Journal of Foot and Ankle Surgery (Asia Pacific)

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VOLUME 11 , ISSUE 3 ( July-September, 2024 ) > List of Articles


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

Donatas Chlebinskas, Dhrumin Sangoi, Venu Kavarthapu

Keywords : Diabetic foot ulcers, Minimally invasive, Off-loading surgery

Citation Information : Chlebinskas D, Sangoi D, Kavarthapu V. Less Invasive Off-loading Surgery of Chronic Plantar Diabetic Forefoot Ulcers: A Narrative Review. J Foot Ankle Surg Asia-Pacific 2024; 11 (3):132-137.

DOI: 10.5005/jp-journals-10040-1330

License: CC BY-NC 4.0

Published Online: 03-07-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Aim and background: It is estimated that between 19 and 34% of people with diabetes will have a diabetic foot ulcer (DFU) at some point in their lives. The forefoot is the most common anatomical region in the foot for the development of an ulcer. DFU leads to a 5-year mortality rate of >50%, which is similar to or even worse than many types of common cancers. Recognized off-loading with total contact casting (TCC) leads to successful ulcer healing but high reulceration rates. Concerns remain high on the wound complication rates following open surgical off-loading procedures due to the associated distal vascular impairment. Less invasive surgical approaches and techniques may reduce these risks when addressing such pathologies. We aimed to review the less invasive and percutaneous surgical off-loading options for chronic diabetic forefoot ulcers. Methods: We have performed a PubMed database search to review the literature on the development, pathophysiology, percutaneous surgical off-loading options, and the key surgical concepts of chronic diabetic plantar foot ulcers. We have reviewed only techniques that are backed by higher than level 5 evidence based on their success rates and complication rates. Results: For the most common lesser toes apical ulcers, percutaneous flexor digitorum longus (FDL) tenotomy has shown 98% ulcer healing rates and 6.4% recurrence rates; however, a 9.9% incidence of transfer ulcers for isolated tenotomies was reported. Hallux plantar ulcers are the second most prevalent plantar foot ulcers, and flexor hallucis longus (FHL) tenotomy has an 82% success rate without recurrence in over a 20-week follow-up. Medial forefoot ulcers are the third most common, and percutaneous Achilles tendon lengthening (ATL), followed by TCC, has demonstrated 100% healing rates and 38% recurrence in 2 years. Peroneus tendon lengthening and dorsal closing wedge osteotomy have been described as treatment methods. The lateral forefoot is the fourth most common site for ulcers, and the initial treatment is ATL. Similarly, dorsal distal to plantar proximal percutaneous distal metatarsal osteotomies have been reported for lesser metatarsal head-based ulcers with up to 100% ulcer resolution and no recurrence at mean 25-month follow-up. Conclusion: Deformity correction using minimally invasive techniques provides a surgical off-loading treatment option for chronic plantar diabetic forefoot ulcers and carries lower recurrence rates than nonsurgical options. Most of the studies reporting the results of these techniques are case reports and small series, and higher evidence-level studies would be needed to confidently recommend some of these techniques for developing guidelines. Clinical significance: Percutaneous and less invasive techniques range from established to emerging methods and are becoming important surgical tools in the armamentarium of a foot and ankle surgeon. These are safe to be used in the prophylaxis and treatment of DFUs and deformities with the benefit of reduced risk of infections and wound complications in these vulnerable patients.

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