MAXIMIZING FOOT SALVAGE BY A COMBINED APPROACH TO FOOT ISCHEMIA AND NEUROPATHIC ULCERATION IN PATIENTS WITH DIABETES

OBJECTIVE- The combination of peripheral neuropathy and arterial insuf ficiency in patients with diabetes frequently results in chronic non-h ealing foot ulcers. These patients often have a protracted course that commonly ends in limb amputation. RESEARCH DESIGN AND METHODS- Since 1987, 39 diabetic patients presented with 42 neuropathic ulcerations b eneath the lesser metatarsal heads, complicated by severe arterial ins ufficiency. A variety of vascular reconstructions were performed to im prove circulation to the foot. After successful vascular reconstructio n, 14 patients with deep ulcers underwent resection of the involved bo ne or joint through a plantar elliptical incision with excision of the ulcer and primary closure (33%). Five patients required a simultaneou s panmetatarsal head resection (12%). For fifteen superficial ulcers, metatarsal osteotomy through a dorsal approach was performed (36%). Ei ght patients underwent a fifth metatarsal head resection through a dor sal approach (19%). RESULTS- In follow-up of 2-64 months (mean 21.2 mo nths), 35 extremities with patent bypass grafts achieved and maintaine d primary healing of their local foot procedure (83%). Two feet requir ed subsequent revision but ultimately healed (5%). Three feet (7%) dev eloped a new plantar ulceration adjacent to the original one. In two e xtremities, The foot remained healed in spite of thrombosis of their g rafts (5%). One patient with a thrombosed graft required a below-knee amputation. One patient died before the foot healed with a patent bypa ss graft. Overall, 40 of 42 extremities (95%) ultimately healed over t he course of the follow-up period. CONCLUSIONS- We conclude that compl ex neuropathic ulcers in diabetic patients can be successfully treated by an aggressive surgical approach that removes infected bone and ulc ers and corrects underlying structural abnormalities provided arterial insufficiency is corrected first.