Metatarsal Head Resection for Diabetic Foot Ulcers Gareth David Griffiths,
FRCS, Thomas Jeffery Wieman, MD
\s=b\ diabetic patients underwent 34 metatarsal head resections for chronic neuropathic ulceration. All ulcers were located on the plantar surface beneath the metatarsophalangeal joints. The ulcers had been present for a mean of 9.0 \m=+-\7.8 months before operation, yet they healed in a mean of 2.4 1.6 months postoperatively. None recurred during the mean follow-up time of 13.8 \m=+-\11.0 months. Moderate peripheral vascular disease, impaired renal function, and retinopathy did not affect the time required for ulcer healing. There were two complications: one wound infection and one hematoma. No extremities were lost, and none of the patients suffered any long-term sequelae. We recommend metatarsal head resection to achieve the healing of chronic diabetic foot ulcers under the metatarsophalangeal
joints.
(Arch Surg. 1990;125:832-835)
The challenge
treatment of diabetic
neuropathic foot ulcers is a seri¬ general surgeon. These lesions are major sources of physical, social, and economic morbidity for ous
for the
adult diabetics. It is estimated that 10% of diabetics will develop foot ulcers at some time in their lives.1 Such ulcers lead to the expenditure of hundreds of millions of dollars on long-term care2 and result in approximately 30 000 major amputations a year in the United States.3 We reviewed our experience with selected patients who developed ulcers on the plantar surfaces of their feet beneath the metatarsophalangeal joints. The patients included in the study were treated between July 1985 and February 1989 at the University of Louisville (Ky) Affiliated Hospitals. PATIENTS AND METHODS A retrospective analysis was performed of the records of diabetic patients who underwent metatarsal head resection at the University of Louisville Affiliated Hospitals. All patients had ulcers that had remained unhealed despite intensive nonoperative therapy, includ¬ ing regular débridement of the ulcer, the use of topical and systemic antibiotics, and non-weight bearing. Information was compiled con¬ cerning age, sex, type and duration of diabetes, neuropathy, retinop-
Accepted for publication March 18,1990. From the Department of Surgery, University
of Louisville (Ky) School of Medicine. Read before the 97th Annual Meeting of the Western Surgical Association, St Louis, Mo, November 14,1989. Reprint requests to Department of Surgery, University of Louisville School of Medicine, 550 S Jackson St, Louisville, KY 40292 (Dr Wieman).
athy, renal function, peripheral vascular disease, smoking habits, foot ulcer history, and details of the operation. These patients were seen, examined, and treated in a clinic dedicated to the treatment of patients with diabetic neuropathic foot disorders. The care and opera¬ tive procedures were supervised or performed by a single surgeon, ensuring reasonable uniformity in management. During resection, the prominent metatarsal head was first identi¬ fied by palpation of the plantar surface of the foot. The skin incision was made on the dorsal surface, extending from the base of the toe to the midpoint of the metatarsal shaft (Fig 1). If adjacent metatarsal heads were prominent, they were resected through one incision sited midway between them. The extensor tendon was protected by re¬ traction while the incision was deepened down to the bone. The periostium was cleared over the shaft dorsally and on either side. At this stage it was important to keep close to the bone to avoid damage to the digital arteries (Fig 2). The metatarsal shaft was then tran¬ sected with the use of rongeurs, with care being taken not to fracture the proximal shaft nor to leave any bone fragments in the wound. A towel clamp was used to grip the distal portion while it was sharply dissected out with a scalpel. The distal end of the remaining metatar¬ sal was beveled (Fig 3) and hemostasis secured. The wound was closed with a subcuticular suture. Closed suction drainage was al¬ ways employed to minimize hematoma formation. Necrotic tissue was débrided from the ulcer at the end of the procedure. A single preoperative dose of a second-generation cephalosporin was used as prophylaxis against infection. The foot remained non-weight bearing until the ulcer had healed and the patient was fitted with protective footwear, such as extra-depth or custom-molded shoes. RESULTS
During a 2-year period, we performed 34 metatarsal head resections on 25 diabetic patients in 32 operations. The mean age of the patients was 57.8 ±9.5 years; 19 were male and 6 were female. The mean duration of diabetes before operation was 13.6 ± 10.6 years; 18 patients were insulin dependent and 7 were not. The predominant indication for operation was a nonhealing ulcer (22 patients); other indications were infected ulcers (five patients), transferred pressure from previous metatarsal head resections (three patients), ulcération after toe amputa¬ tion through the metatarsophalangeal joint (two patients), and painful calluses (two patients). The sites of ulcération are shown in Table 1. The mean time for which ulcers had been present before metatarsal head resection was 9.0 ± 7.6 months. Ulcer heal¬ ing required a mean time of 2.4 ± 1.6 months after metatarsal
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Fig 2.—Transverse section through the metatarsal showing the rela¬ tionship to tendons and the neurovascular bundle.
