John Doolan, DPM discusses the common diabetic neuropathic foot ulcerations as well as prophylactic surgical techniques to assist with wound healing. Dr Doolan also discusses prophylactic surgical procedures for prevention of recurrence, once healing has occurred.
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John Doolan, DPM
Co-Director of Program for Advance Limb Preservation (PALP)
Assistant Professor of Podiatry in Clinical Surgery
Section Chief Podiatry
Division of Vascular & Endovascular Surgery
Weill Cornell Medical College
New York-Presbyterian Hospital
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TAPE STARTS – [00:00]
Speaker: Our next speaker comes to us from Weill Cornell over in New York City. Dr. Doolan is going to be presenting a talk on techniques to assist wound healing. He has a great deal of experience in limb salvage and wound healing. He participates in a number of residency programs in New York City area and is co-director of program for advanced limb preservation at Weill Cornell. So let's welcome Dr. John Doolan.
Dr. John Doolan: Good morning everyone. So just before I get started I just want to comment on the two lectures we already had this morning. I think stem cell therapy is definitely going to be the way of the future for both treating wounds and lot of musculoskeletal disorders both related to podiatry and in general. I just think it's fascinating field and I just know it's going to be the way in the future. And then Dr. Frykberg's presentation this morning, which was unbelievable as far as eye opening on how much diabetes affects the quality of life on the patients and the mortality rates of diabetic foot ulcer. Especially compared to diseases that we all dread and fear and I don't want to belittle them. I am sure there is many people who have personal and professional experiences with breast cancer and prostate cancer, but it is a worse mortality rate -- as far as mortality rate goes -- prognosis for you to be alive if you get diagnosed with a diabetic foot ulcer in five years than if you had breast cancer or prostate cancer.
And I am not sure that us as the physicians or the patients really get that. And I mean that when someone does get diagnosed with those horrible diseases of cancer, they are asking you what kind I do, what can I eat, what doctor should I go to, what do I do. And you are going, you need to see -- not you because we don't treat cancer but their doctor goes you need to see the radiologist, the oncologist, the surgeon. We need to take that serious and have that interdisciplinary approach if we are going to succeed on making these people's lives better and not having such a high mortality rate. And there is no ribbon for diabetic foot month. There is no football game where everyone has a pink ribbon or blue ribbon or anything like that and I think we need to take this more seriously because the truth is they are going to do worse than if you got diagnosed with those other things in five years. And I don't know about you but do we tell them you have a 40% chance of not being here in five years. I think that's scary for them to hear but it might set them a little bit straight and get them more serious at addressing their problems that can be addressed. Just a little note before I start this lecture because it relates to what I am going to do and show you. But we are going to talk a little bit about surgical techniques to address wounds today in the diabetic population. So some disclosures. They are not related to this lecture in any way and I also like to thank to my residents for helping me put together the slides and the data and the pictures on this. I don't know if they are out there but to of my residents, I like to thank them. So first things first. Should we be doing surgery on diabetics to prevent amputation and infection? And if so what surgeries have shown to work and prevent these infections and amputation?
So that's the first thing we got to ask ourselves. The golden rule, do no harm. So what are the facts? The facts are the long-term outcome for prophylactic surgery is very good. 96% of people are ulcer-free three years after followup after prophylactic surgery and I will show you little classification on what I mean by the groups of people that I have diabetes that have surgery. And the infection rate in surgical groups was basically the same as infection rate on non-surgical groups. If you have a diabetic foot ulcer on the toe, there is arguably good percent chance like 30% to 35% that will get infected. Those are the same rates as if you did surgery on the toe to prevent amputation. So while some of the surgical groups have high rates of infection so do the non-surgical groups. And the re-ulceration rate in the surgical groups is much lower than the re-ulceration rate in the non-surgical groups. So here we would like to credit someone in the room. It's always nice. This is little classification of diabetic foot surgery. You got your elective cases, that’s a diabetic with a normal intact neurovascular system that needs a bunion or hammertoe done. That's class 1. Then you got your prophylactic classification and they have risk factors and no active ulcer or healed ulcer. Then you got your class 3. This is what we are going to be talking about most commonly in this lecture and this is the one that where you could really intervene. They have an ulcer and they have risk factors, neurovascular factors and we need to do something to intervene. Some examples, which I am -- this is what the lecture is going to be based upon; tenotomy, arthroplasties, bone or tendon work and there is your class 4.
