Minimal Incision Surgery: Can It Have An Impact In Diabetic Limb Salvage?

For patients with diabetes and rigid forefoot deformities, traditional surgical procedures and prolonged offloading periods have a high risk of potential complications. Accordingly, these authors offer perspectives and step-by-step pearls on the use of percutaneous surgery and minimal incision surgery procedures.

   The direct and indirect costs of foot ulcerations, infections and amputations as a result of diabetes are staggering.1-4 Despite advances in disease management, wound healing, infection control and limb salvage techniques, diabetes will continue to rise as the world’s population continues to become more obese and less active.5-9 It is well known that the primary event preceding amputation is infection.10-13 Furthermore, in the vast majority of instances, a preexisting ulceration serves as a direct portal for bacteria to invade the foot, which results in infection.10-15

   It therefore is intuitive that preventing ulcerations from developing or closing them as rapidly as possible once they do occur will limit the potential for infection to develop. This should logically lower the incidence of amputations.

   Traditionally, there has been an emphasis on conservative measures to relieve pressure and shear about forefoot ulcerations through the use of various offloading devices.16-18 While literature does support this approach as an effective means of healing forefoot ulcerations, it does not support the continued use of these techniques to maintain healing and prevent recurrence.19-23

   This is because the most likely cause for developing the ulcer in the first place is a structural foot deformity, which is most commonly rigid in nature, and is almost always combined with varying degrees of peripheral sensory neuropathy.20-27

Understanding The Challenges Of Addressing Forefoot Deformities In Patients With Diabetes

   Evidence exists to support the concept that realignment of the mechanical forefoot deformities associated with patients with diabetes decreases the need for chronic wound care and improves outcomes.20,28-33 Conceptually, this makes sense. However, when it comes to patients with diabetes, they may have a rigid deformity that usually involves the entire forefoot, dense peripheral sensory neuropathy including the contralateral non-operative limb, erratic glycemic control, malnutrition and varying degrees of medical comorbidities (i.e., coronary artery disease, nephropathy, retinopathy, etc.).

   Accordingly, the application of traditional surgical approaches and techniques including periods of non-weightbearing can be difficult in this patient population as the potential for complications is inherently high.33,34

Can Surgical Offloading Techniques Provide Viable Alternatives?

   In regard to diabetic patients with an ulceration or recurrent ulceration, it seems intuitive that percutaneous surgery techniques (i.e., performed within the smallest possible working incision without direct visualization of the deeper structures) and minimal incision surgery techniques (i.e., performed through the smallest incision necessary) would be beneficial as a means of limb preservation/salvage without extensive soft tissue and osseous trauma.35 However, the use of these techniques in this patient population has only briefly been mentioned in the literature.36-38

   We employ percutaneous soft tissue and minimal incision osseous techniques to perform forefoot realignment in patients who are unlikely to heal with traditional surgical approaches, and would otherwise undergo an amputation or develop repeated ulceration as a result of significant structural pathology that physicians cannot manage with conservative measures.

   Accordingly, let us take a closer look at surgical offloading techniques for ulcerations that are recalcitrant to conservative wound healing modalities or recur despite these treatments. These surgical offloading techniques include:

   • toe tenotomies for distal ulcerations secondary to claw toes;
   • corrective toe osteotomies to realign rigid claw toes;
   • minimal incision metatarsal osteotomies for structural deformities; and
   • endoscopic gastrocnemius recession for equinus contracture.

A Guide To Percutaneous Toe And Metatarsophalangeal Tenotomies

   A percutaneous tenotomy of the long flexor tendon is frequently adequate for flexible contractures of the toes, particularly patients with distal tuft ulcerations.39-44 If the patient has a dorsal ulceration overlying the proximal interphalangeal joint and an additional contracture at the metatarsophalangeal joint, the use of a long extensor tenotomy with or without a metatarsophalangeal joint capsulotomy is beneficial in reducing contracture.44,45

   The surgical technique begins with the patient in a supine position. A tourniquet is not required as blood loss is minimal. Patients with dense peripheral neuropathy will not require anesthesia. However, for sensate patients, one may perform a regional infiltration of local anesthesia.

   Make a 2- to 3-mm incision on the plantar aspect of the toe at the apex of the deformity, which is usually at the level of the proximal or distal interphalangeal joint. Make the incision parallel with the longitudinal axis of the toe (i.e., perpendicular to the course of the tendon) and carry it down to the underlying flexor digitorum longus tendon. Transect this tendon under tension. You can create this tension by simultaneously extending the tip of the toe with the index finger on your non-dominant hand and extending the proximal interphalangeal joint with your thumb.