Fig 1.—Incisions for excision of three of the metatarsal heads. Note the extension of the incisions onto the forefoot and the lateral place¬ ments for the first and fifth metatarsals.
Table 1.—Ulcer Sites No. Metatarsal Head
Right
Left
1st 2nd
2nd/3rd
3rd 3rd/4th 4th
5th
Fig 3.—Line of division of the shaft and appearance of the beveled end at the end of the procedure. head resection, although in one patient another metatarsal head had to be resected in a second operation before his ulcer healed. The patients were followed up for a mean of 13.8 ±11.0 months postoperatively, and none of the ulcers recurred after healing was achieved. There were two compli¬ cations. One patient developed a wound infection that re¬ sponded to antibiotics, and another had a minor postoperative hematoma.
Table 2 shows the mean duration of the ulcers before meta¬ tarsal head resection and the mean time to their healing afterward. The results are presented according to the pres¬ ence or absence of retinopathy, peripheral vascular disease, impaired renal function, and a smoking history. The patients' retinas were assessed by an ophthalmologist, and retinopathy was taken to be present if either background or proliferative disease was seen. Peripheral vascular disease was defined as
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Table 2— Preoperative Ulcer Duration and Healing Times
Postoperative
Mean ± SD
Preoperative
Ulcer Duration, All
cases
Postoperative Healing,
Time to
mo
mo
9.0 ±7.8
2.4 ±1.6
Retinopathy Present (n 10)_10.1 ±10.7_2.6±2.1_ Absent (n 5) 8.2 ±4.4 2.3 ±1.2 =
=
P_NS*_NS_
Peripheral vascular disease 2.3 ±1.0 Present (n 5) 11.3 ±9.5 Absent (n 12)_10.0±8.1_2.8±2.1_ =
=
P
Nephropathy Present (n 9) Absent (n 13) =
=
NS
NS
13.5 + 9.5
2.3 ±2.3 2.5 ±1.1
6.3 ±4.9
P_
FRCS, Thomas Jeffery Wieman, MD
\s=b\ diabetic patients underwent 34 metatarsal head resections for chronic neuropathic ulceration. All ulcers were located on the plantar surface beneath the metatarsophalangeal joints. The ulcers had been present for a mean of 9.0 \m=+-\7.8 months before operation, yet they healed in a mean of 2.4 1.6 months postoperatively. None recurred during the mean follow-up time of 13.8 \m=+-\11.0 months. Moderate peripheral vascular disease, impaired renal function, and retinopathy did not affect the time required for ulcer healing. There were two complications: one wound infection and one hematoma. No extremities were lost, and none of the patients suffered any long-term sequelae. We recommend metatarsal head resection to achieve the healing of chronic diabetic foot ulcers under the metatarsophalangeal
joints.
(Arch Surg. 1990;125:832-835)
The challenge
treatment of diabetic
neuropathic foot ulcers is a seri¬ general surgeon. These lesions are major sources of physical, social, and economic morbidity for ous
for the
adult diabetics. It is estimated that 10% of diabetics will develop foot ulcers at some time in their lives.1 Such ulcers lead to the expenditure of hundreds of millions of dollars on long-term care2 and result in approximately 30 000 major amputations a year in the United States.3 We reviewed our experience with selected patients who developed ulcers on the plantar surfaces of their feet beneath the metatarsophalangeal joints. The patients included in the study were treated between July 1985 and February 1989 at the University of Louisville (Ky) Affiliated Hospitals. PATIENTS AND METHODS A retrospective analysis was performed of the records of diabetic patients who underwent metatarsal head resection at the University of Louisville Affiliated Hospitals. All patients had ulcers that had remained unhealed despite intensive nonoperative therapy, includ¬ ing regular débridement of the ulcer, the use of topical and systemic antibiotics, and non-weight bearing. Information was compiled con¬ cerning age, sex, type and duration of diabetes, neuropathy, retinop-
Accepted for publication March 18,1990. From the Department of Surgery, University
of Louisville (Ky) School of Medicine. Read before the 97th Annual Meeting of the Western Surgical Association, St Louis, Mo, November 14,1989. Reprint requests to Department of Surgery, University of Louisville School of Medicine, 550 S Jackson St, Louisville, KY 40292 (Dr Wieman).
