Katz IA, Harlan A, Miranda-Palma B, et al: A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. .Diabetes Care 28::555. ,2005. .
Bruckner M, Mangan M, Godin S, et al: Project LEAP of New Jersey: lower extremity amputation prevention in persons with type 2 diabetes. .Am J Manag Care 5::609. ,1999. .
Laborde JM: Neuropathic toe ulcers treated with toe flexor tenotomies. .Foot Ankle Int 28::1160. ,2007. .
Lavery LA, Higgins KR, Lanctot DR, et al: Home monitoring of foot skin temperatures to prevent ulceration. .Diabetes Care 27::2642. ,2004. .
Ghanassia E, Villon L, Thuan Dit Dieudonne JF, et al: Long-term outcome and disability of diabetic patients hospitalized for diabetic foot ulcers: a 6.5-year follow-up study. .Diabetes Care 31::1288. ,2008. .
Jeffcoate WJ, Chipchase SY, Ince P, et al: Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. .Diabetes Care 29::1784. ,2006. .
Pound N, Chipchase S, Treece K, et al: Ulcer-free survival following management of foot ulcers in diabetes. .Diabet Med 22::1306. ,2005. .
Vinik A, Ullal J, Parson HK, et al: Diabetic neuropathies: clinical manifestations and current treatment options. .Nat Clin Pract Endocrinol Metab 2::269. ,2006. .
Dellon AL: Treatment of symptomatic diabetic neuropathy by surgical decompression of multiple peripheral nerves. .Plast Reconstr Surg 89::689. ,1992. .
Aszmann O, Tassler PL, Dellon AL: Changing the natural history of diabetic neuropathy: incidence of ulcer/ amputation in the contralateral limb of patients with a unilateral nerve decompression procedure. .Ann Plast Surg 53::517. ,2004. .
Barker AR, Rosson GD, Dellon AL: Wound healing in denervated tissue. .Ann Plast Surg 57::339. ,2006. .
Schaper NC, Huijberts M, Pickwell K: Neurovascular control and neurogenic inflammation in diabetes. .Diabetes Metab Res Rev 24: (suppl 1):S40. ,2008. .
Apfel SC, Asbury AK, Bril V, et al: Positive neuropathic sensory symptoms as endpoints in diabetic neuropathy trials. .J Neurol Sci 189::3. ,2001. .
Vinik AI, Bril V, Kempler P, et al: Treatment of symptomatic diabetic peripheral neuropathy with the protein kinase C β-inhibitor ruboxistaurin mesylate during a 1-year, randomized, placebo-controlled, double-blind clinical trial. .Clin Ther 27::1164. ,2005. .
Flum DR: Interpreting surgical trials with subjective outcomes: avoiding UnSPORTsmanlike conduct. .JAMA 296::2483. ,2006. .
Biddinger KR, Amend KJ: The role of surgical decompression for diabetic neuropathy. .Foot Ankle Clin 9::239. ,2004. .
Hollis Caffee H: Treatment of diabetic neuropathy by decompression of the posterior tibial nerve. .Plast Reconstr Surg 106::813. ,2000. .
Rader AJ: Surgical decompression in lower-extremity diabetic peripheral neuropathy. .JAPMA 95::446. ,2005. .
Siemionow M, Alghoul M, Molski M, et al: Clinical outcome of peripheral nerve decompression in diabetic and nondiabetic peripheral neuropathy. .Ann Plast Surg 57::385. ,2006. .
Wieman TJ, Patel VG: Treatment of hyperesthetic neuropathic pain in diabetics: decompression of the tarsal tunnel. .Ann Surg 221::660. ,1995. .
Wood WA, Wood MA, Werter SA, et al: Testing for loss of protective sensation in patients with foot ulceration: a cross-sectional study. .JAPMA 95::469. ,2005. .
Valdivia JM, Dellon AL, Weinand ME, et al: Surgical treatment of peripheral neuropathy: outcomes from 100 consecutive decompressions. .JAPMA 95::451. ,2005. .
Aszmann OC, Kress KM, Dellon AL: Results of decompression of peripheral nerves in diabetics: a prospective, blinded study. .Plast Reconstr Surg 106::816. ,2000. .
Baravarian B: Surgical decompression for painful diabetic peripheral nerve compression and neuropathy: a comprehensive approach to a potential surgical problem. .Clin Podiatr Med Surg 23::621. ,2006. .
Dellon AL: Neurosurgical prevention of ulceration and amputation by decompression of lower extremity peripheral nerves in diabetic neuropathy: update 2006. .Acta Neurochir Suppl 100::149. ,2007. .
Vinik A: Nerve decompression in the management of diabetic peripheral neuropathy: is there evidence. Paper presented at: ADA 66th Scientific Sessions; June 9–13. ,2006. ; Washington, DC.
Ducic I, Taylor NS, Dellon AL: Relationship between peripheral nerve decompression and gain of pedal sensibility and balance in patients with peripheral neuropathy. .Ann Plast Surg 56::145. ,2006. .
Dellon AL: Diabetic neuropathy: review of a surgical approach to restore sensation, relieve pain, and prevent ulceration and amputation. .Foot Ankle Int 25::749. ,2004. .
Lavery LA, Higgins KR, Lanctot DR, et al: Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. .Diabetes Care 30::14. ,2007. .
Frigg A, Pagenstert G, Schafer D, et al: Recurrence and prevention of diabetic foot ulcers after total contact casting. .Foot Ankle Int 28::64. ,2007. .
Connor H, Mahdi OZ: Repetitive ulceration in neuropathic patients. .Diabetes Metab Res Rev 20: (suppl 1):S23. ,2004. .
Peters EJ, Armstrong DG, Lavery LA: Risk factors for recurrent diabetic foot ulcers: site matters. .Diabetes Care 30::2077. ,2007. .
Lee CH, Dellon AL: Prognostic ability of Tinel sign in determining outcome for decompression surgery in diabetic and nondiabetic neuropathy. .Ann Plast Surg 53::523. ,2004. .
Background: This study reevaluates the previously reported subjective benefits of surgical nerve decompression in diabetes with an easily observable, fully objective outcome measure to eliminate the placebo effect and observer bias.
Methods: A retrospective review was conducted of a series of 75 feet in 65 patients with diabetes and previous neuropathic ulcer who had surgical decompressions of the peroneal and posterior tibial nerve branches at anatomical fibro-osseous tunnels. After a minimum of 12 months of follow-up, the incidence of ipsilateral ulcer was assessed.
Results: Postoperatively, four ulcer recurrences and four new-site ulcers developed in 187 patient-years. Mean follow-up was 2.49 years (range, 1–13 years). The combined linear annual risk of ipsilateral recurrence and new ulcer is 4.28%, the lowest reported in the scientific literature.
Conclusions: Surgical decompression of lower-extremity nerves of high-risk feet at fibro-osseous anatomical tunnels was followed by a low annual incidence of ulcer recurrence. This objective outcome measure suggests benefits of nerve decompression in diabetic neuropathy, as have previous reports using pain and sensory change as subjective measures. Unrecognized nerve entrapment may frequently coexist with diabetic sensorimotor peripheral neuropathy in patients with diabetic foot ulcer. (J Am Podiatr Med Assoc 100(2): 111–115, 2010)