588226
research-article2015
IJLXXX10.1177/1534734615588226The International Journal of Lower Extremity WoundsSanz-Corbalán et al
Clinical and Translational Research
Analysis of Ulcer Recurrences After Metatarsal Head Resection in Patients Who Underwent Surgery to Treat Diabetic Foot Osteomyelitis
The International Journal of Lower Extremity Wounds 2015, Vol. 14(2) 154–159 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734615588226 ijl.sagepub.com
Irene Sanz-Corbalán, DPM, PhD1, José Luis Lázaro-Martínez, DPM, PhD1, Javier Aragón-Sánchez, MD, PhD2, Esther García-Morales, DPM, PhD1, Raúl Molines-Barroso, DPM, PhD1, and Francisco Javier Alvaro-Afonso, DPM, PhD1
Abstract Metatarsal head resection is a common and standardized treatment used as part of the surgical routine for metatarsal head osteomyelitis. The aim of this study was to define the influence of the amount of the metatarsal resection on the development of reulceration or ulcer recurrence in patients who suffered from plantar foot ulcer and underwent metatarsal surgery. We conducted a prospective study in 35 patients who underwent metatarsal head resection surgery to treat diabetic foot osteomyelitis with no prior history of foot surgeries, and these patients were included in a prospective follow-up over the course of at least 6 months in order to record reulceration or ulcer recurrences. Anteroposterior plain X-rays were taken before and after surgery. We also measured the portion of the metatarsal head that was removed and classified the patients according the resection rate of metatarsal (RRM) in first and second quartiles. We found statistical differences between the median RRM in patients who had an ulcer recurrence and patients without recurrences (21.48 ± 3.10% vs 28.12 ± 10.8%; P = .016). Seventeen (56.7%) patients were classified in the first quartile of RRM, which had an association with ulcer recurrence (P = .032; odds ratio = 1.41; 95% confidence interval = 1.04-1.92). RRM of less than 25% is associated with the development of a recurrence after surgery in the midterm follow-up, and therefore, planning before surgery is undertaken should be considered to avoid postsurgical complications. Keywords diabetic foot, ulcer recurrence, osteomyelitis Diabetic foot is a serious complication of diabetes mellitus that occurs in approximately 3% to 4% of patients with diabetes around the world.1 In some cases, the presence of a foot ulcer precedes a minor or major amputation. Peripheral arterial disease (PAD) and diabetic foot infections (both soft tissue infections and osteomyelitis) have been described as being the main causes of limb loss.2 Although benefits of surgery for soft tissue infections have been demonstrated, especially in necrotizing soft tissue infections, the best therapy for diabetic foot osteomyelitis is still a matter of debate.3 One approach for treating osteomyelitis is the combination of surgery and systemic antibiotics. Some studies have demonstrated that conservative surgery can treat bone infections, preserving the anatomy and function of the foot instead of resorting to minor amputations, such as ray or transmetatarsal amputations.4,5 The plantar surface is a common location of diabetic foot ulcers, especially in the forefoot where there is a protrusion of the metatarsal heads. Metatarsal head resection is a
common and standardized treatment that is used as part of the surgical routine for metatarsal head osteomyelitis.6 Surgery should be considered when the following indications are found: the metatarsal head shows damage in a plain X-ray, bone can be observed at the bottom of the ulcer, the foot ulcer is associated with rigid deformity, the bone infection is associated with spreading soft tissue infection, and when previous antibiotic therapy with appropriate offloading has not shown any improvement over the previous 6 weeks.7,8 Some studies9-11 have suggested that metatarsal head resection should also be used to decrease the peak plantar 1
Complutense University Clinic, Madrid, Spain La Paloma Hospital, Las Palmas de Gran Canaria, Spain
2
Corresponding Author: Irene Sanz-Corbalán, Avda. Complutense s/n., Edificio Facultad de Medicina, Pabellón 1, 28040 Madrid, Spain. Email: [email protected]
Downloaded from ijl.sagepub.com at Duke University Libraries on November 16, 2015
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Figure 1. Flow chart of the process of inclusion of patients in the present study.
