The effect of flexor tenotomy on healing and prevention of neuropathic diabetic foot ulcers on the distal end of the toe

282

226

Background Prevention of foot ulcers in patients with diabetes is extremely important to help reduce the enormous burden of foot ulceration on both patient and health resources. A comprehensive analysis of reported interventions is not currently available, but is needed to better inform caregivers about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to prevent first and recurrent foot ulcers in persons with diabetes who are at risk for ulceration.

Section: Resultsmentioning

confidence: 99%

“…Four of the seven studies also assessed effects of digital tenotomy of a toe where no ulcer was present at the time of the procedure, in a cumulative total of 58 patients with impending ulcers (i.e. abundant callus on tip of the toe or thickened nails) and presented no ulcer occurrence in a mean 11–31 months follow‐up .…”

Section: Resultsmentioning

confidence: 99%

Prevention of foot ulcers in the at‐risk patient with diabetes: a systematic review

Netten

Raspovic

Lavery

et al. 2016

282

226

“…While controlled studies on this topic are lacking, various studies have shown that a digital flexor tendon tenotomy may reduce the risk of a recurrent plantar foot ulcer in selected patients with initially nonhealing ulcers when compared with non‐surgical treatment for these ulcers . Flexor tenotomy may also reduce the risk of ulcer development in patients with abundant callus on the tip of their toes or thickened nails . We consider flexor tenotomy a promising procedure in a patient who has a toe ulcer, or a pre‐ulcerative sign on the toe, that fails to respond to non‐surgical treatment, and requires normalization of foot structure to prevent ulceration.…”

Section: Treating Risk Factors For Ulcerationmentioning

confidence: 99%

“…The possible benefits of digital flexor tenotomy likely outweigh the harm, as few complications have been reported . Patients who have pre‐ulcerative lesions for which they have frequent non‐surgical treatment that does not improve outcome may value and prefer treatment by flexor tenotomy.…”

Section: Treating Risk Factors For Ulcerationmentioning

confidence: 99%

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

Bus

Lavery

Monteiro‐Soares

et al. 2020

363

609

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at‐risk patient about appropriate foot self‐care and treat any pre‐ulcerative sign on the foot. Instruct moderate‐to‐high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non‐surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high‐risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days, and to reduce the patient and health care burden of diabetic foot disease.

“…Seven retrospective case series of percutaneous digital flexor tendon tenotomy performed in patients with the goal of healing distal toe ulcers showed in a cumulative total of 231 treated patients that 92–100% ulcers healed in a mean time to healing of 21–40 days, with a low rate of reported complications . While controlled studies on this topic are lacking, we consider this procedure to be a promising intervention in patients with hammertoes and recalcitrant toe ulcers that fail conservative treatment.…”

Section: Surgical Offloading Interventionsmentioning

confidence: 99%

IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes

Bus

Armstrong

Deursen

et al. 2016

173

196

RecommendationsCasting and prefabricated healing devices 1. To heal a neuropathic plantar forefoot ulcer without ischemia or uncontrolled infection in a patient with diabetes, offload with a non-removable knee-high device with an appropriate foot-device interface. (GRADE strength of recommendation: strong, Quality of evidence: high) 2. When a non-removable knee-high device is contraindicated or not tolerated by the patient, consider offloading with a removable knee-high walker with an appropriate foot-device interface to heal a neuropathic plantar forefoot ulcer in a patient with diabetes, but only when the patient can be expected to be adherent to wearing the device. (Weak; Moderate) 3. When a knee-high device is contraindicated or cannot be tolerated by the patient, consider offloading with a forefoot offloading shoe, cast shoe, or custom-made temporary shoe to heal a neuropathic plantar forefoot ulcer in a patient with diabetes, but only when the patient can be expected to be adherent to wearing the shoes. (Weak; Low) Therapeutic footwear4. To protect their feet, instruct an at-risk patient with diabetes not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside. (Strong; Low) 5. Instruct an at-risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent nonplantar ulcer. When a foot deformity or a pre-ulcerative sign is present, consider prescribing therapeutic shoes, custom-made insoles, or toe orthosis. (Strong; Low) 6. To prevent a recurrent plantar foot ulcer in an at-risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressurerelieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) 7. Do not prescribe, and instruct a patient with diabetes not to use, conventional or standard therapeutic shoes to heal a plantar foot ulcer. (Strong; Low) 8. Consider using shoe modifications, temporary footwear, toe spacers, or