These are emergent cases. These are limb and life threatening disease where you need to do incision and drainages and/or amputations. So this is a good thing to keep in mind when you are looking at a diabetic surgery. So something to consider before doing surgery and before I even talk about this, for the rest of the lecture, just assume that we are practicing good wound care that we have done a vascular consult. I mean these things I know the audience here I am sure it's a second nature, that we are offloading properly and that we are doing all the standard of care. But in addition to that, we see that as hemoglobin A1c goes from 7.3 to 9.8, there is a rapid increase in infection and that was at Journal of Foot and Ankle Surgery, 2014. And patients with hemoglobin A1c over 7 have greater odds of getting bone complications. Again Journal of Foot and Ankle Surgery, 2013. So we want to optimize these patients before they get to the operating room. This is non-podiatric. Well, I shouldn't say it's non-podiatric. It has to do with everything that we are talking about. Just what a signification reduction of 1% in hemoglobin A1c does to your life, 14% reduction in MI, 21% reduction in death and you guys could read the rest. So it's important. I like to give my patient goals. So the general goals before we do surgery -- try to get the hemoglobin A1c to 7 or lower. There is old saying if it's not at 8, don't operate, but 7 is even better. Weight loss, smoke cessation and the rest of the things that you could read there. What I would like to do is I have a patient whose hemoglobin A1c is 10.1. I like to give them a goal. I say, Mr. Smith if you get your hemoglobin A1c down to 8 over the next three to six months, I would like to do this tenotomy on you.
And then it does two things. One it makes them a lower risk but two, it makes them have skin in the game and shows that they are going to be compliant with your treatment and that helps. Another thing with compliance is you want to get the wound closed if possible before doing elective surgeries that will cut your infection rate down. And weight loss, it's nice to have a goal with that too. Mr. Smith, you are 315 pounds right now. If you get to 265, we will do something or something like that. It gives them a goal and it makes them have skin in the game and it becomes a team that you are doing this together. But do "reward them with surgery." These patients are not patients you want to do surgery on. You know that there is going to be nightmares if they are smokers, if they are overweight, if their hemoglobin A1c but if they are doing their part and they are showing they are trying, you should really do your part and do surgery on them when indicated. So we talked about this morning with Dr. Frykberg, the neuropathy, different kinds of neuropathy and vascular diseases. The other thing that happens in diabetics is tendinopathy and there has been multiple studies on tendon disease in diabetics, but I am going to summarize these basically tendons become contracted and non-elastic due to glycosylation products as you could see here in disorganized tissue on electro-microscopy and there are numerous studies showing that tendons become dysfunctional and it's not just the Achilles tendon. These tendons pull in the wrong direction and they are going to cause inversion, eversion or excessive plantar flexion in the foot. And we got to know that and address it. So let's go over some of the things that we see all the time. I would like to try and break this up into toe ulcers and metatarsal ulcers as you will see and go over the options. So toe deformities are common in diabetics, especially if you have over 10 years due to the motor effects of the intrinsic muscles.
There is a very high re-ulceration rate when treated non-surgically when offloading. Total contact casting works. It's one of the best things that ever happened to podiatry as far as getting wounds to heal. But it does not address the underlying muscular problems and tendinopathy once you stop doing it. So toe ulcers, here is the non-surgical treatment. You can see a fungal nail with toe ulcer, debride the fungal nail and debride the hyperkeratotic tissue and offload. It does work but as I said the re-ulceration rate is high. So is the toe flexible or rigid? Is there a hammertoe? Is it plantar flexed? Does it have osteomyelitis? If so, what bone is infected? So let's go to some surgical techniques. Flexible toe, distal toe, tip of the ulcer, Bonanno in 2017, this is a recent article in Journal of Foot and Ankle Surgery, studied 264 toe ulcers, open foot 207 days. I know I am reading to you guys right now because these numbers are important. 97% healing rate. I mean that's a great healing rate. We got to start doing this and recurrence of only 6%. These are high quality studies that show very high efficacious procedure of tenotomy. Extremely easy procedure. I am sure everyone in the audience has done it. I do these in the office. I don't even take them to the OR. I make a small incision. I localize the long flexor. I put a hemostat under it and I cut it. Put two sutures in it and send them home. Give me another procedure that has a 97% success rate at getting rid of an ulcer and you know this is a beautiful thing.
