Boyko, EJ, JH Ahroni, V Stensel, et al. :A prospective study of risk factors for diabetic foot ulcer: the Seattle Diabetic Foot Study. .Diabetes Care 22::1036. :1999. .
Boyko, EJ, JH Ahroni, V Cohen, et al. :Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. .Diabetes Care 29::1202. :2006. .
Singh, N, DG Armstrong, and BA Lipsky. :Preventing foot ulcers in patients with diabetes. .JAMA 293::217. :2005. .
Lavery, LA, DG Armstrong, RP Wunderlich, et al. :Risk factors for foot infections in individuals with diabetes. .Diabetes Care 29::1288. :2006. .
Lavery, LA, RP Wunderlich, and JL Tredwell. :Disease management, for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. .Diabetes Res Clin Pract 70::31. :2005. .
Lavery, LA, KR Higgins, DR Lanctot, 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. .
Pecoraro, RE, GE Reiber, and EM Burgess. :Pathways to diabetic limb amputation: basis for prevention. .Diabetes Care 13::513. :1990. .
Moulik, PK, R Mtonga, and GV Gill. :Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. .Diabetes Care 26::491. :2003. .
Armstrong, DG, J Wrobel, and JM Robbins. :Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J 4::286. :2007. .
Maciejewski, ML, GE Reiber, DG Smith, et al. :Effectiveness of diabetic therapeutic footwear in preventing reulceration. .Diabetes Care 27::1774. :2004. .
Cavanagh, PR and SA Bus. :Off-loading the diabetic foot for ulcer prevention and healing. .Plast Reconstr Surg 127( suppl 1:):248S. ,2011. .
Dorresteijn, JA, DM Kriegsman, WJ Assendelft, et al. :Patient education for preventing diabetic foot ulceration. .Cochrane Database Syst Rev 5::CD001488. :2010. .
Dorresteijn, JA, DM Kriegsman, and GD Valk. :Complex interventions for preventing diabetic foot ulceration. .Cochrane Database Syst Rev 1::CD007610. :2010. .
Bus, SA, GD Valk, RW van Deursen, et al. :Specific guidelines on footwear and offloading. .Diabetes Metab Res Rev 24( suppl 1:):S192. :2008. .
Katz, IA, A Harlan, B Miranda-Palma, 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. .
Faglia, E, C Caravaggi, G Clerici, et al. :Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial. .Diabetes Care 33::1419. :2010. .
Wu, SC, JL Jensen, AK Weber, et al. :Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care 31::2118. :2008. .
Edmonds, ME, MP Blundell, ME Morris, et al. :Improved survival of the diabetic foot: the role of a specialized foot clinic. .Q J Med 60::763. :1986. .
Arad, Y, V Fonseca, A Peters, et al. :Beyond the monofilament for the insensate diabetic foot: a systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes. .Diabetes Care 34::1041. :2011. .
Armstrong, DG, K Holtz-Neiderer, C Wendel, et al. :Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. .Am J Med 120::1042. :2007. .
Dellon, AL . :A cause for optimism in diabetic neuropathy. .Ann Plast Surg 20::103. :1988. .
Lee, CH and AL Dellon. :Prognostic ability of Tinel sign in determining outcome for decompression surgery in diabetic and nondiabetic neuropathy. .Ann Plast Surg 53::523. :2004. .
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. .
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. .
Dellon, AL . :The Dellon approach to neurolysis in the neuropathy patient with chronic nerve compression. .Handchir Mikrochir Plast Chir 40::1. :2008. .
Chaudhry, V, JC Stevens, J Kincaid, et al. :Practice advisory: utility of surgical decompression for treatment of diabetic neuropathy: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. .Neurology 66.:1805. ,2006. .
Chaudhry, V, J Russell, and A Belzberg. :Decompressive surgery of lower limbs for symmetrical diabetic peripheral neuropathy. .Cochrane Database Syst Rev 3::CD006152. :2008. .
Aszmann, O, PL Tassler, and AL Dellon. :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. .
Nickerson, DS . :Low recurrence rate of diabetic foot ulcer after nerve decompression. .JAPMA 100::111. :2010. .
Wukich, DK, NJ Lowery, RL McMillen, 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. .
Jeffcoate, WJ, SY Chipchase, P Ince, et al. :Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. .Diabetes Care 29::1784. :2006. .
Ghanassia, E, L Villon, Dit Thuan, JF Dieudonné, 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. .
Vinik, A, J Ullal, HK Parson, et al. :Diabetic neuropathies: clinical manifestations and current treatment options. .Nat Clin Pract Endocrinol Metab 2::269. :2006. .
Krishnan, ST, C Quattrini, M Jeziorska, et al. :Neurovascular factors in wound healing in the foot skin of type 2 diabetic subjects. .Diabetes Care 30::3058. :2007. .
Rosson, GD, AR Larson, EH Williams, et al. :Tibial nerve decompression in patients with tarsal tunnel syndrome: pressures in the tarsal, medial plantar, and lateral plantar tunnels. .Plast Reconstr Surg 124::1202. :2009. .
Ducic, I, NS Taylor, and AL Dellon. :Relationship between peripheral nerve decompression and gain of pedal sensibility and balance in patients with peripheral neuropathy. .Ann Plast Surg 56::145. :2006. .
Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies.
Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels.
The cohort’s previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression.
The prospective, objective, statistically significant finding of a large, long-term diminution of diabetic foot ulcer recurrence risk after operative nerve decompression compares very favorably with the historical literature and the contralateral legs of this cohort, which had no decompression. This finding invites prospective randomized controlled studies for validation testing and reconsideration of the frequency and contribution of unrecognized nerve entrapments in diabetic sensorimotor polyneuropathy and diabetic foot complications. (J Am Podiatr Med Assoc 103(5): 380–386, 2013)