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

Abstract

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.