• 1

    Boulton AJ, Kirsner RS, Vileikyte L: Clinical practice: neuropathic diabetic foot ulcers. .N Engl J Med 351::48. ,2004. .

  • 2

    Boulton AJ, Armstrong DG, Albert SF, et al: Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. .Diabetes Care 31::1679. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Reiber GE, Vileikyte L, Boyko EJ, et al: Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. .Diabetes Care 22::157. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Frykberg RG: Biomechanical considerations of the diabetic foot. .Lower Extremity 2::207. ,1995. .

  • 5

    Cavanagh PR: Therapeutic footwear for people with diabetes. .Diabetes Metab Res Rev 20: (suppl 1):S51. ,2004. .

  • 6

    Veves A, Murray HJ, Young MJ, et al: The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. .Diabetologia 35::660. ,1992. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Frykberg RG, Lavery LA, Pham H, et al: Role of neuropathy and high foot pressures in diabetic foot ulceration. .Diabetes Care 21::1714. ,1998. .

  • 8

    van Schie CH: A review of the biomechanics of the diabetic foot. .Int J Low Extrem Wounds 4::160. ,2005. .

  • 9

    Wukich DK, Lowery NJ, McMillen RL, et al: Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. .J Bone Joint Surg Am 92::287. ,2010. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Fernando DJ, Masson EA, Veves A, et al: Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. .Diabetes Care 14::8. ,1991. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Abbott CA, Carrington AL, Ashe H, et al: The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. .Diabet Med 19::377. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Boyko EJ, Ahroni JH, Stensel V, et al: A prospective study of risk factors for diabetic foot ulcer: the Seattle Diabetic Foot Study. .Diabetes Care 22::1036. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Frykberg RG, Zgonis T, Armstrong DG, et al: Diabetic foot disorders: a clinical practice guideline (2006 revision). .J Foot Ankle Surg 45: (suppl):S1. ,2006. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Sanders LJ, Frykberg RG: “Diabetic Neuropathic Osteoarthropathy: The Charcot Foot,” in The High Risk Foot in Diabetes Mellitus, ed by RG Frykberg, p 325, Churchill Livingstone, New York. ,1991. .

    • PubMed
    • Export Citation
  • 15

    Wukich DK, Sung W: Charcot arthropathy of the foot and ankle: modern concepts and management review. .J Diabetes Complications 23::409. ,2009. .

  • 16

    Boulton AJ: Diabetic neuropathy: classification, measurement and treatment. .Curr Opin Endocrinol Diabetes Obes 14::141. ,2007. .

  • 17

    Vinik AI, Maser RE, Mitchell BD, et al: Diabetic autonomic neuropathy. .Diabetes Care 26::1553. ,2003. .

  • 18

    Boulton AJ, Vinik AI, Arezzo JC, et al: Diabetic neuropathies: a statement by the American Diabetes Association. .Diabetes Care 28::956. ,2005. .

  • 19

    Andersen H, Gjerstad MD, Jakobsen J: Atrophy of foot muscles: a measure of diabetic neuropathy. .Diabetes Care 27::2382. ,2004. .

  • 20

    Lavery LA, Armstrong DG, Boulton AJ: Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. .JAPMA 92::479. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Armstrong DG, Stacpoole-Shea S, Nguyen H, et al: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. .J Bone Joint Surg Am 81::535. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Mueller MJ, Sinacore DR, Hastings MK, et al: Effect of achilles tendon lengthening on neuropathic plantar ulcers: a randomized clinical trial. .J Bone Joint Surg Am 85::1436. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    van Schie CH, Vermigli C, Carrington AL, et al: Muscle weakness and foot deformities in diabetes: relationship to neuropathy and foot ulceration in caucasian diabetic men. .Diabetes Care 27::1668. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Habershaw G, Chzran J: “Biomechanical Considerations of the Diabetic Foot,” in Management of Diabetic Foot Problems, 2nd Ed, ed by GP Kozak, DR Campbell, RG Frykberg, GM Habershaw, p 53, WB Saunders, Philadelphia. ,1995. .