Another study, 2007 Foot and Ankle International, 28 toe ulcers treated with percutaneous tenotomy. I highlighted all. All of them healed and there was a small complication rate and after repeating the procedure they healed. So again this is the literature showing this works. Just again to show you the open technique where identifying the flexor there, the long flexor, right there in like the sulcus area at the base of the digit and when tenotomized again closing. Another study, flexor hallucis longus tenotomy procedure at the distal tip. All ulcerations healed at approximately five weeks, almost all -- I'm sorry -- 98%, 12.1% recurrence. And that's a long-term study. It's over a year out. That's a really high rate and I know what many of you might be saying, total contact casting heals them too and I agree. I used total contact casting all the time but the re-ulceration rate in total contact casting is much higher and I will show you some stats on that. So there is a pre and postop view of flexor tenotomy and again this is the procedure that we probably all have done or easily can do but it's something that when I see distal toe ulcer like this right there, contracted toe, I just say when we are doing the tenotomy in Mr. Smith. So let's go now to digital arthroplasty. When the deformity is not flexible, it's rigid or it's at the proximal interphalangeal joint or distal interphalangeal joint, arthroplasty is probably a better option. This is study done by Armstrong. Evaluated arthroplasty and 96% of the patients went on to heal and remained ulcer-free at 12 months.
Again, these are very high healing rates in diabetic foot ulcer patients. Another study done by Kim reported diabetes with osteomyelitis and 72 arthroplasties performed. They were doing the arthroplasty for both removal of a bony prominence, source control of an infection and ulcer control and 79% of the toes went to complete healing in 32 days. These are people with osteomyelitis and still almost 80% went on to heal. It's a pretty high rate. Again, we should be doing these procedures. When we see an ulcer with osteomyelitis in a digit, the treatment choice should be arthroplasty. It certainly shouldn't be medical management of this. When I say that we can do medical management in addition to this, it shouldn't be solely medical management. Okay. So another thing if you have osteomyelitis in the tip of the toe, I showed some doing the flexor tenotomy and that works great, but if the bone is compromised with osteomyelitis, I would do a distal amputation and there is literature to support this also. Buffelli [phonetic] has 81% healing rate on this one and then again Buffelli distal Syme's done in the office, I might add, all 48 patients healed in 29 months. So these are pretty staggering numbers of high success rates and these are on papers by our peers in our journals and they are all recent. So if the distal tip of a digit has an osteomyelitis within ulcer, my recommendation would be to do the distal amputation. So about half of the ulcers that we see in our practice will be on the hallux or first metatarsal phalangeal joint.
So these are the ones that I really want to give you some different ideas for and different ways to look at including metatarsal head ulcers not on the first. I wanted to show you some stats that I find really interesting. So this is the one that comes to your wound center. This is the one that I see all the time and any of you deal with wounds, even if you don't have a wound care center or a clinic, this is the kind that comes to your office. This is a really common ulcer. So what do we do with these? So first, we got to evaluate it. Is it flexible or rigid? Is there a hallux limitus? Where is the ulcer? The IPJ, the tip or the base of the hallux? Is there an IPJ sesamoid? I will tell you if there is IPJ sesamoid, just take it out and they should do better, but let's go to when there is not. So study in Journal of Foot and Ankle Surgery, 2015 by Lou showed two groups surgical and non-surgical group of treating hallux ulcers with an arthroplasty. The surgical group had a faster time to healing 3.5 weeks versus nine weeks, a lower reoccurrence. This is significant. 8% reoccurrence versus 54. So yes, we could you in nine weeks, but yes, you will be open 50% of the time after that. So it's great to heal someone and I don't mind if you want to heal someone first before doing the surgery to correct their biomechanical problem, but 54% recurrence, do you tell them that when you put them into a total contact cast? I am going to heal you, but 50% chance you will be open again in a short period of time. If you don't, you aren't telling them the full picture. The surgical group also had few amputations, 0% versus 38%. So these are significant factors.
Again, like I asked in the beginning of the lecture, do you tell your patient that they are going to be 40% chance to not going to be here in five years? Do you tell them I could not do surgery on you and you are going to recur or there is a 38% chance you are going to have an amputation or do you go ahead with the procedure? Keller, this is my work course for the hallux ulcer and this is why. So again, Journal Foot and Ankle Surgery 2005, 13 patients with Keller, all healed in less than six months and 8 of 13 remained healed at one year, 5 developed transfer lesion. Transfer lesions happen, complications happen but they are usually better than the controlled group, which is non-surgical. Armstrong, diabetes care 2003 found performing an arthroplasty at the first metatarsophalangeal joint resulting faster healing time, fewer recurrent ulcers and no increased infection rate of the hallux. So this is the study that was done almost 15 years ago that showing Keller is the way to go when you have this ulcer and you have fewer recurrent ulcers and faster healing time. Again, Lin, 2000 reported 14 to 14 plantar hallux ulcers healed in 23 days whereas the 15 randomly selected controls took an average of 47 days with TCC. All the surgical candidates had ABI of 0.65. Now, here it is, there were no reoccurrence or other complications 26 weeks after surgery on the surgical group. So these are significant numbers. That's a preop and postop of a Keller. That's six weeks later, same toe. This is when we start getting to the more serious stuff. Diabetic foot ulcers onto the first metatarsal, that is a serious problem.
