UK study finds new outpatient surgical procedure speeds effective healing, reduces recurrence and amputation rates, and reduces healthcare costs by 88% compared to conservative care
Performing proactive surgery to adjust foot mechanics appears to be effective in treating diabetic foot ulcers, a common and debilitating complication of diabetes, without potential complications and at a significantly lower cost compared to conservative treatment.
The preliminary study, which was presented at the annual meeting of the European Association for the Study of Diabetes (EASD), held this year (September 19 to 24), describes how these outpatient procedures in 19 patients successfully resolved all the Foot ulcers prevented diabetic foot sepsis and reduced recurrence and amputation rates compared to 15 patients treated conservatively.
"Although the procedure is relatively simple, its potential is revolutionary," says lead author Dr Adrian Heald, of Salford Royal NHS Foundation Trust, Salford, UK.
Diabetic foot ulcers are open sores or wounds that occur in around 15% of people with diabetes at some point in their lives, at an estimated cost of £935 million to the NHS. Ulcers are commonly located in areas subject to higher weight bearing, such as the sole of the foot, and are responsible for about 80% of lower extremity amputations in people with diabetes.
In the UK, mortality rates after diabetic foot ulceration are high, with up to half of patients dying within 5 years of developing an ulcer, rising to 70% within 5 years after to an amputation.
Early intervention is important in the treatment of diabetic foot ulcers, as people who receive expert care the quickest have the best results. Orthopedic and vascular surgeons have joined most UK multidisciplinary diabetic foot teams to provide reactive interventions to the common complication of diabetic foot sepsis, such as abscess drainage or amputation.
In this study, researchers describe how a daily case list of procedures within multidisciplinary teams specializing in diabetic foot has affected outcomes when performing proactive simple surgical procedures.
Between April 2019 and April 2021, 19 patients with diabetic foot ulcers (without associated abscesses) were offered a percutaneous procedure performed under local anesthesia by an orthopedic surgeon, while 14 patients were treated conservatively, with the best medical and podiatric management.
The goal of the surgery was to adjust the mechanics of the foot to remove pressure on the ulcerated region to speed healing.
All 19 patients undergoing surgery had evidence of diabetes and/or neuropathy (nerve damage). Of these, 10 patients (average age 71 years, 8 men, 2 women) with toe apex ulcers and damaged flexor tendons underwent toe tendon releases in which the tendon is cut to relax the toe in a straight position .
Another 9 patients (average age 49 years, all male) with ulcers on the sole of the foot behind the toes and tension in the Achilles tendon underwent Achilles tendon lengthening to stretch the tendon and allow the patient to walk with flat feet .
After one year of follow-up, all patients in the surgery group achieved successful ulcer resolution (mean time 3.3 to 4.5 weeks) compared with three patients (36%) in the usual care group (mean time 20-week average; see table in notes to editors).
During follow-up, no patients in the surgery group were admitted for diabetic foot sepsis compared with seven (46%) in the usual care group. And ulcer recurrence occurred in only two patients (10%) in the surgery group compared with 10 (66%) in the conservative treatment cohort.
Similarly, amputation was more common in the usual care group (7 patients, 66%) than in the surgery group (2 patients, 10%). No patients died in the surgery cohort, while six died in the conservative care group.
Researchers estimate that compared to the average cost of usual care of £9,902, the average cost of the new procedure was £1,211, representing an average saving of £8,691 per patient, an 88% reduction in costs medical care after the procedure.
“Our study is the first in the UK to demonstrate the practical and financial feasibility of simple orthopedic interventions to accelerate the healing of mechanical forefoot ulcers in patients with diabetic neuropathy,” says Dr Heald. “We urge other multidisciplinary diabetic foot teams to explore this treatment option.”
