difficult to treat in this situation. In order to know the results of conservative surgery in diabetic foot osteomyelitis, we report a series consisting of 185 patients and you can see initially were treated with conservative approach 60%, minor amputation were required initially in 38.4% and major amputation were required in 1.6%. We analyzed the predictive factor of failure in conservative surgery. The failure of conservative surgery was defined as the inability to perform conservative procedure during the initial operation. You can see, for example, soft tissue infection, severe. The failure of conservative surgery was also defined as the need to perform an amputation after initially doing a conservative approach. You can see the final outcome of the series, conservative surgery 49%, minor amputation 43% and major amputation 8%. In the 60% of the patient who initially require conservative surgery, a conservative surgery was successful in 82% of the patients, minor amputation 12% and major amputation 6% of these patients. In the logistic of aggressive model, the predicted variable of failure of conservative surgery were the bone exposed, the lower limb ischemia or necrotizing soft tissue infection accompanying osteomyelitis.
In order to analyze the safety of conservative surgery to know the recurrences and reulceration after conservative surgery, we designed a new prospective cohort of patient. In this new cohort of patients, the recurrence was only diagnosed in 3 out of 65 patients, 4.6% of the patient, and the recurrence appeared between 51 and 105 days after apparent healing. After the recurrence, the infection was resolved after a new minor procedure. For the reason it would work, the conservative surgery is a safe option to treat osteomyelitis with a low rate of recurrence. We also analyzed the clinical presentation of diabetic foot osteomyelitis for both classification based into four classes depending on the presence of ischemia and soft tissue involved. And you can see in the Chi square for trend, there was significant association between the classes, the severity of infection, the change of undergoing any amputation, the high level of amputation and mortality. As you can see in the class 1, osteomyelitis with no ischemia and soft tissue involved, no amputation were required in this group. For the reason conservative surgery may avoid any type of amputation in non-ischemic feet without complicated with soft tissue involvement. In cases with soft tissue involvement and ischemia, the patient will require to provide a good blood supply in order to save the limb.
However despite the fact that limb ischemia is a well-known complication with diabetic foot lesion, it's not well-treated in patient with diabetic foot infections. For example, you can see this series in Spain, 78 patients admitted for diabetic foot infection, infectious disease and vascular department, peripheral arterial disease was diagnosed in 70.5% and vascular reconstruction was performed in only 5.4%. A new series from France, 291 patients admitted for diabetic foot infection in a specialized department, foot pulses absent in 45% of the patient, imaging was carried out in 21% and vascular reconstruction was performed in 25 patients. I am going to show you very recent series from Netherlands. 129 cases of foot sparing surgery in a wound spare clinic. You can see 52% of healing, 56% need reparation and 30% a major amputation. The risk factors for non-healing for major amputation were infection, ischemia, history of peripheral arterial occlusive disease and smoking. And finally, the order of this series recognize that not all the patients undergoing vascular assessment and in half of the patient, there was a delay in undergoing revascularization.
Therefore, what doesn't work? Performing foot sparing surgery in cases [indecipherable] [08:11] adequately being aggressive. Because when limb ischemia is well-treated, for example this series from Harbor Group, every patient of this series underwent a successful vascular reconstruction and after the vascular reconstruction, 33% of the patients underwent the resection of the involved bone with incision of the ulcer and primary pressure, 12% metatarsal head resection, 36% of the patient with metatarsal osteotomy through dorsal approach and 19% of the patients fifth metatarsal head resection through dorsal approach with a mean follow-up of 21.2 months, 83% with primary healing and 7% of re-ulceration. Therefore, what works? The toe and flow concept as the essential component and [indecipherable] [09:17] of the amputation prevention team. And what doesn't work, thinking that the work is finished when the healing is achieved. For example, you performed this very aggressive surgery, you have achieved total healing of the patient and the patient had re-ulceration because the clinician involved in diabetic foot care should understand that maintaining the patient in remission is sometimes more difficult than saving the limb in the acute phase. This is a very recent review about the recurrences in diabetic foot disease. You can see after five years of followup, more than 70% of the patients will have recurrence.
In this same paper, the author analyzed the intervention to reduce the risk of recurrence. As you can see the full surgery have a higher mean efficiency [phonetic] 61.8%; however, more research is needed in order for a definitive step in the role of foot surgery for preventing recurrences in the diabetic foot. A group of friend in Italia from Alberto Piaggesi Group performed this interesting study. Conservative surgical approach versus non-surgical management for diabetic foot neuropathic ulcer. As you can see the patient undergoing surgery have a higher healing rate, shorter healing time, have less infectious complication. Those who underwent surgery had 14% recurrence versus 41% recurrence with standard care. But it's very important that the recurrences occur in the same site of previous ulceration in the group of but in different site in the group, this is pressure transfer ulcer. Now, we are going to analyze a recent series from China. You can see 245 patients who underwent toe amputation.
You can see the reulceration 57.3% after one year of followup and reulceration after three years of followup 57.2% and after five years of followup 76.4% of the patient underwent reulceration, 47% underwent reamputation, 32.7% during the followup. This is confirmed that we now know the five-year life expectancy of some diabetic foot problem is worse than some type of common cancer. And this is especially worrying with the amputation of the great toe. This is a classical series, 90 patients undergo amputation of the big toe, 60% of the patient underwent second amputation and 17% of these had below-the-knee amputation. Because the great toe amputation produced severe disturbances in the biomechanics of the foot. It has been reported the development of Charcot neuropathy after big toe amputation. You can see this young lady with type 1 diabetes developed forefoot neuropathy and developed severe deformity of the first metatarsal bone stem and reulceration in the mid foot location. What doesn't work? The amputation of the big toe to treat osteomyelitis. It should be avoided if possible.
