Diabetic foot is one of the major complications of diabetes, affecting 15% of patients with diabetes. This study aims to evaluate and compare the clinical and radiographic outcomes of patients with diabetes affected by forefoot plantar preulcerative or ulcerative lesions who have undergone minimally invasive distal metatarsal diaphyseal osteotomy (MIS-DMDO) to assess its efficacy in the prevention and treatment of chronic plantar diabetic foot ulcers (CPDFUs).
Methods:
The study included 60 patients, 38 with preulcers and 22 with ulcers, with at least 2 years of clinical and radiologic follow-up. Clinical outcomes were assessed using the European Foot and Ankle Society (EFAS) score, the Foot Function Index (FFI), and the Manchester-Oxford Foot Questionnaire (MOXFQ). The radiographic evaluation was performed according to the Maestro criteria.
Results:
Both groups improved in clinical and radiologic outcomes when comparing baseline measurements to those at the final follow-up. There were no statistical differences between preulcer and ulcer groups in terms of both clinical and radiologic outcomes, with the only exception being FFI, which was lower in the preulcerative group. In multivariate analysis, gender and glycated hemoglobin (HbA1c) were predictors of better outcomes. Specifically, FFI and MOXFQ (P < .05) exhibited larger improvements in females, while Maestro 1 and 2 were better in patients with lower HbA1c (P < .05). All patients were considered healed at the final follow-up.
Conclusion:
Carefully performed minimally invasive distal metatarsal diaphyseal osteotomy can be an effective approach to the care of impending or chronically present plantar diabetic foot ulcers.
Al-RubeaanKAl DerwishMOuiziS, et alDiabetic foot complications and their risk factors from a large retrospective cohort study. PLoS One. 2015;10(5):e0124446. doi:10.1371/journal.pone.0124446
3.
ArmstrongDGBoultonAJMBusSA.Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375. doi:10.1056/NEJMra1615439
4.
ArmstrongDGLaveryLAHarklessLB.Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21(5):855-859. doi:10.2337/diacare.21.5.855
BizCBelluzziECrimìA, et alMinimally invasive metatarsal osteotomies (MIMOs) for the treatment of plantar diabetic forefoot ulcers (PDFUs): a systematic review and meta-analysis with meta-regressions. Appl Sci. 2021;11(20):9628.
7.
BizCCorradinMKuete KanahWT, et alMedium-long-term clinical and radiographic outcomes of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) for central primary metatarsalgia: do Maestro criteria have a predictive value in the preoperative planning for this percutaneous technique?Biomed Res Int. 2018;2018:1947024. doi:10.1155/2018/1947024
Budiman-MakEConradKJRoachKE.The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol. 1991;44(6):561-570. doi:10.1016/0895-4356(91)90220-4
11.
BusSAArmstrongDGCrewsRT, et alGuidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024:40(3):e3647. doi:10.1002/dmrr.3647
12.
BusSAvan DeursenRWArmstrongDGLewisJECaravaggiCFCavanaghPR.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;32Suppl 1:99-118. doi:10.1002/dmrr.2702
13.
BusijaLPausenbergerEHainesTPHaymesSBuchbinderROsborneRH.Adult measures of general health and health-related quality of life: Medical Outcomes Study Short Form 36-Item (SF-36) and Short Form 12-Item (SF-12) Health Surveys, Nottingham Health Profile (NHP), Sickness Impact Profile (SIP), Medical Outcomes Study Short Form 6D (SF-6D), Health Utilities Index Mark 3 (HUI3), Quality of Well-Being Scale (QWB), and Assessment of Quality of Life (AQoL). Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S383-S412. doi:10.1002/acr.20541
14.
CoughlinMJMannRASaltzmanCL.Surgery of the Foot and Ankle. Mosby; 2007.
15.
CrausSMulaACoppiniDV.The foot in diabetes - a reminder of an ever-present risk. Clin Med (Lond). 2023;23(3):228-233. doi:10.7861/clinmed2022-0489
16.
CychoszCCPhisitkulPBelattiDAWukichDK.Preventive and therapeutic strategies for diabetic foot ulcers. Foot Ankle Int. 2016;37(3):334-343. doi:10.1177/1071100715611951
17.
DallimoreSMKaminskiMR.Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis. J Foot Ankle Res. 2015;8(1):33. doi:10.1186/s13047-015-0085-6
18.
DayerRAssalM.Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing. J Bone Joint Surg Br. 2009;91-B(4):487-493. doi:10.1302/0301-620x.91b4.21598
19.
EverettEMathioudakisN.Update on management of diabetic foot ulcers. Ann N Y Acad Sci. 2018;1411(1):153-165. doi:10.1111/nyas.13569
20.
FleischliJEAndersonRBDavisWH.Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int. 1999;20(2):80-85. doi:10.1177/107110079902000203
21.
FriggAPagenstertGSchäferDValderrabanoVHintermannB.Recurrence and prevention of diabetic foot ulcers after total contact casting. Foot Ankle Int. 2007;28(1):64-69. doi:10.3113/fai.2007.0012
22.
FrykbergRGWukichDKKavarthapuVZgonisTDalla PaolaL.Surgery for the diabetic foot: a key component of care. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3251. doi:10.1002/dmrr.3251
23.
HazenbergCEvan BaalJGManningEBrilABusSA.The validity and reliability of diagnosing foot ulcers and pre-ulcerative lesions in diabetes using advanced digital photography. Diabetes Technol Ther. 2010;12(12):1011-1017. doi:10.1089/dia.2010.0088
24.
IbrahimA.IDF clinical practice recommendation on the diabetic foot: a guide for healthcare professionals. Diabetes Res Clin Pract. 2017;127:285-287. doi:10.1016/j.diabres.2017.04.013
25.
