Can Metatarsal Head Resection Be A Viable Treatment Option For Neuropathic DFUs?

A newly accepted paper in Advances in Wound Care sheds some light on the role of metatarsal head resection for neuropathic diabetic foot ulcers (DFUs).¹

In a meta-analysis that included 11 studies, 494 feet and 593 neuropathic DFUs, Yammine and colleagues found that metatarsal head resection for recent, non-infected DFUs resulted in a shorter time to healing, better rates of healing, less ulcer recurrence and less infection in comparison to standard care.¹

Additionally, the study authors found that amputations occurred twice as often in the standard care groups in comparison to those patients who had metatarsal head resection.¹ The team found similar results in patients who had chronic and recalcitrant diabetic foot ulcers (DFUs) as well. Combining all of this data, the authors recommend that physicians consider metatarsal head resection earlier and more often in the management of DFUs.

I generally consider metatarsal head resection when patients have an open wound, typically with bone involvement. While the literature definitely supports doing metatarsal head resections or pan metatarsal head resections in complex parabolas, our group at SALSA have moved to doing floating metatarsal osteotomies if the patient has a pre- or post-ulcerative callus, and no significant bone involvement.^2,3 We also continue to explore the use of fat grafting (autologous and donor) as you may have recalled from previous blog posts.⁴ I also will not hesitate to do an Achilles tendon lengthening for these patients to further reduce normal stress across the forefoot.^5,6

The aforementioned study by Yammine and coworkers mirrors our strong belief that we need to move away from the idea of "wound care" and toward an idea of "wound closure."¹ This involves not only "nursing" a wound (which is really important) but also "doctoring" it. In some cases, this involves surgical intervention, which I believe we all become blinded to when we see often very small changes in week to week visits in our clinics. For all of us (including and especially me), I think it is important to step back and regard the whole patient rather than the “hole” in the patient. 

Dr. Armstrong is Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA). 

Editor’s Note: This blog originally appeared at: 

https://diabeticfootonline.com/2020/09/06/meta-analysis-of-the-outcomes-of-metatarsal-head-resection-for-the-treatment-of-neuropathic-diabetic-foot-ulcers/ . It is adapted with permission from the author.

References

1. Yammine K, Kheir N, Assi C. Meta-analysis of the outcomes of metatarsal head resection for the treatment of neuropathic diabetic foot ulcers. Adv Wound Care. 2020. Available at: https://www.liebertpub.com/doi/abs/10.1089/wound.2020.1261 . 
2. Armstrong DG, Fiorito JL, Leykum BJ, Mills JL. Clinical efficacy of the pan metatarsal head resection as a curative procedure in patients with diabetes mellitus and neuropathic forefoot wounds. Foot Ankle Spec. 2012;5(4):235-240.
3. Armstrong DG, Rosales MA, Gashi A. Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration. J Am Podiatr Med Assoc. 2005;95(4):353-356.
4. Armstrong DG. What the latest research reveals about plantar tissue stiffness in patients with diabetes. Podiatry Today. Available at: https://www.podiatrytoday.com/blogged/what-latest-research-reveals-about-plantar-tissue-stiffness-patients-diabetes . Published September 8, 2020. Accessed September 28, 2020.
5. Shahin TB, Vaishnav KV, Watchman M, et al. Tissue augmentation with allograft adipose matrix for the diabetic foot in remission. Plast Reconstr Surg Glob Open. 2017;5(10):e1555. 
6. Luu CA, Larson E, Rankin TM, Pappalardo JL, Slepian MJ, Armstrong DG. Plantar fat pad grafting and tendon balancing for the diabetic foot ulcer in remission. Plast Reconstr Surg Glob Open. 2016;4(7):e810.