Diabetes, and the complications that come with its natural history, entwine with morbidity and mortality data that, unfortunately, have not improved over several decades. In fact, in my experience, prevalence rates of such adverse outcomes across the globe continue to rise. There are persistent commonalities in the data that, when present, point to several significant findings that dramatically worsen prognosis in patients at high risk for developing diabetes-related lower extremity complications. These commonalities include diabetic symmetric peripheral neuropathy, diabetic neuropathic ulceration, and osteomyelitis.1 While many other important factors impact outcomes, a presence or history of these findings mentioned above is strongly supported in the scientific literature as leading to high amputation rates.
I contend that we can add deformities to this list, which, when present in a patient who is insensate, increase shear and pressure. Thus, this may result in a predisposition to ulceration and infection of both the soft tissue and bone. The closer bones and joints are to the soft tissue envelope, the sooner osteomyelitis can occur. Osteomyelitis remains a common cause for amputation in patients with diabetes who develop ulcers in the foot and ankle.
There are many different types of these deformities that can lead to increased pressures that predispose patients to ulceration, primarily, in my experience, to the plantar foot. I have found that aside from sub-metatarsal head ulcers, the most common area I see ulcerate is actually on the dorsum of the foot, specifically dorsal proximal interphalangeal joint (PIPJ) ulcers of the lesser toes.
Dorsal PIPJ ulcers that stem from hammertoes are problematic for several reasons. Usually, I find these ulcers are infected, and the idea of a hammertoe correction then becomes contraindicated. Moreover, in my observation, these ulcers often reveal themselves with pre-existing osteomyelitis, which triggers an all-too-quick amputation mindset for some.
I have performed many resection arthroplasties that completely eradicated both soft tissue and osseous infection, allowed primary closure of the index ulcer, and salvaged an otherwise normal toe. In most cases, patients did not require a second procedure for prophylactic deformity correction, however with proper surgical selection, I find this route does provide the best outcomes.
In my opinion, the procedure is simple, quick, and low-risk. This entails ulcer excision, resection of the head of the proximal phalanx and the base of the intermediate phalanx, debridement of any devitalized tissue, and subsequent closure. The prerequisites for this procedure are the same as for any; adequate distal perfusion and the understanding that additional surgery may be necessary. Work-up for osteomyelitis can be as simple as X-rays and intraoperative bone biopsy for cultures to tailor antibiotics. A more comprehensive set of labs and imaging may also take place, particularly if other pathology exists. However, this procedure is best utilized for patients with isolated and early wounds to the PIPJ as a means of amputation prevention. A toe with extensive soft tissue and osseous loss may still necessitate amputation.
While my description above certainly simplifies this algorithm, I suggest that overthinking would be a mistake if the alternative is an amputation. I would add that should this approach still require amputation in the future, no bridges are burned. I have yet to find a patient that would fit this scenario.
There are a few undeniable truths that we should acknowledge in the space of diabetic limb salvage and amputation prevention. One obvious and important tenet is that we work in a health care system that typically does not embrace prevention, and as such, most of what we do, whether we admit this or not, is reactionary. The best treatment here is to address such problems before they manifest into issues that increase morbidity and mortality, increase amputations, and impact quality of life and function. This is a much bigger elephant that sits in our proverbial room, that deserves its due attention and discussion. For now, however, we will continue to find clever ways to address common problems. This approach is one that I personally find helpful, effective, and that I share with the hopes of saving a few more toes in this fragile patient population. After all, digital amputations are a predictor of future limb loss.2 Thus, might this practical and straightforward pathway allow us to ultimately save toes and limbs in the process?
Dr. Elmarsafi is a fellowship-trained foot and ankle surgeon with Vascular Surgery Associates, LLC, in Maryland.
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1. Amin N, Doupis J. Diabetic foot disease: from the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities. World J Diabetes. 2016;7(7):153-164. doi: 10.4239/wjd.v7.i7.153.
2. Griffin KJ, Rashid TS, Bailey MA, Bird SA, Bridge K, Scott JDA. Toe amputation: a predictor of future limb loss? J Diabetes Complications. 2012;26(3):251-254. doi: 10.1016/j.jdiacomp.2012.03.003.