pressure of the forefoot, thus avoiding a possible recurrence, to allow faster healing of the plantar foot ulcer. Griffiths and Wieman,6 in 1990, described metatarsal head resection in diabetic patients, and they defined it as a bone osteotomy at the surgical neck of the metatarsal, from which the metatarsal head is removed. The most common complication associated with this procedure was a pressure transfer lesion. This condition will move the peak pressure to the adjacent metatarsal joints, and consequently, a new ulcer may develop.12,13 Another concern that has, until now, not been adequately investigated is the possibility of ulcer recurrences at the same area of the surgery,14 especially when the metatarsal head resection was not located at the surgical metatarsal neck. Removing more or less of the distal portion of the infected metatarsal may be associated with an increased probability of reulceration or recurrences after surgery. When recurrences have occurred, in some cases, revision surgery was required. Nevertheless, in the majority of the previous studies, reulceration and ulcer recurrence were not evaluated as being different outcomes and were instead assessed as being the same complication.15-17 Until now, the surgical procedure for removing the metatarsal head has not been well defined, and often the surgeon will not know how much of the bone has to be removed. There is no clear indication regarding the metatarsal amputation level in the literature,16 and knowledge of the postsurgical implications of whether the bone is cut above or below the surgical neck of the metatarsal is unknown. The aim of this study was to define the influence of the amount of the metatarsal resection on the development of
reulceration or ulcer recurrence in patients who suffered from plantar foot ulcer and underwent metatarsal surgery.
Patients and Methods Between October 2011 and October 2013, 50 patients underwent metatarsal head resection surgery to treat diabetic foot osteomyelitis at the Diabetic Foot Unit of the Complutense University of Madrid, Spain. Of these, there was no prior history of foot surgeries in 35 patients, and these patients were included in a prospective follow-up over the course of at least 6 months in order to record reulceration or ulcer recurrences (see flow chart in Figure 1). Inclusion criteria were as follows: diabetes patients aged >18 years, neuropathic ulcers complicated by osteomyelitis, ability to attend during the follow-up period, and agreeing to be included in the study by means of written consent. Exclusion criteria were as follows: patients with previous surgery or previous amputation, inability to measure the metatarsal length due to significant damage to the metatarsal head, patients suffering from PAD,18 previous history of metatarsal fracture or Charcot foot, and patients who did not understand the purpose of the study or refused to be included. The demographic and clinical characteristics of the study population are shown in Table 1. The diagnosis of osteomyelitis was established on the basis of a combination of a probing-to-bone test and plain X-rays, as previously published.19 The probe-tobone test was performed using metal forceps (Halsted
Downloaded from ijl.sagepub.com at Duke University Libraries on November 16, 2015
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The International Journal of Lower Extremity Wounds 14(2)
Table 1. Baseline Clinical Data of Subjects (N = 35).
•• Maximum length of the metatarsal (MLM) was measured before the surgery and was considered to be the distance between the tip and the most distal point of the head.22 •• Postsurgical length of the metatarsal (PLM) was measured after the surgery and was considered to be the distance between the tip and the most distal point of the resection surface. •• Length of the metatarsal resection (LMR) was the difference between the MLM and the PLM (Figure 2).
Male/female, n Age (years), mean ± SD Diabetes mellitus (years), mean ± SD Diabetes mellitus type 1/type 2, n Retinopathy, n (%) Nephropathy, n (%) Neuropathy, n (%) Body mass index (kg/m2), mean ± SD HbA1c (mmol/mol), mean ± SD
30/5 63.67 ± 16.06 15.80 ± 7.88 5/30 13 (43.3%) 7 (23.3%) 35 (100%) 27.11 ± 7.11 55.58 ± 13.63%
Abbreviations: SD, standard deviation; HbA1c, glycated hemoglobin.
