Diabetic Foot Ulcers

Meetings of diabetologists justifiably occupy much time debating the management of ulcers of the feet, since a significant percentage of diabetics develop intractable ulcers leading to amputations.

These medical meetings correctly emphasise the importance of sensation loss and insufficiency of blood perfusion. However there is another necessary factor in the cause of foot ulcers, which is seldom discussed in these meetings, the abnormalities of alignment of the skeletal structures of the foot.  Examples are clawing, veering and rotation of the toes and dislocations of the toe joints. These cause dangerous high foot-pressure areas which are a necessary prerequisite for foot ulcers.

Such deformities worsen progressively[i], and once deformation has started ulceration in the insensate foot becomes inevitable with time. Therefore these abnormalities require correction immediately they appear, immediately the toes begin to claw, immediately the calluses show on the soles, and immediately any abrasions or corns appear on their feet.

Most non-diabetics with these foot deformities readily seek treatment because they are prompted by pain.

However, those who cannot feel do not complain, and so often progress to ulcers, with eventual loss of the foot by amputation

Naturally vascular supply surgery might also be necessary but, once the ulcers have appeared, other treatments like full contact casts, debridement of ulcers and bone, and various forms of direct application are all too little, too late, and often fail.

This is a tragedy because correction of the anatomical alignment of the forefoot (claw toes, hammer toes, “bunions”, corns calluses, metatarsal high pressure, and similar) can usually be easily, safely and permanently corrected by soft tissue releases. This reduces the incidence of ulceration dramatically and lessens the amputation rate.

Soft tissue realignment procedures are performed regularly on non-diabetics. Why then are they not performed in the far more urgent circumstances of diabetic sensation loss?

One reason is that podiatric and orthopaedic management commonly involves dividing and realigning perfectly normal bones, and often destroying perfectly normal joints. These procedures are dangerous (particularly in diabetics) because divided bones might not unite. Bones infected subsequent to surgical damage are exceedingly difficult to treat. Plates, screws, pins, spacers and Silastic hinges implanted in “conventional” surgery all increase the risks of infection. Further, bone surgery necessitates long periods of immobilisation which is detrimental to the physiology of the lower limb, producing yet another set of dangerous complications[ii]: Those without feeling run a high risk of abrasion by casts or other “immobilising” devices.

Clearly “conventional” surgery to bone is precluded in those without sensation or with complicated diabetes.

The belief that it is necessary to operate on bone has come about, and become entrenched dogma, because of irrationality. Bones cannot produce deformities and it is irrational to assault them. Deformities can only be caused by soft tissues pulling the bones into misalignment. The target for correction should therefore be the deforming soft tissues.

Because diabetologists have also been lead into this misapprehension they shy away from referring their patients for appropriate surgery, to the detriment of those who rely on their advice.

Soft tissue surgery is often performed successfully and safely on diabetics and those with sensory loss.

Leaving foot skeletal abnormalities in diabetics and sensory loss feet in the hope that complications will not occur is a misguided invitation to catastrophe.

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[i] For various reasons the skeletal deformities of the foot are far more common in diabetics and those with vascular and neurological disease.

[ii] These include oedema, deep vein thrombosis, fungal dermatitis and sensitivities to the contact material.

Diabetic Foot Ulcers

Meetings of diabetologists justifiably occupy much time debating the management of ulcers of the feet, since a significant percentage of diabetics develop intractable ulcers leading to amputations.

These medical meetings correctly emphasise the importance of sensation loss and insufficiency of blood perfusion. However there is another necessary factor in the cause of foot ulcers, which is seldom discussed in these meetings, the abnormalities of alignment of the skeletal structures of the foot.  Examples are clawing, veering and rotation of the toes and dislocations of the toe joints. These cause dangerous high foot-pressure areas which are a necessary prerequisite for foot ulcers.

Such deformities worsen progressively[i], and once deformation has started ulceration in the insensate foot becomes inevitable with time. Therefore these abnormalities require correction immediately they appear, immediately the toes begin to claw, immediately the calluses show on the soles, and immediately any abrasions or corns appear on their feet.

