Elevated plantar pressure and ulceration in diabetic patients after panmetatarsal head resection: Two case reports

Panmetatarsal head resection (variously called forefoot arthroplasty, foref oot resection arthroplasty, the Hoffman procedure, and the Fowler procedure ) was developed for the relief of pain and deformity in rheumatoid arthriti s. Although there are successful retrospective series reported in the liter ature, such an approach is not supported by carefully designed controlled t rials. This procedure has also been advocated by some for the relief of pla ntar pressure in diabetic patients who are at risk for plantar ulceration. The efficacy of the procedure in this context is not supported by existing pressure measurements on rheumatoid arthritis patients in the literature, w hich has tended to show that although pain relief is obtained, the procedur e results in elevation of forefoot pressure. Case reports are described of two patients (three feet) with sensory neuropathy who presented to our clin ic 1 to 2 years after panmetatarsal head resections had been performed. Pea k plantar pressures in these feet during first step gait were above the 99t h percentile and outside the measuring range of the device used (EMED SF pl atform; NOVEL Electronics Inc., St. Paul, MN). Both patients had also exper ienced plantar ulcers subsequent to the surgery. Combining the information on patients with rheumatoid arthritis (RA) with that from our two case stud ies, we conclude that panmetatarsal head resection does not necessarily eli minate focal regions of elevated plantar pressure.