mosquito forceps), and the result was considered positive when the researcher felt a hard or gritty surface. We considered the plain X-rays (2 standard views) “positive” for osteomyelitis if they showed cortical disruption, periosteal elevation, a sequestrum or involucrum, or gross bone destruction. The neurological examination was conducted using a Semmes-Weinstein 5.07/10 g monofilament (Novalab Ibérica, Alcalá de Henares, Madrid, Spain) and a Horwell’s biotensiometer (Novalab Ibérica). Neuropathy was diagnosed in patients who did not feel 1 of the 2 tests.20 PAD was diagnosed if the patient met the following criteria: absence of both distal pulses and/or ankle brachial index
research-article2015
IJLXXX10.1177/1534734615588226The International Journal of Lower Extremity WoundsSanz-Corbalán et al
Clinical and Translational Research
Analysis of Ulcer Recurrences After Metatarsal Head Resection in Patients Who Underwent Surgery to Treat Diabetic Foot Osteomyelitis
The International Journal of Lower Extremity Wounds 2015, Vol. 14(2) 154–159 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734615588226 ijl.sagepub.com
Irene Sanz-Corbalán, DPM, PhD1, José Luis Lázaro-Martínez, DPM, PhD1, Javier Aragón-Sánchez, MD, PhD2, Esther García-Morales, DPM, PhD1, Raúl Molines-Barroso, DPM, PhD1, and Francisco Javier Alvaro-Afonso, DPM, PhD1
Abstract Metatarsal head resection is a common and standardized treatment used as part of the surgical routine for metatarsal head osteomyelitis. The aim of this study was to define the influence of the amount of the metatarsal resection on the development of reulceration or ulcer recurrence in patients who suffered from plantar foot ulcer and underwent metatarsal surgery. We conducted a prospective study in 35 patients who underwent metatarsal head resection surgery to treat diabetic foot osteomyelitis with no prior history of foot surgeries, and these patients were included in a prospective follow-up over the course of at least 6 months in order to record reulceration or ulcer recurrences. Anteroposterior plain X-rays were taken before and after surgery. We also measured the portion of the metatarsal head that was removed and classified the patients according the resection rate of metatarsal (RRM) in first and second quartiles. We found statistical differences between the median RRM in patients who had an ulcer recurrence and patients without recurrences (21.48 ± 3.10% vs 28.12 ± 10.8%; P = .016). Seventeen (56.7%) patients were classified in the first quartile of RRM, which had an association with ulcer recurrence (P = .032; odds ratio = 1.41; 95% confidence interval = 1.04-1.92). RRM of less than 25% is associated with the development of a recurrence after surgery in the midterm follow-up, and therefore, planning before surgery is undertaken should be considered to avoid postsurgical complications. Keywords diabetic foot, ulcer recurrence, osteomyelitis Diabetic foot is a serious complication of diabetes mellitus that occurs in approximately 3% to 4% of patients with diabetes around the world.1 In some cases, the presence of a foot ulcer precedes a minor or major amputation. Peripheral arterial disease (PAD) and diabetic foot infections (both soft tissue infections and osteomyelitis) have been described as being the main causes of limb loss.2 Although benefits of surgery for soft tissue infections have been demonstrated, especially in necrotizing soft tissue infections, the best therapy for diabetic foot osteomyelitis is still a matter of debate.3 One approach for treating osteomyelitis is the combination of surgery and systemic antibiotics. Some studies have demonstrated that conservative surgery can treat bone infections, preserving the anatomy and function of the foot instead of resorting to minor amputations, such as ray or transmetatarsal amputations.4,5 The plantar surface is a common location of diabetic foot ulcers, especially in the forefoot where there is a protrusion of the metatarsal heads. Metatarsal head resection is a
common and standardized treatment that is used as part of the surgical routine for metatarsal head osteomyelitis.6 Surgery should be considered when the following indications are found: the metatarsal head shows damage in a plain X-ray, bone can be observed at the bottom of the ulcer, the foot ulcer is associated with rigid deformity, the bone infection is associated with spreading soft tissue infection, and when previous antibiotic therapy with appropriate offloading has not shown any improvement over the previous 6 weeks.7,8 Some studies9-11 have suggested that metatarsal head resection should also be used to decrease the peak plantar 1
Complutense University Clinic, Madrid, Spain La Paloma Hospital, Las Palmas de Gran Canaria, Spain
2
Corresponding Author: Irene Sanz-Corbalán, Avda. Complutense s/n., Edificio Facultad de Medicina, Pabellón 1, 28040 Madrid, Spain. Email: [email protected]
Downloaded from ijl.sagepub.com at Duke University Libraries on November 16, 2015
155
Sanz-Corbalán et al
Figure 1. Flow chart of the process of inclusion of patients in the present study.
