A 2-Stage Approach in Managing Diabetic Forefoot Ulcers

Background: Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer. Methods: A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations. Results: Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion. Conclusion: TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months. Level of Evidence: Level IV, retrospective case series.