Forefoot Ulcers Research Articles

Management of Diabetic Foot Ulcers with Two Forefoot Offloading Techniques: Case Series.

Offloading is a key principle to healing diabetic foot ulcers. Nonremovable knee-high offloading devices are considered the criterion standard for offloading plantar forefoot ulcers. However, patients exhibit a limited tolerance for these devices, which contributes to a lack of use. In this case series describing two patients, the authors share two alternative offloading modalities for the treatment of diabetic plantar forefoot ulcers. One patient was managed using a football offloading dressing, and the other was managed with a modified felted football dressing. The football and modified felted football offloading dressings provide a cost-effective, less time-consuming application and often are a better-tolerated alternative to nonremovable knee-high offloading devices. Clinical findings support further investigation into dressing options tolerated by patients with improved adherence and optimal healing outcomes.

Less Invasive Off-loading Surgery of Chronic Plantar Diabetic Forefoot Ulcers: A Narrative Review

Less Invasive Off-loading Surgery of Chronic Plantar Diabetic Forefoot Ulcers: A Narrative Review

Examining characteristics of those who receive pedorthic services: A clinical audit.

Diabetes-related foot complications, including neuropathic plantar forefoot ulcers, are a significant contributor to morbidity and increased healthcare costs. This retrospective clinical audit examines the characteristics of people accessing pedorthics services who are at risk of neuropathic plantar forefoot ulcer (re)occurrence and the pathways and funding models used to access these services. A clinical record audit was conducted on all patients accessing a pedorthics service who had diabetes and neuropathy with a history of plantar forefoot ulceration. The data included demographics, diabetes and neuropathy duration, main forefoot pathology and other comorbidity, footwear and insole interventions, and health fund access status. A total of 70 patient records were accessed, and relevant data was extracted. The mean age of participants was 64.69 (standard deviation (SD) 11.78) years; 61% were male and 39% female. Duration of diabetes ranged from one to 35 years, with a mean of 14.09 years (SD 6.58). The mean duration of neuropathy was 8.56 (SD 4.16) years. The most common forefoot conditions were bony prominences at 71% (n = 50), rigid flat foot and limited joint mobility (53%, n = 37), and hallux abductovalgus at 47% (n = 33). All participants had hyperkeratosis; 34% (n = 24) had forefoot amputation, and around 34% (n = 24) had a history of digital amputation. Various publicly funded packages and private health insurance were accessed. This study investigates the sociodemographic and medical profiles of individuals with diabetes-related foot complexities prone to neuropathic plantar forefoot ulcers. It is the first to examine patients receiving pedorthic services, informing practitioner surveys and preventive care strategies. Understanding patient characteristics aids in optimising multidisciplinary care and reducing ulcer incidence. Further studies are warranted to explore the field to establish an effective multidisciplinary care approach between medical professionals, podiatrists and pedorthists to optimise patient outcomes.

A TWO-STAGE APPROACH IN MANAGING DIABETIC FOREFOOT ULCERS

AimForefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers.MethodsConsecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months.Results112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening.In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1st metatarsal and 5th metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up.ConclusionThe described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL.

Predictors of operative management in diabetic foot ulcers.

Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p<0.001), OR 2.19 (p<0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p<0.019) if osteomyelitis was present. Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.

Developing a Practical Tool for Predicting Wound Healing Outcomes of Patients with Diabetic Forefoot Ulcers: Focus on Vasculopathy and Infection.

To develop a preliminary risk scoring system to predict the prognosis of patients with diabetic forefoot ulcers based on the severity of vasculopathy and infection, which are the major risk factors for amputation. Forefoot was defined as the distal part of the foot composed of the metatarsal bones and phalanges and associated soft tissue structures. The degree of vasculopathy was graded as V0, V1, or V2 according to transcutaneous partial oxygen tension values and toe pressure. The degree of infection was graded as I0, I1, or I2 according to tissue and bone biopsy culture results. The risk scores were calculated by adding the scores for the degree of vasculopathy and infection and ranged from 0 to 4. Wound healing outcomes were graded as healed without amputation, minor amputation, or major amputation. The authors evaluated wound healing outcomes according to risk scores. As the risk score increased, the proportion of patients who underwent both major and minor amputations increased (P < .001). In the multivariate logistic analysis, the odds ratios of amputation also increased as the risk score increased. Patients with a risk score of 4 were 75- and 19-fold more likely to undergo major and minor amputations, respectively, than patients with a risk score of 0 (P = .006 and P < .001). The risk score can be used as an indicator to predict the probability of amputation in patients with diabetic forefoot ulcers.

