diabetic toe ulcers , heal prevent recurrence

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How to Heal Toe Ulcers, Avoid Recurrence & Hospital Admission for Infection & Amputation J. Monroe Laborde,MD,MS President, N.O.Leadership Council American Diabetes Association www.footulcer.info

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Over 80,000 Amputationsper Year in Diabetics*85% have Foot Ulcers**Prevention & Cure of Foot Ulcers Would Prevent Most Amputations Most common reason for hospitalization risk x15,5%.yr,15%/life 90% over 1 mo over $300 mil/ yr avg/ ulcer =6664 *www.cdc.gov/diabetes **Pecoraro,Diabetes Care,13(5):513-21,1990

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Ulcer Cause = Neuropathy90% of Ulcers can’t feel 5.07 monofilament Protective Sensation (Myelin Glycosylation ) Soft Tissue Tightness (Collagen Glycosylation* &/or Motor Neuropathy) Forefoot Stress *Aoki et al., Diabetologia 36:79-83,1993

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Forefoot Stress Callus Ulcer Infection Amputation Callus Risk of Ulcer 11X Ulcer Risk of Amputation 2-10X

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Decreasing Foot Pressure “Off-loading” Crutches, Wheelchair (Compliance) Walking Boots (Compliance) Shoe Modifications (Effectiveness) Total Contact Casts (30% Complications* 81% Recur **) [Remove Met. Head (Transfer)] TENDON LENGTHENING*** *Guyton,A&F Int,26(11):903-7,2005 **Mueller,JBJS,85(8):1436-45,2003 ***Armstrong,JBJS,81:535-8,1999

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Ulcer Tenotomies Toes 1-5 Toe Flexors 1st Toe F H Brevis

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Toe Flexor Tenotomy for Toe Ulcers(Percutaneus in Office) Toe Ulcers Plantar (& Dorsal) Progressive Callus or Pain from Clawtoes ,Mallet & Hammer Toes

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Flexor Tenotomies for Toe Ulcers Results 96-03 24 Ulcers 14 Patients(10 Diabetics) All Ulcers Healed Average Follow-up 32 Months(0 lost) No Recurrences 11 2nd-5th Toes 3 Recurrences 13 1st Toes (Repeat Tenotomy Healed , not Recur) No Incision Problems or Deformity .

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Flexor Hallucis Brevis Tenotomy More Difficult Grant’s Atlas of Anatomy 5th Ed,Williams & Wilkins.,1962

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Recurrence of Foot Ulcersin 558 Diabetics 1 Year = 34% 3 Years = 61% 5 Years = 70% Apelgrist et al. Long term prognosis for diabetic patients with foot ulcers. J. Intern.Med. 223:485-491,1993 Recurrence of Toe Ulcers much less after Toe Tenotomies (3/24=13% @ 2.7 Yr F/U)

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1st on TL for Toe Ulcers2nd on TL for Diabetic Met. Hd. Ulcers

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CONCLUSIONPlantar Toe Ulcers Cause = Neuropathy & Tight Tendons (Prevention = Calf & Toe Stretching ?) CURE = FLEXOR TENOTOMIES

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J. Monroe Laborde,MD,MSwww.footulcer.info President, N.O. Leadership Council American Diabetes Association Touro Infirmary Asst. Prof. Orthopedic Surgery (Clin.) Asst. Prof. Biomedical Engineering (Adj.) Tulane University Orthopedic Surgery Staff Clin. Asst. Prof. Physical Medicine & Rehab. Medical Center of La. At N.O. L.S.U. Health Sciences Center

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1st Report Peroneus Longus & Posterior Tibial Lengthening for Foot Ulcers, Tendon Lengthening as Primary Rx for Midfoot Ulcers & Charcot Arthropathy

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Apelgrist. J.Intern. Med. 223:485-91,1993 Mueller. JBJS.. 85:1436-45,2003 Laborde .Wounds.17(5);122-130,2005

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