Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer

Background

Diabetic foot ulcers (DFUs) are a significant health concern for patients with diabetes, often leading to severe complications such as infections and amputations. Effective offloading is critical for healing neuropathic plantar forefoot ulcers, which are caused by repetitive pressure in areas of high plantar stress due to neuropathy. This study investigates two offloading approaches: surgical metatarsal head resection (MHR) and a removable knee-high cam-walker device, evaluating their efficacy in promoting ulcer healing, associated morbidity, and recurrence rates.

Study Design and Methods

The retrospective study, conducted from January 2016 to January 2018, included 70 patients with neuropathic plantar forefoot DFUs. Patients were non-randomly assigned to two groups: 35 received surgical offloading via metatarsal head or accessory bone resection, and 35 were treated with a removable knee-high cam-walker. The primary endpoints were the frequency and rate of complete ulcer healing and the reduction in ulcer area within four months. Secondary endpoints included morbidity and ulcer recurrence within 12 months.

Key Findings

After four months, the surgical offloading group demonstrated significantly higher complete healing rates, with 31 patients (88.6%) achieving full healing compared to 24 patients (67.6%) in the cam-walker group (P = .015). The surgical approach also showed a faster reduction in ulcer area. Morbidity and recurrence rates were similar between the two groups, indicating that while surgical offloading was more effective in achieving healing, it did not increase complications or ulcer recurrence compared to the removable device.

Conclusions

The study suggests that metatarsal head resection offers superior healing efficacy for neuropathic plantar forefoot DFUs compared to a removable knee-high cam-walker, without increased morbidity or recurrence. However, the authors note that the evidence supporting surgical offloading as a definitive solution remains weak, and further research is needed to establish its long-term benefits and optimal application.