A 2-Stage Approach in Managing Diabetic Forefoot Ulcers.

Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer. A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations. Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion. TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months. Level IV, retrospective case series.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update).

Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcersin persons with diabetes. It serves as an update of the 2019 IWGDF guideline. We followed the GRADE approach by devising clinicalquestions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement itemsincluding desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice. These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

Offloading of diabetes-related neuropathic foot ulcers at Swedish prosthetic and orthotic clinics.

This study aimed to assess (1) the use of different offloading interventions in Sweden for the healing of diabetes-related plantar neuropathic forefoot ulcers, (2) factors influencing the offloading intervention choice, and (3) the awareness of current gold standard offloading devices. An online questionnaire was distributed via SurveyMonkey to 51 prosthetic and orthotic clinics in Sweden. Thirty-five (69%) practitioners responded to the questionnaire. Eighty-six percent of the practitioners provided modified off-the-shelf footwear combined with insoles to treat diabetes-related plantar neuropathic forefoot ulcers. A total contact cast (TCC) was provided by 20% of the practitioners, and a nonremovable knee-high walker was provided by 0%. Multiple practitioner-, patient-, intervention-, and wound-related factors were considered when practitioners provided offloading interventions to patients with this type of ulcer. The majority of the practitioners did not or were unsure whether they considered TCC or a nonremovable knee-high walker to be the gold standard treatment. Practitioners mainly provided the offloading intervention that the International Working Group on the Diabetic Foot strongly recommends not be provided, namely, modified off-the-shelf footwear with insoles. In contrast, TCC and nonremovable knee-high walkers, as the gold standards, were vastly underutilised. Therefore, the pattern of providing offloading interventions was almost exactly opposite to the recommendations of evidence-based guidelines. Different factors were considered when providing offloading interventions to patients with diabetes-related plantar neuropathic forefoot ulcers. The practitioners' lack of awareness regarding gold standard devices may have contributed to the underutilisation of TCC and nonremovable knee-high walkers.

A COMPARATIVE STUDY BETWEEN PRESSURE OFFLOADING DEVICE DRESSING VERSUS CONVENTIONAL BETADINE AND NORMAL SALINE DRESSINGS IN TREATMENT OF PLANTAR DIABETIC FOOT ULCER

Ofoading is redistribution of weight bearing from a small area to a large area, reducing unit of load per unit surface area of foot, thereby decreasing pressure over plantar ulcers . A Randomised Controlled Study conducted in GGH, Vijayawada in plantar diabetic foot ulcers, based on exclusion and inclusion criteria allocated to Ofoading device dressing(50), Conventional Dressing(50).Forefoot ulcers (19), hindfoot ulcers (81) were included with a mean size of ulcers at week 0 among control group(5.32cm) and study group(5.91cm) respectively. A reduction in size to 2.28 cm, 1.25 cm has been noticed at end of 6 weeks respectively (p= &lt; 0.0001). Control group and study group had 40 and 46 Grade2 ulcers respectively. A reduction in grade to Grade1 has been noticed at end of 6 weeks in 25 and 45 patients respectively. Necrotic tissue score on ulcers at week 0 among control group and study group were, Grades (2 =26, 3 = 24 and 2 =28, 3 =24) (p= 0.38) respectively. A reduction in percentage of necrotic tissue to has been noticed at end of 6 weeks respectively ( p= 0.0001).Granulation tissue score on ulcers at week 0 among control group and study group were Grades (1 = 35, 2 =15 and 1 = 28 ,2= 22 respectively) . An increase in granulation tissue score to Grades (4 = 20 ,3= 28 and 4 =44 and 3 = 4), has been noticed at end of 6 weeks respectively (p= 0.0001). Number of debridements required for the ulcer healing until week 6 among the control group and study group was 27( 2), 22 (1) and 36 (1) , 13 (2) respectively (p =0.0006). A statistically signicant difference in patient satisfaction was noted. Mandakini Ofoading Device is cost-effective, easily available, efcient ,technically easy, less time consuming, good patient compliance and satisfaction, less restriction to mobility, fewer secondary infection rates, fewer recurrence rates, earlier reduction in size of ulcers

