Surgical Offloading Techniques Should be Used More Often and Earlier in Treating Forefoot Diabetic Ulcers: An Evidence-Based Review

Abstract

Conservative treatment is the basis for diabetic foot ulcer (DFU) management, whereas surgical treatment is usually reserved for patients with failed, recurrent, or nonresponsive infected wounds. However, many reports demonstrated good to excellent results following surgery. Evidence synthesis on surgical offloading techniques and clear guidelines regarding the timing of surgery are lacking. The present study aimed to investigate the evidence behind surgical offloading techniques and propose a cutoff time for surgical indication following failed conservative treatment of neuropathic diabetic forefoot ulcers. Electronic databases were searched from inception to identify the best evidence level articles related to non-vascular surgical treatment of DFUs, such as metatarsal head resection, resection arthroplasty, metatarsal osteotomy, Achilles tendon lengthening, gastrocnemius recession, and flexor tenotomy, that have been employed for managing DFUs. Based on the highest level of evidence available, surgery was found to generate better values than standard conservative care for all outcomes except for the transfer rate. In particular, surgical bony offloading procedures demonstrated significantly better outcomes than standard conservative nonsurgical care in terms of higher healing rates, shorter healing durations, and lower recurrence rates. Moreover, 96% of DFUs healed in <1 month following surgical bony offloading, whereas 68% of ulcers healed within 3 months after standard care. The findings could challenge the classical guidelines of DFU management. This evidence-based review indicates that surgical offloading could be used more often and be proposed earlier during the course of ulcer management. The results imply that a period of 12 weeks could be considered a reasonable cutoff value to consider surgical treatment for patients with nonhealing DFUs.

Effect of Mini-invasive Floating Metatarsal Osteotomy on Plantar Pressure in Patients With Diabetic Plantar Metatarsal Head Ulcers

“…Operative (or internal) offloading for curing and preventing the recurrence of diabetic foot ulcers is becoming more feasible due to the newer technologies in foot surgery including mini-invasive surgery. 6 , 30 , 37 , 38 The complication rate with these methods is acceptable. There were fewer complications than the recurrence rate with conservative treatment.…”

Minimally Invasive Metatarsal Osteotomies (MIMOs) for the Treatment of Plantar Diabetic Forefoot Ulcers (PDFUs): A Systematic Review and Meta-Analysis with Meta-Regressions

“…However, the current crucial issue is to relieve the pressure because the wound never heals until the pressure is off-loaded. There are many methods to relieve it [47] including body weight reduction, total contact casts [48], corrective shoes with customized insoles [49] and even surgical correction, such as metatarsal head resection and ray amputation [20][21][22]33]. In this context, MIS has been proposed as an effective intervention [24].…”

“…A recent meta-analysis about the contemporary management of diabetic neuropathic foot ulcerations revealed disappointing functional outcomes [33]. Moreover, the metaanalysis showed that minimally invasive surgery for PDFUs by metatarsal osteotomies is a poorly investigated topic [33], contrary to the several traditional surgical techniques explored in the literature [20][21][22]33].…”

Surgery Versus Nonsurgical Methods in Treating Neuropathic Plantar Forefoot Ulcers: A Meta-Analysis of Comparative Studies

“…20,22 With significantly better healing rate and fewer complications, surgery has been found to compare better with NST in the treatment of diabetic forefoot ulcers. 34,35 An impartial analysis of the literature reporting results of nonsurgical management reveals a dim picture; the clinical outcomes are found to be far less than optimal throughout the literature. For instance, healing rates were reported to range from 24.2% to 60% by 12 weeks and from 30.9% to 71% by 20 weeks.…”