athy, renal function, peripheral vascular disease, smoking habits, foot ulcer history, and details of the operation. These patients were seen, examined, and treated in a clinic dedicated to the treatment of patients with diabetic neuropathic foot disorders. The care and opera¬ tive procedures were supervised or performed by a single surgeon, ensuring reasonable uniformity in management. During resection, the prominent metatarsal head was first identi¬ fied by palpation of the plantar surface of the foot. The skin incision was made on the dorsal surface, extending from the base of the toe to the midpoint of the metatarsal shaft (Fig 1). If adjacent metatarsal heads were prominent, they were resected through one incision sited midway between them. The extensor tendon was protected by re¬ traction while the incision was deepened down to the bone. The periostium was cleared over the shaft dorsally and on either side. At this stage it was important to keep close to the bone to avoid damage to the digital arteries (Fig 2). The metatarsal shaft was then tran¬ sected with the use of rongeurs, with care being taken not to fracture the proximal shaft nor to leave any bone fragments in the wound. A towel clamp was used to grip the distal portion while it was sharply dissected out with a scalpel. The distal end of the remaining metatar¬ sal was beveled (Fig 3) and hemostasis secured. The wound was closed with a subcuticular suture. Closed suction drainage was al¬ ways employed to minimize hematoma formation. Necrotic tissue was débrided from the ulcer at the end of the procedure. A single preoperative dose of a second-generation cephalosporin was used as prophylaxis against infection. The foot remained non-weight bearing until the ulcer had healed and the patient was fitted with protective footwear, such as extra-depth or custom-molded shoes. RESULTS
During a 2-year period, we performed 34 metatarsal head resections on 25 diabetic patients in 32 operations. The mean age of the patients was 57.8 ±9.5 years; 19 were male and 6 were female. The mean duration of diabetes before operation was 13.6 ± 10.6 years; 18 patients were insulin dependent and 7 were not. The predominant indication for operation was a nonhealing ulcer (22 patients); other indications were infected ulcers (five patients), transferred pressure from previous metatarsal head resections (three patients), ulcération after toe amputa¬ tion through the metatarsophalangeal joint (two patients), and painful calluses (two patients). The sites of ulcération are shown in Table 1. The mean time for which ulcers had been present before metatarsal head resection was 9.0 ± 7.6 months. Ulcer heal¬ ing required a mean time of 2.4 ± 1.6 months after metatarsal
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Fig 2.—Transverse section through the metatarsal showing the rela¬ tionship to tendons and the neurovascular bundle.
Fig 1.—Incisions for excision of three of the metatarsal heads. Note the extension of the incisions onto the forefoot and the lateral place¬ ments for the first and fifth metatarsals.
Table 1.—Ulcer Sites No. Metatarsal Head
Right
Left
1st 2nd
2nd/3rd
3rd 3rd/4th 4th
5th
Fig 3.—Line of division of the shaft and appearance of the beveled end at the end of the procedure. head resection, although in one patient another metatarsal head had to be resected in a second operation before his ulcer healed. The patients were followed up for a mean of 13.8 ±11.0 months postoperatively, and none of the ulcers recurred after healing was achieved. There were two compli¬ cations. One patient developed a wound infection that re¬ sponded to antibiotics, and another had a minor postoperative hematoma.
Table 2 shows the mean duration of the ulcers before meta¬ tarsal head resection and the mean time to their healing afterward. The results are presented according to the pres¬ ence or absence of retinopathy, peripheral vascular disease, impaired renal function, and a smoking history. The patients' retinas were assessed by an ophthalmologist, and retinopathy was taken to be present if either background or proliferative disease was seen. Peripheral vascular disease was defined as
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Table 2— Preoperative Ulcer Duration and Healing Times
Postoperative
Mean ± SD
Preoperative
Ulcer Duration, All
cases
Postoperative Healing,
Time to
mo
mo
9.0 ±7.8
2.4 ±1.6
Retinopathy Present (n 10)_10.1 ±10.7_2.6±2.1_ Absent (n 5) 8.2 ±4.4 2.3 ±1.2 =
=
P_NS*_NS_
Peripheral vascular disease 2.3 ±1.0 Present (n 5) 11.3 ±9.5 Absent (n 12)_10.0±8.1_2.8±2.1_ =
=
P
Nephropathy Present (n 9) Absent (n 13) =
=
NS
NS
13.5 + 9.5
2.3 ±2.3 2.5 ±1.1
6.3 ±4.9
P_