Saving the foot: Simple orthopaedic surgical intervention demonstrates improved outcomes and reduced costs

BackgroundForefoot ulceration in diabetes requires significant resources, with high cost and low rates of success. The authors present the results of tendon procedures (percutaneous toe tenotomy and percutaneous tendo-achilles lengthening) under local anaesthetic to adjust mechanics in patients with diabetic neuropathic forefoot ulceration. MethodsRetrospective review of electronic patient record of 19 patients (22 feet) undergoing local anaesthetic tendon procedures between April 2019 and April 2021 with a 12 month follow up period. Size of ulcer, rate of ulcer healing, complication rates and ulcer recurrence were recorded and compared to a population of conservatively-managed patients (14 patients, 15 feet) treated prior to the introduction of tendon procedures. All clinical information obtained from electronic patient records. ResultsAll patients undergoing tendon procedures achieved complete ulcer healing at a mean time of 3.3 weeks for toe tip ulcers (after toe tenotomy) and 4.5 weeks for metatarsal head ulcers (after Achilles lengthening). There were no admissions for diabetic foot sepsis, reduced recurrence, reduced amputation rates and no mortality.Of the conservatively managed cohort, only 3 of the 15 achieved ulcer resolution without recurrence within the 12 month study period.The cohort managed conservatively had an average cost of £ 9902 per patient, per annum. The intervention cost was £ 1211 per patient, saving an average of £ 8691 per patient, per annum with ulcer resolution (88 % reduction in costs). ConclusionSignificant patient benefit, reduction in resource use and cost saving was seen with this simple intervention, which merits full evaluation in a clinical trial. Level of EvidenceLevel-IV

Footwear and insole design parameters to prevent occurrence and recurrence of neuropathic plantar forefoot ulcers in patients with diabetes: a series of N-of-1 trial study protocol

BackgroundFoot complications occur in conjunction with poorly controlled diabetes. Plantar forefoot ulceration contributes to partial amputation in unstable diabetics, and the risk increases with concomitant neuropathy. Reducing peak plantar forefoot pressure reduces ulcer occurrence and recurrence. Footwear and insoles are used to offload the neuropathic foot, but the success of offloading is dependent on patient adherence. This study aims to determine which design and modification features of footwear and insoles improve forefoot plantar pressure offloading and adherence in people with diabetes and neuropathy.MethodsThis study, involving a series of N-of-1 trials, included 21 participants who had a history of neuropathic plantar forefoot ulcers. Participants were recruited from two public hospitals and one private podiatry clinic in Sydney, New South Wales, Australia. This trial is non-randomised and unblinded. Participants will be recruited from three sites, including two high-risk foot services and a private podiatry clinic in Sydney, Australia. Mobilemat™ and F-Scan® plantar pressure mapping systems by TekScan® (Boston, USA) will be used to measure barefoot and in-shoe plantar pressures. Participants’ self-reports will be used to quantify the wearing period over a certain period of between 2 and 4 weeks during the trial. Participant preference toward footwear, insole design and quality-of-life-related information will be collected and analysed. The descriptive and inferential statistical analyses will be performed using IBM SPSS Statistics (version 27). And the software NVivo (version 12) will be utilised for the qualitative data analysis.DiscussionThis is the first trial assessing footwear and insole interventions in people with diabetes by using a series of N-of-1 trials. Reporting self-declared wearing periods and participants’ preferences on footwear style and aesthetics are the important approaches for this trial. Patient-centric device designs are the key to therapeutic outcomes, and this study is designed with that strategy in mind.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000699965p. Registered on June 23, 2020

Exploring in-shoe plantar pressure differences at the metatarsal pad position for patients with diabetes and toe deformities: A pilot study

