Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer

El‐Barbary, A. A.; Sallam, Emad; Ismail, Ahmed M.

doi:10.1177/1534734620971106

Cited by 3 publications

(20 citation statements)

References 31 publications

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“…11,19 Over the past 4 years, a number of new trials have been performed in the area of offloading that add to the evidence base for treating people with DFU. [23][24][25][26][27][28][29] Ulcer healing is still recognised as the key critically important outcome for people with DFU. However, other outcomes of importance to people with DFU are receiving more attention and also require careful consideration when developing recommendations in new offloading guidelines, such as effects on plantar pressure, weight-bearing activity, adherence, adverse effects, quality of life, and costs.…”

Section: A)mentioning

confidence: 99%

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Bus

Armstrong

Crews

et al. 2023

Diabetes Metabolism Res

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AimsOffloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes‐related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.Materials and MethodsWe followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient‐Intervention‐Control‐Outcome) format, undertaking a systematic review and meta‐analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.ResultsFor healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non‐removable knee‐high offloading device as the first‐choice offloading intervention. If contraindications or patient intolerance to non‐removable offloading exist, consider using a removable knee‐high or ankle‐high offloading device as the second‐choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third‐choice offloading intervention. If such a non‐surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non‐plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.ConclusionThese offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes‐related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

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Section: A)mentioning

confidence: 99%

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Bus

Armstrong

Crews

et al. 2023

Diabetes Metabolism Res

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“…See the Comparison 7 SoF tables and forest plots in Supplementary File S2. Note as there was controlled study evidence for six different surgical offloading interventions, we reviewed each separately and produced six SoF tables for this comparison, including Achilles tendon lengthening 81,82,[114][115][116][117][118] (Comparison 7A), metatarsal head resections 34,83,91,93,94,[119][120][121][122][123][124][125] (Comparison 7B), joint arthroplasties 95,96,[126][127][128][129] (Comparison 7C), joint arthrodeses 80 (Comparison 7D), metatarsal osteotomies 92,[130][131][132][133][134] (Comparison 7E), and digital flexor tenotomies 36,50,51,[135][136][137][138][139][140][141][142][143][144][145] (Comparison 7F...…”

Section: Comparisons 7: Surgical Offloading Interventions Versus Non-...mentioning

confidence: 99%

“…Ulcers healed Meta-analysis of 3 studies (1 RCT, 83 2 other controlled studies 34,91 ), and 2 other controlled studies reporting similar findings that could not be pooled 93,94 and 7 non-controlled studies, [119][120][121][122][123][124][125] found metatarsal head resection (MHR) with offloading devices or therapeutic footwear versus devices or footwear alone may cause moderate increases in proportions of ulcers healed (RR 1.33, 1.12-1.58; p = 0.001; I 2 = 23%; N = 3; n = 165; Low CoE).…”

Section: Critical Outcomementioning

confidence: 99%

“…Amputations Meta-analysis of 5 studies (1 RCT, 83 4 other controlled studies 34,91,93,94 ) found MHR with devices or versus devices alone may cause moderate decreases in amputations, but evidence is very uncertain (RR 0.68, 0.28-1.66; p = 0.39; I 2 = 0%; N = 5; n = 283; Very low CoE). Sensitivity analysis found similar effects for controlled studies at low-risk bias (RR 0.43, 0.13-1.43; p = 0.17; I 2 = 0%; N = 2; n = 133).…”

Section: New (Transfer) Lesionsmentioning

confidence: 99%

“…Eleven RCTs 17,36,37,62,68,73,[75][76][77]79,82 and 8 other controlled studies 34,35,57,84,85,87,88,90 reported baseline infection or ischaemia characteristics, with only one 85…”

Section: Comparisons 8: Any Offloading Interventions Versus Another F...mentioning

confidence: 99%

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Effectiveness of offloading interventions for people with diabetes‐related foot ulcers: A systematic review and meta‐analysis

Lazzarini

Armstrong

Crews

et al. 2023

Diabetes Metabolism Res

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BackgroundOffloading treatment is crucial to heal diabetes‐related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU.MethodsWe searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight‐bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost‐effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta‐analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed.ResultsFrom 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non‐controlled), 35 meta‐analyses performed, and 128 evidence statements developed. We found non‐removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09–1.41; N = 14, n = 1083), and may increase adherence, cost‐effectiveness and decrease infections, but may increase new lesions. Removable knee‐high offloading devices may make little difference to ulcers healed compared to removable ankle‐high offloading devices (RR 1.00, 0.86–1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89–2.18; N = 5, n = 235) and cost‐effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05–5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97–1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers.ConclusionsNon‐removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non‐surgical offloading interventions to heal most plantar DFU. However, all these interventions have low‐to‐moderate certainty of evidence supporting their outcomes and more high‐quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

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Elective Surgery in the Diabetic Foot to Heal Foot Ulcerations and Prevent Re-ulceration

Lavery

Grigoropoulos

Killeen

et al. 2022

Diabetic Foot Reconstruction

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Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer

Cited by 3 publications

References 31 publications

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Effectiveness of offloading interventions for people with diabetes‐related foot ulcers: A systematic review and meta‐analysis

Elective Surgery in the Diabetic Foot to Heal Foot Ulcerations and Prevent Re-ulceration

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