   Alternatively, one can make the incision at the plantar aspect of the base of the proximal phalanx. Doing so will release both the flexor digitorum longus and brevis tendons. Surgeons should reserve this technique for severe contractures as it will result in a non-functional, albeit straightened, toe. Following the transection of the flexor digitorum longus tendon, manipulating the toe facilitates the release of any remaining tendon fibers and disrupts the plantar plates to the proximal and distal interphalangeal joints (i.e., phalangeal set procedure).46 Once you have achieved correction, close the surgical site with a single metallic staple or nylon suture if appropriate. Otherwise, one can leave the site open to heal via secondary intent.

   If one has fully corrected the toe contracture but the metatarsophalangeal joint remains contracted, the surgeon may perform a percutaneous extensor tenotomy with or without a capsulotomy.

   Grasp the toe with your non-dominant hand and simultaneously distract and plantarflex at the metatarsophalangeal joint. Doing so places the extensor tendon and capsule under tension, and makes them more superficial. Insert a no. 11 blade through the skin overlying the metatarso-phalangeal joint. Proceed to deepen the tip of the blade a few millimeters and in a lateral direction. Rotate the tip of the blade medially but take care to avoid further incision of the skin as this would release the extensor tendon.

   Manipulate the toe in plantarflexion at the metatarsophalangeal joint level and ascertain the degree of correction by loading the forefoot. If the release is complete, the toe will lie in a rectus position at the metatarsophalangeal joint. However, if the correction is not adequate, one can reinsert the blade into the incision and deepen it to the metatarsophalangeal joint capsule. Proceed to incise the capsule by using the same technique. Once one has achieved correction, close the surgical site with a single metallic staple or nylon suture if appropriate. Otherwise, you can leave the site open to heal via secondary intent.

   After completion of these procedures, the surgeon should apply a specialized dressing. This consists of placing a gauze padding over the dorsal aspect of the metatarsophalangeal joints and at the plantar aspect of the toes. Doing so maintains reduction of the deformities.44,45

   One can allow guarded full-weightbearing in a postoperative shoe. Remove the initial surgical dressings in three to five days unless there is a wound that requires closer monitoring. Then ensure dressing changes every seven to 10 days thereafter until full healing has occurred. Once healed has occurred, the patient with diabetes may return to extra-depth shoe gear with accommodative multi-density insoles for life.

How To Perform Percutaneous Toe Osteotomies

   After the surgeon has performed percutaneous toe and metatarsophalangeal tenotomies/capsulotomies, he or she can ascertain the degree of the osseous claw toe deformity by loading the forefoot to select the best location of the wedge osteotomy/osteotomies for correction. The location of these osteotomies would be at the base of the proximal phalanx in the metaphyseal-diaphyseal area and the diaphysis of the middle phalanx.

   When it comes to correction of the mild to moderate osseous claw toe deformity, our choice is a wedge osteotomy at the base of the proximal phalanx. We employ a combination of wedge osteotomies at the base of the proximal phalanx and middle phalanx for severe claw toe deformity.

   The surgical technique begins with the patient in a supine position. A tourniquet is not required as blood loss is minimal. Patients with dense peripheral neuropathy will not require anesthesia. However, for sensate patients, one can perform a regional infiltration of local anesthesia.

   Draw a 2- to 3-mm incision on the plantar aspect of the base of the proximal phalanx. We usually employ intra-operative image intensification to facilitate a portal incision, using a no. 64 blade directly to the base of the proximal phalanx at the metaphyseal-diaphyseal junction. Under direct image intensification, one may use a 1.5-mm drill (i.e., Shannon 44 burr) to perform the through and through wedge osteotomy with the apex located dorsally. The surgeon can best create this wedge osteotomy by applying plantar tension distal to the osteotomy site with the non-dominant hand. Be cautious about maintaining proper burr speed in order to minimize thermal necrosis of the soft tissue and osseous structures.

   Internal wire fixation is up to the surgeon’s discretion and one can perform this percutaneously from the distal tip of the digit under direct image intensification. Once you have achieved correction, close the surgical site with a single metallic staple or nylon suture if appropriate. Otherwise, you can leave the site open with healing via secondary intent.

   If further surgical correction is necessary to correct a severe claw toe deformity, one can perform a wedge osteotomy at the diaphysis of the middle phalanx with the apex of the wedge osteotomy located plantarly.