And it has serious complications when not dealt with correctly. Roukis in diabetic foot and ankle 2012, partial first ray amp, one of five will go on to a more proximal reamputation or re-ulcer. That's a pretty percentage, 20% if you do a partial first ray. I am going to show you some more stats. Some of the stats are from different studies obviously. So they have different numbers, but I think the take-home message will be the same when we look at this. So I am going to talk about a little bit just to give you some stats on other metatarsal head ulcers, but does it matter where the ulcer is as far as the prognosis? Again, do you tell your patients? If I am going to do a first met head resection on you, do I tell you that we have a 36.4% success rate? What does success mean? No ulceration and no other wounds. Do I tell you that the re-ulcer rate was 69% when I pop out your first met head? We got to think about that. We got to say maybe you need a different procedure. Both of these studies here show success rates on different metatarsal head resections and long-term success rates and you could see that basically short of the first met, which has a success rate of almost 78%, we are not doing so good if you just pop out a met head. It's not a great idea. Again, the size of the study matters a little bit but these are not good numbers and they are very similar to these numbers. First met head re-ulcerate 69%, second met 44%, third met 52% and it gets 50% on the fifth. I will tell you that most of the studies show that fourth and fifth if isolated have the best prognosis, but still not good if we are just popping out met heads.
So when I first saw all these studies, I started saying to myself, do I let my patient know I could cure that wound under the fourth or fifth met head or first or second by taking out the met head, but there is a pretty good chance that you are going to see me for the next couple of years with new ulcers and new infections? So met head procedures, going back to JAPMA 1993, they analyzed 34 pan met head resections and ultimately 97% of the ulcers healed and remained ulcer-free for 21 months. It's a pretty good numbers there. This is just showing another negative number in my opinion, found that 52% of patient develop transfer lesions in 35 months after a met head resection. That's high. Cohen, 1991, showed that both pan met and TMA significantly high at clinical success rate compared with solitary partial resection. It's a pretty significant. And we can't think of TMA or pan met head resection as a failure. This is a minor amputation compared to below the knee or above the knee. It is highly functional and has a low reoccurrence rate compared to solitary met head resection. We must consider doing TMA or pan met and I am going to show you some other things we can consider as well in a second. If there is more than one met head involved or toe and met head, and it's a different toe from the met head, this is a personal thing for me. I pushed towards a pan met head, TMA or one of these tendon procedures that I am about to show you. So just a little more data on met head resections. Armstrong and JAPMA, 2005, showed that fifth met head resection. Again fifth met head works well, heal faster than the controlled group and re-ulceration rate was low.
When you do a fifth met head resection or fifth ray resection, try to preserve at least 50% of the fifth ray. If you cut it shorter than 50%, you are going to have complications and I will show you some ways to potentially salvage that. 2017, metatarsal head resection had less postoperative complications and lower hospitalization rate. Again, this is not necessarily saying what met head. I think I would go with the fifth met head being the most successful. This is another study. Metatarsal head resections and metatarsal osteotomies after bypass. This is basically supporting that the combined efforts of a vascular surgeon and podiatrist team are successful. So the one illustration I have here is the fifth met head resection because that's the one that works most commonly for me and in the literature and I used a dorsal approach even if there is a plantar ulcer most commonly. Take out the met head, try to preserve more than 50% of the fifth ray there and that goes on to healing most of the time. So what else can we do for the sub first met head ulcers. And let's talk about peroneal tendon transfers and gastroc or TALs and think about what the peroneal tendon does. We know the anatomy. It's an everter and plantar flexor of the first ray. So it is pulling down that first metatarsal head. So maybe we should weaken it or transfer it to get it out of there. In addition, we talked about tendinopathy and this is on the plantar aspect of the foot and the Achilles tendon lengthening, which I will talk about in a little while. So some studies were done on that. So 2008 in Foot and Ankle International, a combination of peroneus longus tendon transfer or tenodesis to the brevis and a gastroc. 18 of 19 ulcers healed with 3 out of 18 reoccurrence. And then [indecipherable] [25:57] 2009 bone and joint, gastroc peroneal longus combination, 22 of 23 with one recurrence.
