06/12/2015    Ed Cohen, DPM

Surgery to Prevent Ulcers in Diabetic

It would be helpful to have pictures of the feet
and measurements of at least the dorsiflexion of
the foot. Dr. Monroe Laborde does a lot of
gastroc recessions and other soft tissue
procedures for these high risk diabetic patients.
The gastroc recession has proven to be an
extremely valuable procedure for taking weight
off the ball of the foot.

MIS metatarsal osteotomies and MIS toe
straightening surgeries are excellent for
correcting and preventing metatarsal head
ulcerations. The treatment of toe ulcers, crooked
toes and metatarsal balancing with or without
dislocated MPJs is a topic that I am very
interested in.The distal toe ulcer is usually
easily fixed by MIS flexor tenotomies and or
proximal and middle phalangeal osteotomies.

Ulcerations on digital side-by-side toes at the
PIPJor DIPJ can be easily corrected by removing
bone on the adjacent toe which is causing the
ulcer on the other toe. Severely crooked toes
with or without dislocated MPJs should almost
never be amputated because even the most
grotesque toes can usually be nicely straightened
with MIS procedures.

These procedures include bone spur resections
digital osteotomies, tenotomies and occassional
capsulotomies. A lot of times in order to get the
toe straight you need to perform an MIS
metatarsal osteotomy. In the dislocated joint
removing the metatarsal head is usually an
inferior procedure as the the problem can be
corrected by a MIS Haspel metatarsal head
decompression combined with an MIS metatarsal
osteotomy. I remember when I did my first case my
staff and patient as well as I could not believe
how good the clinical results were.

I am very disappointed at all the crooked toes
that get amputated although this trend has
significantly slowed in my 37 years of practice.
At the AAFAS meetings at LSU, you can see
horrible cases that are salvaged mostly with MIS
procedures and occasionally some great
traditional soft tissue and bone. procedures.

These meeting have a lot of diabetic salvage
procedures where the general concensus would be
to amputate or to remove metatarsal heads. These
MIS procedures are also employed with severely
arthritic foot deformities.The best surgery is
the least invasive that achieves the desired
results and MIS surgery wins almost every time.
At the AAFAS meeting, we have orthopedists and
podiatrists from around the world lecturing on
how these MIS procedures are less invasive can
achieve superior results in most cases to
traditional surgery.

One of the best cases I have ever seen was by Dr.
Peacock who corrected a distal big toe ulcer with
osteomyelitis .using MIS surgery.He cleaned out
the osteomyelitis and did a proximal hallux
osteotomy to straighten the toe.While the
accepted treatment would be to amputate, he
corrected the deformity and the patient was free
of a bone infection and had a nice functional
toe. For anyone having an interest in this MIS
surgery the next meeting will be at Temple
September 19,20 and January 7-9 at LSU Medical
School presented by the AAFAS.

Ed Cohen, DPM, Gulfport, MS

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06/11/2015    Tip Sullivan, DPM

Surgery to Prevent Ulcers in Diabetic

Simply based upon the history and data supplied,
I tend to go the opposite way and be more
aggressive with a pan met head. I would add that
especially if the patient is obese. Of course
this is said without seeing the patients gait,
and actual foot exam (which is very important in
making individual patient decisions).

I have had the opportunity to do isolated met
head resections on diabetics and for some it
works well, especially in the acute stages. I
have also been able to follow patients over a
long period and have seen my share of transfer
ulcerations from this approach-even with custom
shoes. I think that a detailed biomechanical and
gait evaluation is needed before making this
decision with consideration of the patients
overall medical status.

If anyone is not comfortable or experienced
enough to do that, they should send the patient
to a colleague who has experience for a second
opinion. That colleague should send a detailed
report and opinion back to the referring
podiatrist or even better video it and discuss it
on phone. Then the referring podiatrist can do
the appropriate surgery and compare their
original evaluation to the more experienced one—
it is called learning.

Just as a thought-- I have also done many
metatarsal dorsiflexory osteotomies at the base
and neck but here again patient selection is
where it is at!! This does not sound like a good
candidate for this approach.

I would make sure to evaluate for a TAL or
gastroc resection—although I have no experience
in gastroc resections (out of scope in my state)
a TAL is simple and easy to do and will decrease
forefoot pressures dramatically. If you do end
up in the OR with this patient I would suggest
following the old saying “protect her from
herself” in her post op care. Typically, I use
either a Jones cast or a hard cast in a
significantly plantarflexed position and a
wheelchair.

Tip Sullivan, DPM, Jackson, MS