Amputation in diabetic foot ulcer: A treatment dilemma

Diabetic foot: Which one comes first, the ulcer or the contracture?

Introduction: The effectiveness and efficiency of the treatment has long been important in diabetes and its complications, especially in the developing countries. Prolonged hospitalization and repeated surgery should be avoided due to clinical and economical reasons. Wound breakdowns or necrosis can occur after amputation procedures, and subsequently will require reamputation. This study analysed susceptibility factors in diabetic foot patients undergoing prior great toe amputation that are thought to be related to early reamputation. Method: We performed a retrospective analysis in 107 patients that have undergone amputation for great toe gangrene, during May 2014-April 2019. Demographic data, clinical features, laboratory results and treatment modality were documented and statistically analysed by simple and multiple logistic regression method. Results: Of all 107 patients, 17 patients had to undergo early reamputation. Limited dorsiflexion, level of amputation, and sepsis condition is shown to be significantly associated with early amputation. Multiple logistic regression analysis confirmed a significant association of early reamputation with amputation or disarticulation at level of metatarsophalangeal joint. Conclusion: While limited ankle dorsiflexion and sepsis condition need to be addressed comprehensively, from the surgical options point of view we suggest ray amputation to be preferred over metatarsophalangeal joint disarticulation to prevent early reamputation.

Chronic hyperglycemia can increase extracellular matrix (ECM) accumulation that leads to tendon fibrosis and subsequent contracture. Considering the reversibility of fibrosis, it is important to identify factors that are associated with it. The purpose of this study was to determine whether elevated HbA1c levels are associated with the development of Achilles tendon contracture in diabetes mellitus patients. We reviewed 206 patients with diabetic foot problems between January 2015-December 2019. Demographic data, the presence of Achilles tendon contracture, and laboratory results were documented and statistically analysed between patients with contracture and without contracture. Patients’ mean age was 58.46 ± 6.67 years old. Contracture was found in 84 out of 206 patients (40.78%) patients, with female predominance (45/84 patients; 53%). While contracture was found significantly associated with sex difference (0.035) and age groups (p=0.006), there was no meaningful association with HbA1c level groups (p=0.324). Findings do not support the use of HbA1c level as a sole determinant of Achilles tendon contracture. Seemingly, there are other confounding factors affecting the Achilles tendon contracture development in diabetes mellitus patients. It should be emphasised that albeit the association between chronic hyperglycemia and contracture development, the low HbA1c should not be overlooked as having no risk of Achilles tendon contracture and vice versa.

Hallux valgus interphalangeus (HVIP) is a deviation of the distal phalanx in relation to the proximal phalanx. Its etiology is considered multifactorial, including growth development disturbances, external pressure, and biomechanical alteration involving the interphalangeal joint. Here, we report a case of HVIP with the presence of a large ossicle at the lateral side, which was considered related to HVIP development. A 21-year-old woman presented HVIP that had developed since childhood. She complained of pain in her right great toe that worsened in the previous several months, particularly when walking and wearing shoes. Surgical correction consisted of Akin osteotomy, fixation with headless screw, ossicle excision, and medial capsulorrhaphy. The interphalangeal joint angle was improved from 28.69⁰ pre-operatively to 8.93⁰ post-operatively. The wound healed uneventfully and the patient was satisfied. Akin osteotomy with concomitant ossicle excision was effective in this case. Gaining more knowledge regarding ossicles around the foot will provide a better understanding of deformity correction, especially from the biomechanical standpoint.

Running had been known producing a posterior muscle tightness in lower extremity, particularly calf muscles, resulting in a relative equinus deformity. Numerous study reported the association between equinus deformity and foot pain, partially due to the increased plantar pressure of forefoot. This study was directed to find a relation between running intensity and increased forefoot plantar pressure. Subjects were divided into two groups according to running intensity as classified as runner or non-runner. Forefoot plantar pressures data were obtained using a foot imprinter and analyzed into numerical values. Ankle maximum dorsiflexion was also examined in an extended knee to detect the calf tightness. Mean forefoot plantar pressure value was Grau 2.89 (range 2-4) in runner group, and Grau 2.15 (range 1-4) in non-runner group (p=0.004). Ankle maximum dorsiflexion was also limited in runner group (16.05±1.98⁰) compared with 19.30±1.38⁰ in non-runner group (p<0.001). There was an association found between running intensity and plantar pressure elevation. Considering the potential damaging effects to the foot, it is recommended for runners or treating physician to look into this problem as well as to make sure that regular calf stretching is advocated.