However, a group from Italy again from Luca Dalla Paola, they stated that reulceration and reamputation after big toe amputation could probably be reduced in a specialized multidisciplinary postoperative treatment based in customized foot care. For example, they designed a silicon prosthesis, customized sole, customized shoes may reduce the recurrence after big toe amputation and to place importance of designing preventative postoperative method in a multidisciplinary team probably works in avoiding big toe amputation. We are developing new surgical techniques in order to avoid the big toe amputation. You can see separation and destruction of the distal phalanx of the big toe. This is very easy-to-do surgery. This is a very simple technique. You can see the bone piece to be sent to microbiology pathology department, the postoperative period and finally the healing time 104 days, 15 years without recurrence in this case. You can see the x-ray 15 years after the patient had regrowth of the distal phalanx of the big toe.
When we perform conservative surgery, we have to have a prophylactic as well. This is what we call surgical offloading. When we have this type of ulceration, we have to analyze the biomechanical disturbances because sometimes an arthroplasty may avoid the big toe amputation. Sometimes, the interphalangeal arthroplasties, the use of antibiotic cement. External fixator, as you can see after removal of the external fixator, we performed second metatarsal head resection and dorsal osteotomy because there was an overload in the central metatarsal head. And probably what works? The conservative surgery to save the big toe in cases of osteomyelitis using different approach, but we need, again, well-designed studies in order to determine the role of this type of surgery. This is a very common situation. This patient was treated with antibiotics for one year. The healing was not achieved. Serous drainage daily, probe-to-bone test was positive and there was severe radiological bone destruction. This problem is very easy to resolve with metatarsal head resection. You can see the healing was achieved in 84 days, neither recurring nor reulceration had been found at the CGS or followup.
But this is not very common because the reulceration at new site may appear in 37% of the cases with conservative surgery. And the reulceration are related to the plantar location of the ulcer during the first episode and pressing ulcer caused deformity. We performed this study to determine the transfer lesion in patients who underwent surgery for plantar ulcer. As you can see, different percentage depending all the metatarsal head, which was removed. In the concept of aggressive model, we were able to see that the first metatarsal showed the a higher risk for reulceration with the ratio of 3.3. You can see 69% of reulceration after removal of the first metatarsal bone. However, the removal of the fifth metatarsal bone was a very safe procedure with low rate of recurrences. This was also demonstrated by Armstong et al [phonetic] that compare two groups, a group with fifth metatarsal head resection versus counter group treated with offloading, wound care. You can see the time to healing was shorter in the fifth metatarsal head resection and their recurrence after seeing long followup were lower in the surgical group. For the reason, what works? Metatarsal head resection is an excellent conservative approach to metatarsal head osteomyelitis but is associated with high rate of transfer ulcer.
The first metatarsal head resection is not a good choice and should be avoided. It leads to a similar disturbance, the big toe amputation in case if fifth metatarsal head resection is associated with the best outcome. In cases of complications in the lesser toe, this is a very common situation. You can see deformity of the second toe with osteomyelitis of the distal phalanx. In this situation, you can perform a removal of the distal osteomyelitis, simultaneously performing flexor tenotomy with a very good results with total save of the limb. Recently, it has been reviewed this flexor tenotomy in order to heal the diabetic toe ulcers. You can see the healing rates in several series were high with very low rate of postoperative complications, and most time may be done in adult patient facility and sometimes in cases complicated by osteomyelitis. This is another type of lesion. This is also complicated with osteomyelitis of the interphalangeal joint. You can see in this case we performed an open arthroplasty with very good result with total healing of the patient. Probably, the flexor tenotomy or the toe arthroplasty may work but again we need more evidence, we need well-designed research.
Probably one of the best method research about conservative surgery, about surgical offloading is this article in which the author compared the Achilles tendon lessening plus total contact cast versus a total contact cast alone. You can see the [indecipherable] [22:23] that all ulcers heal in the Achilles tendon lessening group and the risk for recurrence was 75% less at seven months and 52% less at two years than in group treated with total contact cast alone. For the reason Achilles tendon lessening should be considered and a strategy to reduce the recurrence of neuropathic ulceration on the plantar aspect of the forefoot especially with patient with limited ankle dorsiflexion. In conclusion, conservative surgery can be successful in almost 50% on non-selective cases of diabetic foot osteomyelitis between 87% in non-ischemic patient. Conservative surgery in patient with severe ischemia should be avoided until blood supply is restored, the toe and flow concept. Minor amputation, especially big toe amputations are associated with biomechanical changes, reulceration and reamputation. The metatarsal head resections are associated with recurrence due to the pressure transfer. The recurrence could be reviewed using customized sole, shoes and orthosis in a multidisciplinary team. The conservative curative surgery should be performed with prophylactic as well. And finally, arthroplasty, flexor tenotomy, Achilles tendon lessening will have an important role in preventing recurrence, but more result in it.
To finalize, this is probably the view that some colleague and some patients have about the diabetic foot surgeon. Probably, a modern diabetic foot surgeon may be able to change this view because today we have many, many tool to save the limb of a patient. Thank you very much.
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