Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England, E1 4DG, UK.
Surgeon. 2021 Dec;19(6):e526-e535. doi: 10.1016/j.surge.2021.01.005. Epub 2021 Feb 26.
Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration.
We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations.
Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements.
Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.
糖尿病周围神经病变导致足部畸形、软组织损伤和步态失衡，所有这些都会增加足部所承受的机械压力，引发夏科氏关节病。目前，《糖尿病足国际指南》的国际工作组专注于管理与压力相关的神经病变性足部溃疡：他们的 9 项建议中只有 2 项涉及手术干预。我们评估了手术技术在减压方面的作用，以治愈和可能预防糖尿病足溃疡。
我们系统地分析了 2000 年 1 月至 2020 年 11 月发表的数据，以评估手术减压的方法和相关的手术重建结果。我们试图确定愈合率、缓解率、恢复步行能力、并发症和局限性。
在顽固性溃疡中使用了 5 种不同类别的手术减压方法：1. 小趾切开术；2. 跖骨头切除术+跟腱松解术；3. 拇趾手术；4. 骨切除的骨下减压术；5. 复杂的足部重建手术。包括外科放置抗生素输送系统在内的辅助治疗方法显示出一定的前景，但需要进一步的研究来阐明它们在减轻全身抗生素需求方面的作用和效果。
手术对于长期减压和足部保护至关重要，它可以稳定和协调足部结构。手术不应仅保留给顽固病例，还应扩展到溃疡预防和缓解。进一步的比较研究将有助于手术决策，以避免复发，并确定何时手术减压可以防止不可挽回的组织损失/再溃疡。