Those are pretty good numbers. So sub-first met head ulcers, gastroc or TAL and peroneus longus tendon transfer or tenodesis to the brevis at the level of the ankle or between the ankle and the fifth met. So interesting study done on salvage of neuropathic foot using bone resection and tendon rebalancing. Again, going to this peroneal theory, this is done by Rush. 10 patients with lesser met ulcers non-first ray had combined peroneus longus transfer to brevis, gastroc resection and lesser met two, three, four and five; all 10 healed without even a transfer callus. Again, small study, would like to see larger stuff on this, but pan met head except the first with a peroneus longus and gastroc. It's a very interesting work being done out there. Just trying to point it out options for limb salvage. Case study in podiatry, just two months ago, showing gastroc with a peroneus longus transfer and that's a preop on it, that's a postop. No bone resection. And talking about when that fifth ray becomes compromised when you take over 50% or you take the whole fifth ray because remember you are losing peroneus brevis insertion. This is a paper done by Buffelli in 2016 where he did a peroneal tendon transfer to the cuboid in a two-stage procedure after packing it with antibiotic beads and shows 76% healing rate at three years. I know once I lose the peroneus brevis insertion on the lateral side or if you lose the tibialis posterior anterior on the medial side, your foot is going to go one way or the other and this is the way of tendon rebalancing as far as limb salvage goes.
The lateral foot ulcer, fifth met. We talked about the fifth met head resection already but other tendon procedure are out there to try to accommodate this. You got your tibialis anterior lengthening. Remember the tibialis anterior is a supinator. In 2015, Journal of Foot and Ankle Surgery, the group down with Ettinger and Steinberg suggested that doing a stat or just a tibialis anterior lengthening will decrease the supinatory pressures on the lateral column ulcers, especially the more distal lateral column of fourth and fifth metatarsals. So this was a significant enlightenment to me and I started doing this procedure a little more in my private practice and I am getting great success with it. This is a picture of how they do it. This is the tibialis anterior lengthening or, if you will, weakening. Just do a Z-slide of the tibialis anterior. That's a small incision. I think everyone in New York can do this without any problem. The stat is a little more complex and it's shown to be very similar in efficacy, but that's a sub-fifth met head ulcer and you could do that with or without fifth metatarsal head resection. If there is osteomyelitis, I would like to pop it out. If there is no osteomyelitis, I would like to leave it in and try this. Again, another paper by Armstrong showing a tibialis anterior tendon transfer and fat pad augmentation. Again, the ulcers on the lateral column here. This is a little more proximal but still it worked and he augmented the fat pad as well with belly fat if I remember the study correctly. Real quick, I am running out of time, but I want to just talk about TAL versus TCC. Tendon lengthening heals more ulcers and wounds than total contact cast. Multiple studies have shown that. 34% of TCC went on to re-ulcerate after 18 months. There is only one randomized head to head TCC versus TAL.
There is 81% re-ulceration rate after TCC and 30% ulceration rate after TAL. There, you could see me in a total contact cast. Diabetics are three times more likely to have elevated foot pressures than non-diabetics. And then again, Armstrong, bone and joint, 1999 confirmed Achilles lengthening decreases the pressure of the forefoot recommending the procedure as adjunct therapeutic and prophylactic measure to reduce the risk of re-ulceration. So we should be doing these procedures on our plantar wounds. The common ways to do them, I think we are familiar with them but I will just show you some pictures. There is gastroc versus TAL. They have similar effects. You could argue one way or other which one is better but it's not in the scope of this lecture. There is classic three incision. Achilles tendinopathy, which confirmed an 89% of patients with diabetes with ultrasound. Armstrong, again percutaneous TAL reduces forefoot pressure by 27% and then this was the head to head again with TAL versus TCC. The control groups, the re-ulceration rates at 7 and 24 months, 15% for the TAL, 38% for the total contact cast. And time to re-ulcer, 431 days for the TAL, 131 for the total contact cast. So you could see that Achilles tendon lengthening and gastroc is superior to total contact casting for long-term keeping the wound closed. I was going to show some plastic techniques to quickly do this, but I think I am running low on time, right Dr. Frykberg? Okay. So I am going to wrap it up here.
All those techniques I just showed you can be as far as metatarsal head resections and tendon resections and tendon transfers can be done with plastic approaches, but I am going to leave it there for now. Thank you.
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