Patients with diabetes are often prescribed insoles with metatarsal pads intended to prevent and offload forefoot ulcers. However, to our knowledge, the plantar pressures specifically at the metatarsal pad had not previously been researched. The aim of this study was therefore to explore plantar pressures at the metatarsal pad position by comparing three toe deformity groups, claw toe (CT)/hammer toe (HT) and hallux valgus (HV), with a control group (NONE). In-shoe plantar pressures were measured using F-ScanTM and a polygon region of interest at the metatarsal pad position was created. Mean peak pressure (MPP), pressure-time integral (PTI) and percentage foot-insole contact area at the metatarsal pad position (%CA) were analysed from 24 patients (48 feet) in the metatarsal pad area. No significant difference was found between the groups regarding MPP, PTI or contact area. For MPP, the highest value was found in CT/HT (140kPa ± 61) and the lowest in HV (112kPa ± 33). In PTI, the highest value was for CT/HT (2.0 Ns/cm2 ± 1.0) and the lowest for HV (1.3 Ns/cm2 ± 0.4). The %CA was highest in CT/HT/HV (95%) and lowest in NONE (70%). A new quantitative approach was presented, assessing the metatarsal pad pressure effect on its corresponding plantar area of the foot. Further studies are needed to identify the conditions in which a metatarsal pad affects different foot statuses with regard to plantar pressure.

Management of diabetic ulcers of the dorsum of the foot and distal leg ulcers.

Diabetic foot ulceration of toes, forefoot and heel have been extensively studied; however, the dorsum of the foot and the distal leg have rarely been addressed. The objective of this study was to assess diabetic ulcers of the dorsum of the foot and of the distal leg (DUDFDLs) as primary sites, or extended lesions from other foot locations, with regard to possible causes, management and outcomes. This was a retrospective study conducted in Jabir Abu Eliz Diabetic Centre (JADC) in Khartoum from January 2018 to August 2019. All patients with a primary DUDFDL, or one extending from a plantar or heel ulcer, were included. A cohort of 102 patients with DUDFDLs were studied; 74 (72.5%) were male and 28 (27.5%) were female, with a male-to-female ratio of 2.6:1, and a mean age of 57±12 years. The ulcer was a primary DUDFDL in 38 patients and a secondary ulcer in 64 patients. The outcome in 38 patients with primary DUDFDL was healing without amputation in 26 cases (68.4%), amputation of toes in 12 cases (31.6%), and no major amputation or death. Of the 64 patients presenting with secondary DUDFDL extending from the plantar surface, there was extension to the dorsum of the foot through the forefoot ulcer in 54 patients and through the ankle joint to the distal leg in 10 patients. For the plantar ulcers extending to the dorsum, five cases healed without amputation (9.3%), minor amputation was necessary in 29 cases (53.7%), major amputation in 14 cases (25.9%) and six patients died (11.1%). For the distal leg ulcers with extension through the ankle joint, five healed without amputation and five required minor amputation. Primary DUDFDLs had a favourable outcome. Dorsum extension of diabetic foot ulcer from the plantar aspect of the foot carries a high risk for major limb amputation and death.

5-Year Follow-Up of Neuropathic Minimally Invasive Surgery for the Management of Diabetic Forefoot Ulcers

Category: Diabetes; Bunion; Lesser Toes Introduction/Purpose: Diabetic forefoot ulcers are associated with a high risk of recurrence, subsequent infection and amputation. Patients who have an amputation for diabetic foot disease have a significantly increased 5-year morbidity and mortality. Minimally invasive surgery to redistribute forces includes any combination of percutaneous Achilles/extensor tendon lengthening, osteotomy/excision of the metatarsal head or sesamoids, and phalangeal osteotomy. The purpose of this case- controlled cohort study is to determine if there is any significant reduction in re-ulceration and amputations rates in patients treated with Neuropathic Minimally Invasive Surgeries, versus conservative management with wound debridement, antibiotics and total contact casting. Methods: Patients who had presented to the diabetic foot clinics that subsequently underwent Neuropathic Minimally Invasive Surgery over a 5-year period were matched with a similar group of patients (age, sex, neuropathy, peripheral vascular disease) who were managed conservatively. The conservative group of patients were identified from the Scottish SCI-Diabetes database. Outcomes of recurrent ulceration and amputation, time to heal and number of clinic visit were all compared. Results: Patients who underwent minimally invasive surgery had predictable healing of their ulcers in 6 weeks. Very few represented a recurrent ulcer, though some did develop an ulcer at a different site. Subsequent amputation rates were lower in the surgical group versus the non-surgical group. The number of clinic visits significantly reduced in the operated group, versus the conservatively treated group. Conclusion: Patients with recurrent diabetic foot ulcers benefit from early assessment to determine if they would be a good surgical candidate for Neuropathic Minimally Invasive Surgery. Many diabetic patients have an alteration in their foot biomechanics, whether soft tissue, osseous or both. Minimally invasive surgeries provide relatively predictive times to ulcer healing. Re-ulceration at the same time is reduced. This has a significant impact on the patients' quality of life. There is also a major benefit to healthcare systems where there is a significant burden of the health care budget being allocated for regular dressings and wound reviews.

