Elevated Plantar Pressure and Ulceration in Diabetic Patients After Panmetatarsal Head Resection: Two Case Reports

Abstract

Panmetatarsal head resection (variously called forefoot arthroplasty, forefoot resection arthroplasty, the Hoffman procedure, and the Fowler procedure) was developed for the relief of pain and deformity in rheumatoid arthritis. Although there are successful retrospective series reported in the literature, such an approach is not supported by carefully designed controlled trials. This procedure has also been advocated by some for the relief of plantar pressure in diabetic patients who are at risk for plantar ulceration. The efficacy of the procedure in this context is not supported by existing pressure measurements on rheumatoid arthritis patients in the literature, which has tended to show that although pain relief is obtained, the procedure results in elevation of forefoot pressure. Case reports are described of two patients (three feet) with sensory neuropathy who presented to our clinic 1 to 2 years after panmetatarsal head resections had been performed. Peak plantar pressures in these feet during first step gait were above the 99th percentile and outside the measuring range of the device used (EMED SF platform; NOVEL Electronics Inc., St. Paul, MN). Both patients had also experienced plantar ulcers subsequent to the surgery. Combining the information on patients with rheumatoid arthritis (RA) with that from our two case studies, we conclude that panmetatarsal head resection does not necessarily eliminate focal regions of elevated plantar pressure.

The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review

“…Several uncontrolled studies suggest that ATL and metatarsal head resections reduce pressure in the forefoot [53,105]. Metatarsal head resections, however, may increase plantar pressure in other areas of the foot [106,107]. Furthermore, regular callus removal has been reported to have a beneficial effect on the reduction of plantar pressure [108,109].…”

The Biomechanics of the Foot in Diabetes Mellitus

“…6-30), with subsequent almost intractable recurrent ulceration. 411 Our suspicion is that this procedure is very technique dependent, but further study is required to confirm this.…”

PedCAT for Radiographic 3D-Imaging in standing position

“…This will allow for investigator independent analysis of these angles. The advantage of investigator independent definition of parameters have been shown for the pedography as described above [3].…”

“…This mapping process does not include manual determination of landmarks [16]. The outlines of the foot and the different regions are determined by the software using an algorithm as reported [3]. This software algorithm is based on geometric characteristics of a maximum pressure picture using an individual sensing threshold [16].…”