   Make a 2- to 3-mm incision on the dorsal medial or dorsal lateral aspect of the middle phalanx. One can employ intraoperative image intensification to facilitate a portal incision, using a no. 64 blade directly to the diaphysis of the middle phalanx. Under direct image intensification, the surgeon can use a 1.5-mm drill (i.e., Shannon 44 burr) to perform the through and through wedge osteotomy with the apex located plantarly. One can best create this wedge osteotomy by applying dorsal tension distal to the osteotomy site with the non-dominant hand.

   As noted above, internal wire fixation is up to the surgeon’s discretion. Close the skin incision and apply a specialized dressing as noted above. The patient may have guarded, full weightbearing in a postoperative shoe. Remove the initial surgical dressing in three to five days unless there is a wound that requires closer monitoring. Then ensure dressing changes every seven to 10 days thereafter until full healing has occurred. Once healing has occurred, the patient with diabetes may return to extra-depth shoe gear with accommodative multi-density insoles for life.

   As a final note, if there is any medial or lateral deviation of the claw toe deformity, one can address this at the time of surgical correction by changing the apex of the through and though wedge osteotomy at the location of the deformity.

Step-By-Step Pointers On Minimal Incision Central Metatarsal Osteotomies

   Minimal incision central metatarsal osteotomies are frequently adequate for an elongated or plantarly displaced central metatarsal that is associated with a plantar forefoot neuropathic ulceration.23-27 This provides surgical offloading of the associated ulceration, which leads to rapid soft tissue healing.36,38

   The surgical technique begins with the patient in a supine position. A tourniquet is not required as blood loss is minimal. Patients with dense peripheral neuropathy will not require anesthesia but one can perform a regional infiltration of local anesthesia for sensate patients. We usually employ intraoperative image intensification to create a 1-cm transverse incision at the level of the metaphyseal-diaphyseal junction (i.e., subcapital region) of the underlying central metatarsal.

   Alternatively, a predictable maneuver to identify the proper location in order to perform a minimal incision central metatarsal osteotomy is to first place a thumb over the metatarsal head or plantar ulceration. One would proceed to place an index finger over the dorsal aspect of the metatarsal parallel with the thumb. This creates an “okay” sign and identifies the metaphyseal-diaphyseal junction of the metatarsal (i.e., surgical neck) where the surgeon should perform the osteotomy.

   Make a 1-cm transverse incision through the skin just proximal to your index finger and use a hemostat to dissect to the level of the periosteum overlying the osteotomy. Once you have palpated the underlying bone, open the hemostat jaws with one jaw medial and the other lateral until you can advance the hemostat from dorsal-to-plantar. This maneuver elevates the soft tissue from the medial, dorsal and lateral aspects of the metatarsal surgical neck.

   Under intraoperative image intensification control, use a narrow width power saw blade to create an osteotomy from dorsal to plantar with slight angulation proximal to distal. This orientation allows for simultaneous dorsal and proximal translation of the capital fragment. Following use of the saw blade, perform the same thumb to index finger maneuver described above. Follow this with repeated dorsal to plantar translation of the metatarsal head to verify complete release of any soft tissue or osseous structures, which would otherwise limit the mobility of the osteotomy.

   Internal fixation is not necessary as the metatarsal head is bound by the deep transverse intermetatarsal ligaments and dense capsule-ligamentous structures about the metatarsophalangeal joint, which limit excessive displacement when one performs the osteotomy as described.

   Then irrigate the surgical site and close the skin with a single non-absorbable suture in vertical mattress fashion or with metallic skin staples. Apply a bulky, well-padded dressing from the toes to the knee, using extra padding directly plantar to the osteotomized metatarsal head in order to maintain dorsal translation.15,47 Allow full weightbearing in the aforementioned postoperative shoe and orthosis system, and change the dressings as described above for toe tenotomies.

   When the surgeon performs the osteotomy correctly, one will see the development of robust osseous callus formation, which is followed by maturation and remodeling over time. In our experience, it is a universal finding that the ulceration heals within 10 to 14 days following this osteotomy since the underlying structural osseous deformity has been corrected. As described above, once full healing has occurred, the patient can wear an extra-depth shoe with accommodative multi-density orthoses for life.

What About The Endoscopic Minimal Incision Gastrocnemius Recession?

   Endoscopic minimal incision gastrocnemius recession (EGR) allows direct visualization, which protects the sural nerve and lesser saphenous vein, and ensures complete transection of the entire gastrocnemius aponeurosis.48-50

   A thigh or sterile high calf tourniquet is required to ensure a dry surgical field, which prevents the endoscope from becoming obscured. This is a downside in comparison with a percutaneous tendo-Achilles lengthening since the use of a tourniquet is contraindicated in patients with a history of peripheral arterial disease or peripheral arterial bypass surgery, and is not well tolerated by the patient without the use of spinal or general anesthetic.

