Panmetatarsal Head Resection Research Articles

IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes.

Recommendations To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower‐extremity amputation, peripheral artery disease, foot deformity, pre‐ulcerative signs on the foot, poor foot hygiene and ill‐fitting or inadequate footwear. (Strong; Low) Treat any pre‐ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) To protect their feet, instruct an at‐risk patient with diabetes not to walk barefoot, in socks only, or in thin‐soled standard slippers, whether at home or when outside. (Strong; Low) Instruct an at‐risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) Instruct an at‐risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non‐plantar, or a recurrent non‐plantar foot ulcer. When a foot deformity or a pre‐ulcerative sign is present, consider prescribing therapeutic shoes, custom‐made insoles or toe orthosis. (Strong; Low) To prevent a recurrent plantar foot ulcer in an at‐risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure‐relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) To prevent a first foot ulcer in an at‐risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) To prevent a recurrent foot ulcer in an at‐risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re‐evaluated once every 1 to 3 months as necessary. (Strong; Low) Instruct a high‐risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high‐risk patient with diabetes, hammertoes and either a pre‐ulcerative sign or an ulcer on the distal toe. (Weak; Low) Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high‐risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at‐risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)

The Too Few Toes principle: A formula for limb-sparing low-level amputation planning

Both single and multiple toe amputations biomechanically alter foot function to varying degrees. In patients with diabetic neuropathy, these changes often lead to increases in deformity, plantar pressure and risk for ulceration, infection and reamputation. While a philosophy that strives to maximize limb length and function by performing the fewest and most distal amputations possible is likely a good one, we believe that a basic “formula” might help serve as a guide for surgeons to balance limb function with tissue preservation. Digital amputations that exceed a “hallux plus one lesser toe” or “lesser toe plus two” digital/ray amputations in our experience often surpass a threshold of mechanical function. For any clinical scenario in which amputation would extend beyond this threshold, a transmetatarsal amputation (TMA) or pan metatarsal head resection (PMHR) should strongly be considered to avoid costly foot complications and the need for excessive revisional surgery. Such an approach still maintains an underlying philosophy of functional limb preservation. We are unaware of any other attempt to standardize the advancement of surgical intervention from multiple toe resections to a full metatarsal level or higher resection. Therefore, we present this simple formula for surgical planning in the hopes of providing the most durable and efficient care of the high-risk diabetic foot when multiple toe amputations are needed.

Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads

To analyse the risk of reulceration caused by the transfer of lesions in patients with diabetes, undergoing resection of at least one metatarsal head. A total of 119 patients with diabetes from the Diabetic Foot Unit (Complutense University, Madrid, Spain), who underwent resection of at least one metatarsal head were analysed prospectively from November 2006 to December 2011 to assess reulceration in the other metatarsal head. Seven patients were excluded for being subjected to a pan-metatarsal head resection and 11 patients dropped out. During a median follow-up period of 13.1 months (interquartile range 6.1-22.8 months), 41% of patients suffered from reulcerations. Reulceration frequency in patients operated on the 1st, 2nd, 3rd, 4th, 5th and several metatarsal heads was 9 (69%), 8 (44%), 12 (52%), 2 (25%), 6 (19%) and 4 (50%) events, respectively. The Cox regression model showed hazard ratios that were significant for the location of the metatarsal resection. The first metatarsal showed the highest risk for reulceration (hazard ratio 3.307; 1.472-7.430) and the fifth metatarsal showed the lowest risk (hazard ratio 0.339; 0.138-0.832). Reulceration is a frequent event following resection of a metatarsal head and should be regarded as an implicit complication of the intervention. The location of the resection determines the risk of reulceration, which is highest for patients operated on the first metatarsal head and lowest for patients operated on the fifth metatarsal head.