Concomitant Achilles Tendon Lengthening with Transmetatarsal Amputation for the Prevention of Late Forefoot Ulceration.

Late development of forefoot ulcers is a common finding after transmetatarsal amputation (TMA). The primary aim of this study was to examine whether concomitant prophylactic Achilles tendon lengthening (ATL) was associated with a reduction in the incidence of forefoot ulcers postoperatively. A retrospective chart review was performed by 2 authors to identify patients who underwent TMA over a period of 5.5 years from January 1, 2015, through July 31, 2020. They identified 110 feet in 107 patients; the 83 patients (85 feet) who had ≥120 days of follow-up were used for the study. Follow-up was performed with telephone calls (80 patients) or during the last office visit (3 patients). Those who were contacted by telephone were asked if they developed an ulcer after healing from the original surgery. Mean follow-up time was 672 ± 258 days for the 30 feet with concomitant Achilles lengthening and 663 ± 434 days for the 55 feet without Achilles lengthening. Demographic data were analyzed for association with late development of forefoot ulceration. Eighty-five feet were included in the analysis. Late forefoot ulcers developed in 35% of feet that had a TMA alone (n = 55) compared with 3% of feet who received a concomitant ATL (n = 30; p < 0.001); the 2 groups had similar mean follow-up times. Mean time to ulcer development was 587 ± 420 days in the 19 patients without Achilles lengthening. Of the patients who developed late forefoot ulcers, 47% also developed osteomyelitis, and 16% went on to proximal amputation. Patients who developed forefoot ulcers were younger (55 ± 12 versus 63 ± 11 years of age; p = 0.006) than those who did not. ATL at the time of TMA is associated with a reduction in the risk of later development of forefoot ulcers, especially in younger patients. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Minimally Invasive Metatarsal Osteotomies (MIMOs) for the Treatment of Plantar Diabetic Forefoot Ulcers (PDFUs): A Systematic Review and Meta-Analysis with Meta-Regressions

Plantar Diabetic Foot Ulcers (PDFUs) are frequent injuries affecting and heavily limiting the quality of life in diabetic patients. PDFUs can be treated both conservatively (with a high recurrence rate) or surgically (with a high rate of complication). Recently, minimally invasive surgery (MIS), performed by small incisions, has been increasingly applied on diabetic feet due to their encouraging outcomes and low complication rate. This systematic review with meta-analysis and meta-regression aims to evaluate for the first time the effectiveness of minimally invasive metatarsal osteotomies (MIMOs) in treating PDFUs and reducing their recurrence rate. A literature search of PubMed/MEDLINE, ISI/Web of Science and Scopus databases was carried out with the keywords “(metatarsal osteotom*) OR (metatarsal AND osteotom*) AND diabet* AND (feet OR foot OR forefoot) AND ulcer”, covering the period from 1980 until June 2021 following PRISMA guidelines. The JBI critical appraisal tool was used for Quality Assessment. Healing rate/time, infection rate, recurrence rate, non-union rate and complication rate were evaluated. When possible, these values were pooled and expressed in effect size (ES), and their 95% confidence interval (CI) was computed. Meta-regression analysis (both uni- and multivariate) was conducted. Eight studies were included in the review, including 189 patients. The healing rate of these studies ranged between 55.1 and 100%, infection rate from 3.3 to 31.8%, recurrence rate from 0.0% and 13.6% and non-union rate from 4.5–30.0%. Overall complication rate was reported in three studies and ranged from 44.9 to 68.2%. Meta-analysis of the various rates revealed an overall healing rate of 91.9% (range from 74.9 to 97.8%), infection rate of 10.9% (4.2–25.2%), recurrence rate 7.2% (3.6–14.2%), non-union rate 16.9% (10.2–26.7%) and finally, the complication rate was computed at 53.2%. Satisfactory short- to medium-term clinical and radiographic results were reported by the studies included in this review, supporting that MIMOs represent an effective surgical approach to treat PDFUs. However, poor quality in the methodology of some studies and the lack of long-term data were reported. Therefore, randomized controlled trials, prospective studies and long-term follow-up studies are needed.