pressure of the forefoot, thus avoiding a possible recurrence, to allow faster healing of the plantar foot ulcer. Griffiths and Wieman,6 in 1990, described metatarsal head resection in diabetic patients, and they defined it as a bone osteotomy at the surgical neck of the metatarsal, from which the metatarsal head is removed. The most common complication associated with this procedure was a pressure transfer lesion. This condition will move the peak pressure to the adjacent metatarsal joints, and consequently, a new ulcer may develop.12,13 Another concern that has, until now, not been adequately investigated is the possibility of ulcer recurrences at the same area of the surgery,14 especially when the metatarsal head resection was not located at the surgical metatarsal neck. Removing more or less of the distal portion of the infected metatarsal may be associated with an increased probability of reulceration or recurrences after surgery. When recurrences have occurred, in some cases, revision surgery was required. Nevertheless, in the majority of the previous studies, reulceration and ulcer recurrence were not evaluated as being different outcomes and were instead assessed as being the same complication.15-17 Until now, the surgical procedure for removing the metatarsal head has not been well defined, and often the surgeon will not know how much of the bone has to be removed. There is no clear indication regarding the metatarsal amputation level in the literature,16 and knowledge of the postsurgical implications of whether the bone is cut above or below the surgical neck of the metatarsal is unknown. The aim of this study was to define the influence of the amount of the metatarsal resection on the development of
reulceration or ulcer recurrence in patients who suffered from plantar foot ulcer and underwent metatarsal surgery.
Patients and Methods Between October 2011 and October 2013, 50 patients underwent metatarsal head resection surgery to treat diabetic foot osteomyelitis at the Diabetic Foot Unit of the Complutense University of Madrid, Spain. Of these, there was no prior history of foot surgeries in 35 patients, and these patients were included in a prospective follow-up over the course of at least 6 months in order to record reulceration or ulcer recurrences (see flow chart in Figure 1). Inclusion criteria were as follows: diabetes patients aged >18 years, neuropathic ulcers complicated by osteomyelitis, ability to attend during the follow-up period, and agreeing to be included in the study by means of written consent. Exclusion criteria were as follows: patients with previous surgery or previous amputation, inability to measure the metatarsal length due to significant damage to the metatarsal head, patients suffering from PAD,18 previous history of metatarsal fracture or Charcot foot, and patients who did not understand the purpose of the study or refused to be included. The demographic and clinical characteristics of the study population are shown in Table 1. The diagnosis of osteomyelitis was established on the basis of a combination of a probing-to-bone test and plain X-rays, as previously published.19 The probe-tobone test was performed using metal forceps (Halsted
Downloaded from ijl.sagepub.com at Duke University Libraries on November 16, 2015
156
The International Journal of Lower Extremity Wounds 14(2)
Table 1. Baseline Clinical Data of Subjects (N = 35).
•• Maximum length of the metatarsal (MLM) was measured before the surgery and was considered to be the distance between the tip and the most distal point of the head.22 •• Postsurgical length of the metatarsal (PLM) was measured after the surgery and was considered to be the distance between the tip and the most distal point of the resection surface. •• Length of the metatarsal resection (LMR) was the difference between the MLM and the PLM (Figure 2).
Male/female, n Age (years), mean ± SD Diabetes mellitus (years), mean ± SD Diabetes mellitus type 1/type 2, n Retinopathy, n (%) Nephropathy, n (%) Neuropathy, n (%) Body mass index (kg/m2), mean ± SD HbA1c (mmol/mol), mean ± SD
30/5 63.67 ± 16.06 15.80 ± 7.88 5/30 13 (43.3%) 7 (23.3%) 35 (100%) 27.11 ± 7.11 55.58 ± 13.63%
Abbreviations: SD, standard deviation; HbA1c, glycated hemoglobin.
mosquito forceps), and the result was considered positive when the researcher felt a hard or gritty surface. We considered the plain X-rays (2 standard views) “positive” for osteomyelitis if they showed cortical disruption, periosteal elevation, a sequestrum or involucrum, or gross bone destruction. The neurological examination was conducted using a Semmes-Weinstein 5.07/10 g monofilament (Novalab Ibérica, Alcalá de Henares, Madrid, Spain) and a Horwell’s biotensiometer (Novalab Ibérica). Neuropathy was diagnosed in patients who did not feel 1 of the 2 tests.20 PAD was diagnosed if the patient met the following criteria: absence of both distal pulses and/or ankle brachial index
