Minimally invasive surgery of diabetic foot - review of current techniques

Abstract

The term diabetic foot is usually used to indicate advanced foot pathology (complex clinical situations correlating diabetic foot ulcers, diabetic foot infections, Charcot foot, and critical limb ischemia). The early recognition of the etiology of these foot lesions is essential for the therapeutic decision in order to achieve a good functional result. Several surgical procedures involving the foot have been developed in order to promote healing and avoid complications. Traditionally, surgery has been performed in an open way. The literature regarding the performance and efficacy of classical osteotomies and arthrodesis is inconsistent. This can be attributed to several variables, such as differences in patient clinical aspects and the panel of surgical techniques utilized. As with other surgical specialties, fluoroscopic imaging and minimally invasive tools are now being incorporated in these procedures. The use of high speed burrs associated with specialized osteosynthesis implants, offers several advantages over classical techniques. The ability to associate these gestures to complex protocols is beginning to be currently developed. The respect for the soft tissues is considered one of the first advantages. Despite the limited time since they were introduced in clinical practice, functional results seemed to be consistent, supporting the use of this technology.

Keywords: arthrodesis; corrective diabetic foot surgery; headless compression screw; midfoot fusion bolts; minimally invasive.

Fig. 1

Clinical appearance of several deformities associated with the diabetic foot: claw toes on left, Charcot with plantar ulcer on right

Fig. 2

Specialized tools used in the minimally invasive surgery of the foot: rasp and beaver blade on top, motorized high-speed burr on the right (POD ®tools provided by Fournitures Hospitalieres)

Fig. 3

Plantar debridement for the release of an abscess

Fig. 4

Release of the flexor tendons through lateral approach using the specialized beaver blade

Fig. 5

Distal metatarsal osteotomy under fluoroscopic guidance

Fig. 6

Gastrocnemius release (incision on the left, intraoperative aspect with 1. gastrocnemius muscle and 2. Released fascia on the right)

Fig. 7

Percutaneous osteotomy – surgical planning using 3D printed models; intraoperative aspect with guiding K-wires and high-speed burr under fluoroscopic guidance

Fig. 8

Midfoot Fusion Bolt technique – minimal incision for arthrodesis followed by the insertion of 6,5 mm screws; X-ray postoperative aspect of the foot and surgical illustration (MFB® Synthes DePuy)