The level of evidence of the publications on conservative surgery for the treatment of diabetic forefoot ulcers: A scoping review

ObjectiveThe diabetic foot disease is one of the most serious complications of diabetes causing high rates of amputations, premature deaths and healthcare cost. While standard non-surgical care is the mainstay of treatment of diabetic foot ulcers (DFU), many reports demonstrated that conservative surgery particularly in the forefoot, compared better in terms of clinical outcomes. Nevertheless, the quality of surgical articles dealing with diabetic ulcers of the forefoot is thought to be average. This paper aimed to quantify the level of evidence of the DFU surgical papers published in the literature. Literature surveyPubMed was searched from inception till Feb 2020. All study designs but case reports were accepted for inclusion. Two outcomes were searched for: a) study design and b) level of evidence. The level of evidence of the studies was based on the classification developed by the Oxford Center for Evidence-based Medicine. ResultsIn total, 90 articles were included for analysis. Only 6 studies (6.7%) had a Level 1 level of evidence. One study had a Level 2 (1.1%) and 13 studies (14.4%) a Level 3. The majority of the included studies had a Level 4 of level of evidence with 70 studies (77.8%) being case-series. ConclusionIt is surprising that a disease with such enormous health-related and financial burden did not generate enough interest among surgeons to invest more into high quality research. The findings should incite surgeons to get more involved in the treatment of forefoot diabetic wound and infection. Large comparative prospective high quality trials to assess the available surgical methods are needed.

Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer.

Although surgical offloading seems a more permanent solution for prevention and treatment of neuropathic plantar diabetic forefoot ulcers (DFUs), the evidence for this assumption is weak and needs further studies to be established. The aim of this retrospective study is to compare the healing efficacy, associated morbidity, and recurrence rates of surgical versus removable knee-high offloading for neuropathic plantar (DFUs) healing. From January 2016 to January 2018, 70 neuropathic plantar forefoot DFUs were nonrandomly assigned to either removable knee-high cam-walker (n = 35), or metatarsal head, or accessory bone resection (n = 35). The primary endpoints were the frequency and rate of complete healing, and the rate of ulcer area reduction within 4 months. The secondary endpoints were 4 months morbidity and ulcer recurrence within 12 months. After 4 months, complete healing was significantly inferior with cam-walker compared with surgical offloading; 24 (67.6%) versus 31 patients (88.6%), respectively, P = .015. Ulcer area reduction was 2.4 cm2 (66.7%) versus 2.6 cm2 (83.9%), P = .001, in the mechanical versus the surgical groups, respectively. The mean healing time was 3.6 ± 2.1 versus 2.8 ± 0.6 months in the mechanical versus the surgical groups, respectively, P = .012. Morbidity and recurrence show nonsignificant differences between both groups. Ulcer recurrence was noted in 5/35 (14.3%) versus 2/35 (5.7%), in mechanical versus surgical groups, respectively, P = .23. Therefore, metatarsal head/accessory bone resection offered improved healing efficacy but similar morbidity and recurrence to the removable cam-walker.

Randomized comparative study between metatarsal head resection and total contact cast in the treatment of diabetic plantar forefoot ulcer

Objective The present study assessed and compared the efficacy of metatarsal head resection (MHR) compared with total contact cast (TCC) in the treatment of neuropathic diabetic foot ulcers located at the plantar surface of metatarsal heads. Materials and methods Between January 2017 and September 2019, this prospective, randomized, comparative study was performed at Menoufia University −Hospitals. One hundred patients suffering from solitary planter forefoot neuropathic ulceration were assigned into two groups: the first group was treated by MHR and the second group was treated by TCC. Wound healing was the primary outcome while ulcer recurrence and complications were the secondary outcomes of this study. Results Baseline patient characteristics were comparable in both groups. Both intention-to-treat and per-protocol analysis were used to evaluate ulcer healing during the treatment period. Percentage of ulcers healed within 12 weeks was 82 and 58% for MHR and TCC groups, respectively (P Conclusion Being an invasive procedure, MHR offers a safe effective offloading option with higher healing potential and lower recurrence rate compared with TCC as the standard offloading modality.