Surgical off-loading of the diabetic foot Robert G. Frykberg, DPM, MPH, Nicholas J. Bevilacqua, DPM, Geoffrey Habershaw, DPM  Journal of Vascular Surgery  Volume 52, Issue 3, Pages 44S-58S (September 2010) DOI: 10.1016/j.jvs.2010.06.008 Copyright © 2010 Terms and Conditions

Fig 1 Intrinsic minus foot. Note the high arched, thin foot with little muscle mass in this patient with advanced peripheral neuropathy. Flexible hammer toes (claw toes) usually accompany this deformity as well. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 2 Acquired second hammer toe after great toe amputation with dorsal ulcer. This is easily treated by a digital arthroplasty or joint resection with excision of the ulceration. A metatarsophalangeal joint release is also usually required for rigid deformities. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 3 Reconstruction for correction of unstable Charcot ankle. A, Preoperative clinical view demonstrates ankle deformity. B, A preoperative radiograph shows osteolysis of the talar dome. C, Circular external fixator in place after talectomy and fusion. D, Postoperative radiograph. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 4 Flexor tenotomy. A, The toe is flexible and ulcer is at the tip. B, Lidocaine is injected at the site of entry, and the patient is asked to dorsiflex the ankle and actively flex all the toes. This makes the long flexor tendon very taught, and can easily be tenotomized as shown here with a #61 Beaver blade. No suture is needed. C, Shows all three middle toes that have had flexor tenotomies. The fourth toe had resection of osteomyelitis, 4 weeks postoperatively, done in the office setting. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 5 Arthroplasty of the hallux for surgical off-loading of a chronic hallux ulceration. A, The ulcer is adjacent to the head of the proximal phalanx. B, Incision placement. C, The head of the phalanx is removed, and the long extensor tendon is repaired. D, The wound closed primarily. Early ambulation is possible with a postoperative shoe. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 6 Metatarsal osteotomy, now performed in the office setting when possible, can be done with simple instruments: bone cutter, hemostat, and freer elevator as a probe. A, Through a dorsal incision, the metatarsal neck is grasped with a large hemostat. B, A double-action bone cutter is introduced adjacent to the hemostat. C, The bone is osteotomized at the metatarsal neck level. D, Multiple osteotomies shown here are all in the proper location, between the anatomic and surgical neck of each metatarsal. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 7 A, Undermining ulceration that probes into deep tissues (including bone or joint) is not appropriate for standard metatarsal osteotomy. B, The ulcer is excised and the adjacent metatarsal is removed. C, Primary closure with a proximal drain is acceptable as long as there is no active sepsis. The drain is pulled in 24 hours, and the patient is kept non-weight bearing for 4 weeks. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 8 Pan metatarsal head resection. A, Failed metatarsal surgeries with transfer ulcer subsecond. B, Transmetatarsal amputation could be done, but the toes are viable. Surgical off-loading can be accomplished through a dorsal or plantar approach; here, a dorsal approach is planned. C, Excision of metatarsal head through a dorsal incision. D, Radiograph several months after procedure. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 9 A, Keller arthroplasty used as a curative procedure for ulcer under a rigid hallux. B, A postoperative radiograph shows the resection of the base of the proximal phalanx to allow for unrestricted dorsiflexion. C, Healed ulceration noted 3 weeks after a Keller arthroplasty was performed. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 10 First metatarsophalangeal joint resection. A, A chronic deep ulcer under the first metatarsal head. B, The joint is resected through a dorsal incision. The elevator illustrates that the plantar ulcer penetrated into the joint. C, A radiograph shows the resection of the metatarsal head, both sesamoids, and the base of proximal phalanx. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 11 A, A gastrocnemius recession performed to augment healing of a plantar forefoot ulceration. B, An image taken 2 years postoperatively demonstrates long-term ulcer healing. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 12 A rocker-bottom Charcot foot is shown with soft tissue visualization of large plantar midfoot ulcer under the apex of the deformity. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 13 A, This chronic midfoot ulcer was treated with a simple exostectomy with tendo-Achilles' lengthening. B, Postoperative image shows a plantar incision that was closed primarily and reinforced with tape strips (tendo-Achilles' lengthening incision not shown). Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions

Fig 14 A, A midfoot Charcot reconstruction using an Ilizarov circular frame. B, A lateral radiograph shows the orientation of the foot and ankle in the frame. In this case, internal fixation was also used. Journal of Vascular Surgery 2010 52, 44S-58SDOI: (10.1016/j.jvs.2010.06.008) Copyright © 2010 Terms and Conditions