Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, Beirut, Achrafieh, Lebanon.
Int J Low Extrem Wounds. 2020 Jun;19(2):112-119. doi: 10.1177/1534734619888361. Epub 2019 Nov 20.
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.
保守治疗是糖尿病足溃疡（DFU）管理的基础，而手术治疗通常保留给治疗失败、复发或无反应性感染伤口的患者。然而，许多报告表明手术后的效果良好甚至极佳。缺乏关于手术减压技术的综合证据和关于手术时机的明确指南。本研究旨在调查手术减压技术背后的证据，并提出在保守治疗失败后，用于治疗神经病变性糖尿病前足溃疡的手术指征的截止时间。从一开始就搜索电子数据库，以确定与 DFU 的非血管外科治疗相关的最佳证据水平文章，例如跖骨头切除术、关节切除成形术、跖骨截骨术、跟腱延长术、腓肠肌萎缩术和屈肌腱切开术，这些方法已用于治疗 DFU。根据现有最高证据水平，手术在所有结果方面都比标准保守治疗产生更好的价值，除了转移率。特别是，手术骨减压手术在愈合率、愈合时间和复发率方面明显优于标准保守非手术治疗。此外，96%的 DFU 在接受手术骨减压后不到 1 个月内愈合，而 68%的溃疡在标准治疗后 3 个月内愈合。这些发现可能会挑战经典的 DFU 管理指南。这一基于证据的综述表明，手术减压可以更频繁地使用，并在溃疡管理过程中更早地提出。结果表明，12 周可能被认为是一个合理的截止值，以考虑对未愈合的 DFU 患者进行手术治疗。