KitaokaHBAlexanderIJAdelaarRSNunleyJAMyersonMSSandersM.Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-53. doi:10.1177/107110079401500701
LazzariniPAArmstrongDGCrewsRT, et alEffectiveness of offloading interventions for people with diabetes-related foot ulcers: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2024;40(3):e3650. doi:10.1002/dmrr.3650
28.
LipskyBABerendtARCorniaPB, et alInfectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173. doi:10.1093/cid/cis346
29.
MaestroMBesseJ-LRagusaMBerthonnaudE.Forefoot morphotype study and planning method for forefoot osteotomy. Foot Ankle Clin. 2003;8(4):695-710. doi:10.1016/s1083-7515(03)00148-7
30.
McDermottKFangMBoultonAJMSelvinEHicksCW.Etiology, Epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetes Care. 2023;46(1):209-221. doi:10.2337/dci22-0043
31.
OyiboSOJudeEBTarawnehINguyenHCHarklessLBBoultonAJ.A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001;24(1):84-88. doi:10.2337/diacare.24.1.84
32.
PallinJAVan NettenJJKearneyPMDinneenSFBuckleyCM.Do we screen, examine or assess to identify the “at-risk” foot in diabetes-time for agreed terms and definitions?Diabet Med. 2023;40(1):e14976. doi:10.1111/dme.14976
33.
PrompersLHuijbertsMApelqvistJ, et alHigh prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50(1):18-25. doi:10.1007/s00125-006-0491-1
34.
RastogiAMukhopadhyaySSahooJP, et alIntensive Glycemic Control for Diabetic Foot Ulcer Healing: a multicentric, randomized, parallel arm, single-blind, controlled study protocol (INGLOBE Study). Int J Low Extrem Wounds. 2022;21(4):443-449. doi:10.1177/1534734620952245
35.
ReevesNDCassidyBAbbottCAYapMH. Novel technologies for detection and prevention of diabetic foot ulcers. In: GefenA, ed. The Science, Etiology and Mechanobiology of Diabetes and Its Complications. Academic Press; 2021:107-122.
36.
RizzoLTedeschiAFallaniE, et alCustom-made orthesis and shoes in a structured follow-up program reduces the incidence of neuropathic ulcers in high-risk diabetic foot patients. Int J Low Extrem Wounds. 2012;11(1):59-64. doi:10.1177/1534734612438729
37.
SchaperNCvan NettenJJApelqvistJBusSAHinchliffeRJLipskyBA.Practical guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36Suppl 1:e3266. doi:10.1002/dmrr.3266
38.
SilvaJAdSouzaECFdEchazú BöschemeierAGCostaCCMdBezerraHSFeitosaEELC. Diagnosis of diabetes mellitus and living with a chronic condition: participatory study. BMC Public Health. 2018;18(1):699. doi:10.1186/s12889-018-5637-9
39.
SinghNArmstrongDGLipskyBA.Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-228. doi:10.1001/jama.293.2.217
40.
SloanGSelvarajahDTesfayeS.Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy. Nat Rev Endocrinol. 2021;17(7):400-420. doi:10.1038/s41574-021-00496-z
41.
TamirEFinestoneASAvisarEAgarG.Mini-invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers. J Orthop Surg Res. 2016;11(1):78. doi:10.1186/s13018-016-0414-x
42.
TamirEFinestoneASBeerYAneksteinYAtzmonRSmorgickY.Radiographic bone healing in minimally invasive floating metatarsal osteotomy for neuropathic plantar metatarsal head ulcers - a retrospective cohort study. Int J Low Extrem Wounds. Published online September 14, 2022. doi:10.1177/15347346221126004
43.
TamirETamarMAyalonMKorenSShohatNFinestoneAS.Effect of mini-invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic plantar metatarsal head ulcers. Foot Ankle Int. 2021;42(5):536-543. doi:10.1177/1071100720976099
44.
TamirEViglerMAvisarEFinestoneAS.Percutaneous tenotomy for the treatment of diabetic toe ulcers. Foot Ankle Int. 2014;35(1):38-43. doi:10.1177/1071100713509604
45.
VadivelooTJeffcoateWDonnanPT, et alAmputation-free survival in 17,353 people at high risk for foot ulceration in diabetes: a national observational study. Diabetologia. 2018;61(12):2590-2597. doi:10.1007/s00125-018-4723-y
46.
Volmer-TholeMLobmannR.Neuropathy and diabetic foot syndrome. Int J Mol Sci. 2016;17(6):917. doi:10.3390/ijms17060917
47.
WalshJWHoffstadOJSullivanMOMargolisDJ.Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med. 2016;33(11):1493-1498. doi:10.1111/dme.13054
48.
WukichDKMotkoJ.Safety of total contact casting in high-risk patients with neuropathic foot ulcers. Foot Ankle Int. 2004;25(8):556-560. doi:10.1177/107110070402500808
49.
XiangJWangSHeYXuLZhangSTangZ.Reasonable glycemic control would help wound healing during the treatment of diabetic foot ulcers. Diabetes Ther. 2019;10(1):95-105. doi:10.1007/s13300-018-0536-8
50.
YammineKAssiC.Surgical offloading techniques should be used more often and earlier in treating forefoot diabetic ulcers: an evidence-based review. Int J Low Extrem Wounds. 2020;19(2):112-119. doi:10.1177/1534734619888361
51.
YangLRongGCWuQN.Diabetic foot ulcer: challenges and future. World J Diabetes. 2022;13(12):1014-1034. doi:10.4239/wjd.v13.i12.1014
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