    • PubMed
    • Export Citation
  • 25

    International Working Group on the Diabetic Foot: International consensus on the diabetic foot. Paper presented at: International Working Group on the Diabetic Foot, May 15. ,2003. , Noordwijkerhout, the Netherlands.

    • PubMed
    • Export Citation
  • 26

    American Diabetes Association: Consensus Development Conference on Diabetic Foot Wound Care. .Diabetes Care 22::1354. ,1999. .

  • 27

    American Diabetes Association: Preventive foot care in diabetes. .Diabetes Care 27: (suppl 1):S63. ,2004. .

  • 28

    Armstrong DG, Lavery LA, Kimbriel HR, et al: Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. .Diabetes Care 26::2595. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Uccioli L, Faglia E, Monticone G, et al: Manufactured shoes in the prevention of diabetic foot ulcers. .Diabetes Care 18::1376. ,1995. .

  • 30

    Chantelau E, Kushner T, Spraul M: How effective is cushioned therapeutic footwear in protecting diabetic feet? a clinical study. .Diabetic Med 7::335. ,1990. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Chantelau E: Therapeutic footwear in patients with diabetes. .JAMA 288::1231. ,2002. .

  • 32

    Edmonds ME, Blundell MP, Morns ME, et al: Improved survival of the diabetic foot: the role of a specialized foot clinic. .Q J Med 60::763. ,1986. .

  • 33

    Piaggesi A, Schipani E, Campi F, et al: Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. .Diabet Med 15::412. ,1998. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Armstrong DG, Lavery LA, Stern S, et al: Is prophylactic diabetic foot surgery dangerous?. J Foot Ankle Surg 35::585. ,1996. .

  • 35

    Catanzariti AR, Blitch EL, Karlock LG: Elective foot and ankle surgery in the diabetic patient. .J Foot Ankle Surg 35::23. ,1995. .

  • 36

    Nicklas BJ: “Prophylactic Surgery in the Diabetic Foot,” in The High Risk Foot in Diabetes Mellitus, ed by RG Frykberg, p 537, Churchill Livingstone, New York. ,1991. .

    • PubMed
    • Export Citation
  • 37

    Frykberg RG: Diabetic foot ulcers: pathogenesis and management. .Am Fam Physician 66::1655. ,2002. .

  • 38

    Frykberg R, Giurini J, Habershaw G, et al: “Prophylactic Surgery in the Diabetic Foot,” in Medical and Surgical Management of the Diabetic Foot, ed by SJ Kominsky, p 399, Mosby, St Louis. ,1993. .

    • PubMed
    • Export Citation
  • 39

    American Diabetes Association: Peripheral arterial disease in people with diabetes. .Diabetes Care 26::3333. ,2003. .

  • 40

    Armstrong DG, Frykberg RG: Classifying diabetic foot surgery: toward a rational definition. .Diabet Med 20::329. ,2003. .

  • 41

    Armstrong DG, Lavery LA, Frykberg RG, et al: Validation of a diabetic foot surgery classification. .Int Wound J 3::240. ,2006. .

  • 42

    Zgonis T, Roukis TS, Frykberg RG, et al: Unstable acute and chronic Charcot’s deformity: staged skeletal and soft-tissue reconstruction. .J Wound Care 15::276. ,2006. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Zgonis T, Roukis TS, Lamm BM: Charcot foot and ankle reconstruction: current thinking and surgical approaches. .Clin Podiatr Med Surg 24::505. ,2007. .

  • 44

    Kim JY, Kim TW, Park YE, et al: Modified resection arthroplasty for infected non-healing ulcers with toe deformity in diabetic patients. .Foot Ankle Int 29::493. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Laborde JM: Neuropathic toe ulcers treated with toe flexor tenotomies. .Foot Ankle Int 28::1160. ,2007. .