   One should ensure supine positioning with the patient’s feet at the end of the table and the arthroscopy tower on the contralateral side of the operative limb for easy viewing. An incision of approximately 1 cm in length is required for the EGR. The surgeon should map this out using topographic landmarks of the lower leg as mentioned above.48

   Incise the skin and deep fascia to expose the gastrocnemius aponeurosis. Incise the gastrocnemius aponeurosis and employ a fascial elevator (A.M. Surgical Endoscopic Tissue Release, Wright Medical Technology) to define the plane between the deep fascia and the gastrocnemius aponeurosis. Use a sweeping motion during removal of the elevator to widen this plane. Doing so facilitates insertion and retrieval of the obturator and cannula as well as subsequent instrumentation.

   Rotate the cannula so its opening is toward the aponeurosis. Proceed to remove the obturator. Insert a 4 mm, 25- to 30-degree endoscope into the cannula. Advance it to visualize the gastrocnemius aponeurosis and confirm that the cannula is in the correct plane. Then rotate the cannula and endoscope posteriorly toward the deep fascia. Withdraw the endoscope so you can visualize the lesser saphenous vein and sural nerve to ensure that the cannula lies anterior to these structures. This prevents injury.

   Once you have confirmed this, rotate the endoscope and cannula back to face the gastrocnemius aponeurosis. Remove the endoscope and lock the endoscope mounted knife blade in place on the endoscope. Insert the endoscope and knife blade into the cannula, and dorsiflex the foot while angling the cannula toward the gastrocnemius aponeurosis. Using both hands, the surgeon advances the endoscope and knife blade in a controlled fashion along the cannula. Doing so incises the gastrocnemius aponeurosis.

   A stopper on the blade prevents extrusion through the skin at the lateral aspect of the lower leg. If portions of the gastrocnemius aponeurosis remain intact, pass the endoscope and knife blade through the cannula to incise the remaining fibers.

   However, do so with caution so you can avoid incising the underlying muscle fibers, which can cause bleeding and subsequent hematoma formation. Utilize a large scissor to transect the medial most fibers of the gastrocnemius aponeurosis at the anterior border of the incision site. If additional correction is required, one can achieve elevation of the gastrocnemius aponeurosis off the underlying soleus with a tissue elevator. Close the deep fascia with absorbable suture and follow with skin closure as described above.

   When experienced surgeons perform this procedure as we have described above, endoscopic minimal incision gastrocnemius recession allows for limited surgical trauma and significant correction of the equinus contracture.48

In Conclusion

   Percutaneous and minimal incision metatarsal soft tissue and osseous surgical techniques can be useful in the management of patients with diabetes. What are the advantages of these techniques?

   • They result in less soft tissue and osseous trauma, specifically the vascular supply to these tissues.
   • They reduce operative time.
   • One can perform these procedures in an outpatient setting and permit early ambulation.
   • These procedures create less post-operative bleeding than traditional open approaches.

   There is a steep learning curve with these procedures. However, combining these procedures with proper, protected postoperative ambulation and lifelong use of appropriate shoe gear rapidly and predictably resolves recalcitrant or recurrent neuropathic ulceration in patients with diabetes by correcting the underlying structural deformity with minimal complications.

Dr. Roukis is the Chief of the Limb Preservation Service in the Vascular/ Endovascular Surgery Service within the Department of Surgery at the Madigan Army Medical Center in Tacoma, Wash. He is also the Director of the Limb Preservation Complex Lower Extremity Surgery and Research Fellowship at the aforementioned facility. The two-year fellowship is approved by the Council on Podiatric Medical Education.

Dr. Markewych is the Director of South Hill Ambulatory Surgical Center and in Private Practice in Spokane, Wash. He is the Past President of the Academy of Ambulatory Foot and Ankle Surgery and currently serves as the Scientific Chairman and as a member of the Board of Directors for the Academy.

Authors’ note: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense.

Editor’s note: For related articles, see “Exploring Limb Salvage Options In Patients With Chronic Limb Ischemia” in the March 2005 issue, “Is Limb Salvage Practical In Patients With Diabetes And Renal Failure?” in the March 2007 issue or “Rethinking Proper Patient Selection For Limb Salvage Interventions” in the August 2006 issue.

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