Yammine K, Assi C, et al.
The international journal of lower extremity wounds. Date of publication 2019 Nov 20;volume ():1534734619888361.
1. Int J Low Extrem Wounds. 2019 Nov 20:1534734619888361. doi:
10.1177/1534734619888361. [Epub ahead of print]
Surgical Offloading Techniques Should be Used More Often and Earlier in Treating
Forefoot Diabetic Ulcers: An Evidence-Based Review.
Yammine K(1), Assi C(1).
Author information:
(1)Lebanese American University Medical Center-Rizk Hospital, Lebanese American
University, Beirut, Achrafieh, Lebanon.
Conservative treatment is the basis for diabetic foot ulcer (DFU) management,
whereas surgical treatment is usually reserved for patients with failed,
recurrent, or nonresponsive infected wounds. However, many reports demonstrated
good to excellent results following surgery. Evidence synthesis on surgical
offloading techniques and clear guidelines regarding the timing of surgery are
lacking. The present study aimed to investigate the evidence behind surgical
offloading techniques and propose a cutoff time for surgical indication following
failed conservative treatment of neuropathic diabetic forefoot ulcers. Electronic
databases were searched from inception to identify the best evidence level
articles related to non-vascular surgical treatment of DFUs, such as metatarsal
head resection, resection arthroplasty, metatarsal osteotomy, Achilles tendon
lengthening, gastrocnemius recession, and flexor tenotomy, that have been
employed for managing DFUs. Based on the highest level of evidence available,
surgery was found to generate better values than standard conservative care for
all outcomes except for the transfer rate. In particular, surgical bony
offloading procedures demonstrated significantly better outcomes than standard
conservative nonsurgical care in terms of higher healing rates, shorter healing
durations, and lower recurrence rates. Moreover, 96% of DFUs healed in <1 month
following surgical bony offloading, whereas 68% of ulcers healed within 3 months
after standard care. The findings could challenge the classical guidelines of DFU
management. This evidence-based review indicates that surgical offloading could
be used more often and be proposed earlier during the course of ulcer management.
The results imply that a period of 12 weeks could be considered a reasonable
cutoff value to consider surgical treatment for patients with nonhealing DFUs.
DOI: 10.1177/1534734619888361
PMID: 31744347
