Top

Journal of Orthopaedic Surgery and Research

Published in:

Open Access 01-12-2016 | Research article

Mini-Invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers

Authors: Eran Tamir, Aharon S. Finestone, Erez Avisar, Gabriel Agar

Published in: Journal of Orthopaedic Surgery and Research | Issue 1/2016

Abstract

Background

Patients with peripheral neuropathy and pressure under a relatively plantar deviated metatarsal head frequently develop plantar foot ulcers. When conservative management with orthotics and shoes does not cure the ulcer, surgical metatarsal osteotomy may be indicated to relieve the pressure and enable the ulcer to heal. The purpose of this study is to evaluate the use of a mini-invasive floating metatarsal osteotomy in treating recalcitrant ulcers or recurrent ulcers plantar to the metatarsal heads in patients with diabetes mellitus (DM) related neuropathy.

Methods

Computerized medical files of patients with diabetic neuropathy treated with an osteotomy during 2013 and 2014 were retrospectively reviewed. There were 20 osteotomies performed on 17 patients (mean age 58 years). The patients had a diagnosis of DM for a mean of 17 years. All ulcers were University of Texas grade 1A; mean ulcer age was 19 months.

Results

After 17/20 operations, the ulcer completely resolved after 6 weeks and did not recur after a mean follow-up of 11.5 months. One patient developed an early post-operative infection with osteomyelitis at the osteotomy site (proximal shaft of the fifth metatarsal) that needed debridement and IV antibiotics. In the other 19 cases, the surgical wound healed within 1 week. Asymptomatic radiological non-union developed in six cases (30 %).

Conclusions

Mini-invasive floating metatarsal osteotomy can cure resistant and recurrent University of Texas grade 1A ulcerations plantar to the metatarsal heads in neuropathic patients.

Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, Wagner EH. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382–7.CrossRefPubMed

Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5):513–21.CrossRefPubMed

Cowley MS, Boyko EJ, Shofer JB, Ahroni JH, Ledoux WR. Foot ulcer risk and location in relation to prospective clinical assessment of foot shape and mobility among persons with diabetes. Diabetes Res Clin Pract. 2008;82(2):226–32.CrossRefPubMed

Ledoux WR, Shofer JB, Cowley MS, Ahroni JH, Cohen V, Boyko EJ. Diabetic foot ulcer incidence in relation to plantar pressure magnitude and measurement location. J Diabetes Complications. 2013;27(6):621–6.CrossRefPubMedPubMedCentral

Myerson M, Papa J, Eaton K, Wilson K. The total-contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am. 1992;74(2):261–9.PubMed

Bus SA, van Deursen RW, Armstrong DG, Lewis JE, Caravaggi CF, Cavanagh PR, International Working Group on the Diabetic Foot. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32 Suppl 1:99–118.CrossRefPubMed

Bus SA, van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, Price PE, International Working Group on the Diabetic Foot. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev. 2016;32 Suppl 1:16–24.CrossRefPubMed

Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care. 2003;26(9):2595–7.CrossRefPubMed

Tamir E. Treating the diabetic ulcer: practical approach and general concepts. Isr Med Assoc J. 2007;9(8):610–5.PubMed

10.

Armstrong DG, Frykberg RG. Classifying diabetic foot surgery: toward a rational definition. Diabet Med. 2003;20(4):329–31.CrossRefPubMed

11.

Martin WJ, Weil LS, Smith SD. Surgical management of neurotrophic ulcers in the diabetic foot. J Am Podiatry Assoc. 1975;65(4):365–73.CrossRefPubMed

12.

Singer A. Surgical treatment of mal perforans. Arch Surg. 1976;111(9):964–8.CrossRefPubMed

13.

Tillo TH, Giurini JM, Habershaw GM, Chrzan JS, Rowbotham JL. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. J Am Podiatr Med Assoc. 1990;80(4):211–7.CrossRefPubMed

14.

Addante JB. Metatarsal osteotomy as an office procedure to eradicate intractable plantar keratosis. J Am Podiatry Assoc. 1970;60(10):397–9.CrossRefPubMed

15.

Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg Br. 1975;57(2):187–92.PubMed

16.

Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996;35(6):528–31.CrossRefPubMed

17.

Colen LB, Kim CJ, Grant WP, Yeh JT, Hind B. Achilles tendon lengthening: friend or foe in the diabetic foot? Plast Reconstr Surg. 2013;131(1):37e–43e.CrossRefPubMed

18.

Armstrong DG, Rosales MA, Gashi A. Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration. J Am Podiatr Med Assoc. 2005;95(4):353–6.CrossRefPubMed

19.

Aragon-Sanchez J, Lazaro-Martinez JL, Hernandez-Herrero C, Campillo-Vilorio N, Quintana-Marrero Y, Garcia-Morales E, Hernandez-Herrero MJ. Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series. Diabet Med. 2012;29(6):813–8.CrossRefPubMed

20.

Dalla Paola L, Faglia E, Caminiti M, Clerici G, Ninkovic S, Deanesi V. Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study. Diabetes Care. 2003;26(6):1874–8.CrossRefPubMed

21.

Fleischli JE, Anderson RB, Davis WH. Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int. 1999;20(2):80–5.CrossRefPubMed

Title: Mini-Invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers
Authors: Eran Tamir
Aharon S. Finestone
Erez Avisar
Gabriel Agar
Publication date: 01-12-2016
Publisher: BioMed Central
Published in: Journal of Orthopaedic Surgery and Research / Issue 1/2016
Electronic ISSN: 1749-799X
DOI: https://doi.org/10.1186/s13018-016-0414-x

At a glance: The STEP trials

Springer Medicine

Mini-Invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2016

Medial collateral ligament reconstruction using bone-patellar tendon-bone allograft for chronic medial knee instability combined with multi-ligament injuries: a new technique

Erratum to: Channel-assisted minimally invasive repair of acute Achilles tendon rupture

Differences in joint morphology between the knee and ankle affect the repair of osteochondral defects in a rabbit model

Reduction of intraarticular adhesion of knee by local application of rapamycin in rabbits via inhibition of fibroblast proliferation and collagen synthesis

Comparison of unilateral and bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a systematic review and meta-analysis

Assessing the negative impact of phenyl alkanoic acid derivative, a frequently prescribed drug for the suppression of pain and inflammation, on the differentiation and proliferation of chondrocytes