  • 46

    Tamir E, McLaren AM, Gadgil A, et al: Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report. .Can J Surg 51::41. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Roukis TS, Schade VL: Percutaneous flexor tenotomy for treatment of neuropathic toe ulceration secondary to toe contracture in persons with diabetes: a systematic review. .J Foot Ankle Surg 48::684. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Hamilton GA, Ford LA, Perez H, et al: Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients. .J Foot Ankle Surg 44::37. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Sayner LR, Rosenblum BI, Giurini JM: Elective surgery of the diabetic foot. .Clin Podiatr Med Surg 20::783. ,2003. .

  • 50

    Tillo TH, Giurini JM, Habershaw GM, et al: Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. .JAPMA 80::211. ,1990. .

  • 51

    Armstrong DG, Rosales MA, Gashi A: Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration. .JAPMA 95::353. ,2005. .

  • 52

    Giurini JM, Habershaw GM, Chrzan JS: Panmetatarsal head resection in chronic neuropathic ulceration. .J Foot Surg 26::249. ,1987. .

  • 53

    Wu SC, Crews RT, Armstrong DG: The pivotal role of offloading in the management of neuropathic foot ulceration. .Curr Diab Rep 5::423. ,2005. .

  • 54

    Armstrong DG, Lavery LA, Vazquez JR, et al: Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in persons with diabetes. .Diabetes Care 26::3284. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Barry DC, Sabacinski KA, Habershaw GM, et al: Tendo Achillis procedures for chronic ulcerations in diabetic patients with transmetatarsal amputations. .JAPMA 83::96. ,1993. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Holstein P, Lohmann M, Bitsch M, et al: Achilles tendon lengthening, the panacea for plantar forefoot ulceration?. Diabetes Metab Res Rev 20: (suppl 1):S37. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    La Fontaine J, Brown D, Adams M, et al: New and recurrent ulcerations after percutaneous achilles tendon lengthening in transmetatarsal amputation. .J Foot Ankle Surg 47::225. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Nishimoto GS, Attinger CE, Cooper PS: Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration. .Surg Clin North Am 83::707. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59

    Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-achilles lengthening and total contact casting. .Orthopaedics 19::465. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60

    Greenhagen R, Johnson A, Peterson MC, et al: Gastrocnemius recession as an alternative to tendoAchillis lengthening for relief of forefoot pressure in a patient with peripheral neuropathy: a case report and description of a technical modification. .J Foot Ankle Surg 49::159.e9. ,2010. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Laborde JM: Midfoot ulcers treated with gastrocnemius-soleus recession. .Foot Ankle Int 30::842. ,2009. .

  • 62

    Frykberg RG, Belczyk R: Epidemiology of the Charcot foot. .Clin Podiatr Med Surg 25::17. ,2008. .

  • 63

    Cofield RH, Morrison MJ, Beabout JW: Diabetic neuroarthropathy in the foot: patient characteristics and patterns of radiographic change. .Foot Ankle 4::15. ,1983. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 64

    Frykberg RG, Eneroth M: “Principles of Conservative Management,” in The Diabetic Charcot Foot: Principles and Management, ed by RG Frykberg, p 93, Data Trace Publishing Co, Brooklandville, MD. ,2010. .

    • PubMed
    • Export Citation
  • 65

    Charcot J-M, Fere C: Affections osseuses et articulaires du pied chez les tabétiques (Pied tabétique). .Arch Neurol 6::305. ,1883. .

  • 66

    Sanders LJ: “The Charcot Foot and Ankle: Historical Perspective,” in The Diabetic Charcot Foot: Principles and Management, ed by RG Frykberg, p 1, Data Trace Publishing Co, Brooklandville, MD. ,2010. .

    • PubMed
    • Export Citation
  • 67

    Sohn MW, Stuck RM, Pinzur M, et al: Lower-extremity amputation risk after Charcot arthropathy and diabetic foot ulcer. .Diabetes Care 33::98. ,2010. .

