Canadian Medical Alliance for the Preservation of the Lower Extremity
"When solving problems, dig at the roots,
instead of just hacking at the leaves."
--Anthony J. D'Angelo
Surgical Offloading of Wounds
We discuss the basics of offloading the foot through
traditional, conservative means (such as specialized
inserts, shoes, boots, and casts) here.
But there are times when the best way to offload a
neuropathic or diabetic foot ulcer is through surgical
intervention. Though diabetics face a variety of very
specialized challenges, in many cases surgery can offer
quicker wound healing, lower rates of re-ulceration,
lower infection rates, and lower amputation rates.
One may argue that diabetics with a foot wound are
at too great a risk for surgery. The patient may not
heal well because of high sugar. The patient may not
heal well because of poor circulation. The patient
may not heal well because he's taking too many
medications, or is too old, or is too sick.
There's certainly room for all these concerns. Foot ulcer patients are at greater risk for infections, poor healing, and other complications. There are times it's not advisable to consider surgery.
But these concerns need to be balanced with the understanding that there is also a risk to having an ulcer and not doing something to address it long term.
The sad truth is that 40% of wounds recur within a year of closure, 60% of ulcers will recur within three years, and two-thirds of wounds will recur within five years of closure (1). And statistics show that one in five of these recurrent wounds will eventually end up with an amputation (2).
Know, too, that each ulcer event has a 50:50 chance of becoming infected (3), that the presence of infection raises the risk of minor amputations by 50% (4), and that nearly one in six patients die within a year of their infection (5).
(1) Armstrong D, Boulton A, Bus S Diabetic Foot Ulcers and Their Recurrence New England Journal of Medicine z
N Engl J Med 2017;376:2367-75. DOI: 10.1056/NEJMra1615439
(2) Lavery, LA, Armstrong DG, Wunderlich RP, et al. Risk factors for foot infections in individuals with diabetes.
Diabetes Care 2006: 29-1288-93
(3) Prompers L, Huijberts M, Apelqvist J, et al. Optimal organization of health care in diabetic foot disease:
introduction to the Eurodiale study. Int J Low Extrem Wounds 2007;6:11-7.
(4) van Battum P, Schaper N, Prompers L, Apelqvist J, Jude E, Piaggesi A, et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation. Diabet Med. 2011;28:199–205.
(5) Fincke BG, Miller DR, Turpin R. A classification of diabetic foot infections using ICD-9-CM codes: application to a large computerized medical database. BMC Health Serv Res. 2010;10:192.
No patient wants surgery. And all physicians want to be conservative with their patients and protect them from unnecessary risk of elective procedures.
But the statistics are sobering. Wounds need to be addressed, and addressed in a way most likely to prevent future ulcerations, for each wound is a risk for severe consequences.
Knowing these facts, we need to weigh how safe it is
to live with a chronic ulcer statistically likely to recur
repeatedly, when we know that the foot continually
resides in a dirty environment, and that overall health,
circulation, and ability to heal will likely deteriorate
over time with how risky it is to have a one-time surgery
to resolve the cause of the ulcer by performing the
procedure in a clean environment when the patient's
blood sugar level and circulation is about as good as it
will get, and you have a better chance to stop such the ulcer from recurring?
This is all fine to discuss in the abstract. But is there any evidence to show surgery may have a role in helping ulcers heal?
In 1998, an Italian study designed to test how well surgical intervention fared in the treatment of neuropathic foot ulcers compared to conventional non-surgical management. Surgical treatment was centered on excising the underlying bony causes of the ulcers and surgical closure.
By every metric, the surgical group fared better.
95.5% of the wounds treated through surgery healed compared to 79.2% of the conservative, non-surgical group.
Surgical wounds closed quicker, too, 46.7 days on average compared to 128.9.
The infection rate in the surgical group was 4.5%. It was 12.5% in the non-surgical group.
And the recurrence rate was 14.3% in the surgical group and 40% in the non-surgical group.
Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, Navalesi R.
Conservative surgical approach versus non-surgical management for diabetic
neuropathic foot ulcers: a randomized trial. Diabet Med. 1998 May;15(5):412-7.
PubMed PMID: 9609364.
A more recent meta-analysis study from June of 2019 looked at seven studies of conservative surgery in chronic, difficult diabetic foot ulcers. 290 patients and 317 ulcers were reviewed, examining several different procedures--resection arthroplasty of the interphalangeal joint, toe-sparing bone excision, and distal Symes amputation.
They reported an overall healing rate of 98.3%, healing time of 6.8 ± 3.9 weeks, recurrence rate of 2.3%, wound dehiscence/recurrent infection rate of 6.4%, skin necrosis rate of 2.8%, and revision surgery rate of 7.4%.
There was no significant differences in outcomes between recalcitrant ulcers and infected ulcers nor between surgery types. Significance was found in relation to ulcer location. Surgeries of the small toes did best. The authors concluded that when compared to antibiotics or amputation, conservative surgery to correct the cause of the ulcer had better outcomes.
Yammine K, Assi C. A Meta-analysis of the Types and Outcomes of Conservative
Excisional Surgery for Recalcitrant or Infected Diabetic Toe Ulcers. Foot Ankle
Spec. 2019 Jun 19:1938640019857795. doi: 10.1177/1938640019857795. [Epub ahead of
print] PubMed PMID: 31216881.
This is certainly interesting as a study examining a variety of surgeries as a whole.
But if you're a patient considering a surgery, or a physician with a patient considering such a surgery for your patient, you may wish to know some details involving the sorts of surgical procedures that may be contemplated by your foot surgeon.
How risky are these procedures? How invasive are they? Do we have any statistics on whether it's safe to perform them?
Each patient is unique, and their are numerous surgeries that could be performed, dependent upon the specifics of each patient's situation. However, we've separated out some of the simpler and more common procedures based on location of the ulcer. We have a page on surgically offloading the great toe, a page on surgically offloading of the small toes of the foot, and a page on surgically offloading wounds in the ball of the foot.
This page written by Dr. S A Schumacher
Surrey, British Columbia Canada
All clinical photographs are owned and provided
by Dr. S A Schumacher. They may be reproduced
for educational purposes with attribution to:
Dr. S A Schumacher, Surrey, BC Canada
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