Clinical Efficacy of the Pan Metatarsal Head Resection as a Curative Procedure in Patients with Diabetes Mellitus and Neuropathic Forefoot Wounds

To evaluate the safety and efficacy of the pan metatarsal head resection (PMHR) compared with nonsurgical management of wounds in the forefoot in people with diabetes. The authors evaluated 92 patients with diabetes (66.3% male), with ulcers classified as University of Texas grade 1A or 2A at the plantar aspect of the forefoot using a case-control model. Cases were patients treated with multiple metatarsal head resections for multiple metatarsal head wounds, and controls received standard nonsurgical care. Both groups received standard off-loading and wound care. Outcomes included time to healing, reulceration, infection, and amputation. Patients in the surgery group (SG) healed significantly faster than those in the standard therapy group (ST; 84.2 ± 39.9 days for the ST vs 60.1 ± 27.9 days for the SG; P = .003) and had fewer recurrent ulcers (39.1% for the ST vs 15.2% for the SG; P = .02; odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.3-9.7) and infections during 1 year of follow-up (64.5% for the ST vs 35.5% for the SG; P = .047; OR = 2.4; 95% CI = 1.0-6.0). There was no significant difference in the proportion of patients receiving an incident amputation in the follow-up period (13.0% for the ST vs 6.5% for the SG; P = .5). The results of this study suggest that the PMHR may be associated with shorter times to healing and lower morbidity compared with standard care alone in patients without digital gangrene and with multiple plantar forefoot ulcers.

Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study.

To evaluate the reulceration and reamputation rates in a cohort of diabetic patients following first ray amputation. We evaluated a cohort of 89 diabetic patients, 63 men and 26 women, who underwent first ray amputation in the period from January 2000 to December 2001. The first ray lesions were Wagner grade 2 in 3 patients, Wagner grade 3 in 47 patients, and Wagner grade 4 in 39 patients. Following surgical wound healing, all patients wore special footwear with rocker bottom soles and custom molded insoles and were put on an intensive secondary prevention program. The mean follow-up duration was 16.35 +/- 6.76 months (range 7-28). Fifteen patients developed new ulcerations, with 11 lesions occurring ipsilaterally and 4 contralaterally to the first ray amputation. In seven patients, the new lesion was treated and healed with dressing. Eight patients underwent a new surgical procedure: panmetatarsal head resection in four patients, toe amputation in two patients, a transmetatarsal amputation in one patient, and Lisfranc's amputation in one patient. In the population studied, the first ray amputation presented a lower reulceration and reamputation rate with respect to that reported in the literature. This finding should therefore be attributed to the follow-up program, which uses shoes with a rocker bottom sole and custom molded insoles and intensive ambulatory check-ups.

Simple method of exacting a desired parabola for pan-metatarsal head resection

Simple method of exacting a desired parabola for pan-metatarsal head resection

Recurrent plantar ulceration following pan metatarsal head resection

Although the pan metatarsal head resection, since it was originally described and performed by Hoffman in 1911, has proven to be an effective and viable procedure in treating many forefoot deformities, it is not without its own complications. The authors provide an historical perspective of the pan metatarsal head resection, a discussion on the complication of recurrent plantar ulceration after the pan metatarsal head resection, and a review of their own experience with this procedure. A retrospective review was performed of all patients having undergone pan metatarsal resections between August 1980 and April 1993. Twenty procedures were performed on 12 patients with diabetic neuropathy, and 21 procedures were performed on 15 patients with rheumatoid arthritis. The incidence of recurrent plantar ulceration after surgical correction was 25% and 28%, respectively. All 27 patients underwent primary healing. The authors, therefore, conclude that the complication of recurrent plantar ulceration after this procedure is a very likely and distinct possibility.

Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation.

While the transmetatarsal amputation has resulted in the salvage of numerous diabetic limbs, it remains an ablative procedure with both short- and long-term complications. The authors reviewed their experience with the panmetatarsal head resection as an alternative to the transmetatarsal amputation. A retrospective review was performed of all patients having undergone this procedure between May 1986 and November 1991. Thirty-seven procedures were performed; of these, 34 were evaluated. The average follow-up period was 20.9 months. Thirty-two feet showed primary healing while one showed delayed healing. One patient had local recurrence of the original ulceration. Primary healing was 94% while overall success was 97%. No patient required amputation of any kind. The authors conclude that the panmetatarsal head resection is a viable alternative to the transmetatarsal amputation in properly selected patients because it avoids many of the structural and biomechanical pitfalls of the transmetatarsal amputation.

Pan metatarsal head resection. A review and new approach.

Pan metatarsal head resection. A review and new approach.