  • 68

    Sohn MW, Lee TA, Stuck RM, et al: Mortality risk of Charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone. .Diabetes Care 32::816. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 69

    Gazis A, Pound N, Macfarlane R, et al: Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot). .Diabet Med 21::1243. ,2004. .

  • 70

    Bevilacqua NJ, Bowling FL, Armstrong DG: “The Natural History of Charcot Neuroarthropathy,” in The Diabetic Charcot Foot: Principles and Management, ed by RG Frykberg, p 13, Data Trace Publishing Co, Brooklandville, MD. ,2010. .

    • PubMed
    • Export Citation
  • 71

    Cavanagh PR, Botek G, Owings T: “Biomechanical Factors in Charcot’s Neuroarthropathy,” in The Diabetic Charcot Foot: Principles and Management, ed by RG Frykberg, p 131, Data Trace Publishing Co, Brooklandville, MD. ,2010. .

    • PubMed
    • Export Citation
  • 72

    Saltzman CL, Hagy ML, Zimmerman B, et al: How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet?. Clin Orthop Relat Res 435::185. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 73

    Frykberg RG, Rogers LC: The diabetic Charcot foot: a primer on medical and surgical management. .J Diabetic Foot Complications 1::19. ,2009. .

  • 74

    Steindler A: The tabetic arthropathies. .JAMA 96::250. ,1931. .

  • 75

    Harris JR, Brand PW: Patterns of disintegration of the tarsus in the anaesthetic foot. .J Bone Joint Surg Br 48::4. ,1966. .

  • 76

    Johnson JT: Neuropathic fractures and joint injuries: pathogenesis and rationale of prevention and treatment. .J Bone Joint Surg Am 49::1. ,1967. .

  • 77

    Bevilacqua NJ, Rogers LC: Surgical management of Charcot midfoot deformities. .Clin Podiatr Med Surg 25::81. ,2008. .

  • 78

    Pinzur MS: Neutral ring fixation for high-risk non-plantigrade Charcot midfoot deformity. .Foot Ankle Int 28::961. ,2007. .

  • 79

    Catanzariti AR, Mendicino R, Haverstock B: Ostectomy for diabetic neuroarthropathy involving the midfoot. .J Foot Ankle Surg 39::291. ,2000. .

  • 80

    Cooper PS: Application of external fixators for management of Charcot deformities of the foot and ankle. .Semin Vasc Surg 16::67. ,2003. .

  • 81

    Farber DC, Juliano PJ, Cavanagh PR, et al: Single stage correction with external fixation of the ulcerated foot in individuals with Charcot neuroarthropathy. .Foot Ankle Int 23::130. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 82

    Burns PR, Wukich DK: Surgical reconstruction of the Charcot rearfoot and ankle. .Clin Podiatr Med Surg 25::95. ,2008. .

  • 83

    Pinzur MS: “Surgical Management: History and General Principles,” in The Diabetic Charcot Foot: Principles and Management, ed by RG Frykberg, p 165, Data Trace Publishing Co, Brooklandville, MD. ,2010. .

    • PubMed
    • Export Citation
  • 84

    Wukich DK, Zgonis T: “Circular External Fixation in Charcot Neuroarthropathy,” in The Diabetic Charcot Foot: Principles and Management, ed by RG Frykberg, p 231, Data Trace Publishing Co, Brooklandville, MD. ,2010. .

    • PubMed
    • Export Citation

Surgical Off-loading of the Diabetic Foot

Robert G. Frykberg Carl T. Hayden VA Medical Center, Phoenix, AZ.

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Nicholas J. Bevilacqua Valley Presbyterian Hospital, Los Angeles, CA.

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Geoffrey Habershaw Boston University Medical Center, Boston, MA.

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Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. Such patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers. (J Am Podiatr Med Assoc 100(5): 369–384, 2010)

Corresponding author: Robert G. Frykberg, DPM, MPH, Carl T. Hayden VA Medical Center, 650 E Indian School Rd, Phoenix, AZ 85012. (E-mail: Robert.Frykberg@va.gov)
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