Most non-diabetics with these foot deformities readily seek treatment because they are prompted by pain.

However, those who cannot feel do not complain, and so often progress to ulcers, with eventual loss of the foot by amputation

Naturally vascular supply surgery might also be necessary but, once the ulcers have appeared, other treatments like full contact casts, debridement of ulcers and bone, and various forms of direct application are all too little, too late, and often fail.

This is a tragedy because correction of the anatomical alignment of the forefoot (claw toes, hammer toes, “bunions”, corns calluses, metatarsal high pressure, and similar) can usually be easily, safely and permanently corrected by soft tissue releases. This reduces the incidence of ulceration dramatically and lessens the amputation rate.

Soft tissue realignment procedures are performed regularly on non-diabetics. Why then are they not performed in the far more urgent circumstances of diabetic sensation loss?

One reason is that podiatric and orthopaedic management commonly involves dividing and realigning perfectly normal bones, and often destroying perfectly normal joints. These procedures are dangerous (particularly in diabetics) because divided bones might not unite. Bones infected subsequent to surgical damage are exceedingly difficult to treat. Plates, screws, pins, spacers and Silastic hinges implanted in “conventional” surgery all increase the risks of infection. Further, bone surgery necessitates long periods of immobilisation which is detrimental to the physiology of the lower limb, producing yet another set of dangerous complications[ii]: Those without feeling run a high risk of abrasion by casts or other “immobilising” devices.

Clearly “conventional” surgery to bone is precluded in those without sensation or with complicated diabetes.

The belief that it is necessary to operate on bone has come about, and become entrenched dogma, because of irrationality. Bones cannot produce deformities and it is irrational to assault them. Deformities can only be caused by soft tissues pulling the bones into misalignment. The target for correction should therefore be the deforming soft tissues.

Because diabetologists have also been lead into this misapprehension they shy away from referring their patients for appropriate surgery, to the detriment of those who rely on their advice.

Soft tissue surgery is often performed successfully and safely on diabetics and those with sensory loss.

Leaving foot skeletal abnormalities in diabetics and sensory loss feet in the hope that complications will not occur is a misguided invitation to catastrophe.

---

[i] For various reasons the skeletal deformities of the foot are far more common in diabetics and those with vascular and neurological disease.

[ii] These include oedema, deep vein thrombosis, fungal dermatitis and sensitivities to the contact material.

Weil, Weil, Weil!

 

In this website enquiries about the Weil Osteotomy  have been frequent. In this web-site (and in conferences around the world) I have asked the surgical community, both orthopaedic and podiatric, to explain how the Weil works. Just what does it do to correct pain? Despite many thousands of hits on my web-site no one has come forward with a valid explanation.

In the literature two pseudo-explanations are offered.

“Restoration of the metatarsal parabola”. Here it is reasoned that an unusually long metatarsal is responsible, particularly the second. It is claimed that the “normal foot” has the metatarsals forming a neat parabolic curve. Is there any evidence for that? Not that I can find. Foot shapes come in great variety. A lifetime of looking at feet has never revealed a “better” or “correct” shape.

Most feet function well for the first three-quarters of life, irrespective of significant variances. There is no hard evidence either that a “long” metatarsal is more prone to pain than a short one. What is true is that the second metatarsal often happens to be the first to become painful, and (by chance association) the second metatarsal also happens to be the longest.

But even if that association (long metatarsal = pain) should be correct, the argument immediately fails when Weil osteotomies are offered on multiple toes, or on a toe which is painful but with a shorter metatarsal.

The ultimate irrationality of this argument is that any given foot anatomy (perhaps with a long metatarsal, or with a “non-parabolic” shape) can function perfectly well for fifty or sixty years. When that foot becomes painful is it because the metatarsal is “long”?

Of course it is not – that metatarsal has had the same length all those years – not only that but it has functioned perfectly when the greatest loads have been on it, with youthful activity, running and jumping, pregnancies, and the rest. So some would try and make be believe that after half a century of service, a bone suddenly becomes “too long”! Really!

The other pseudo-argument promoting the Weil goes like this:

“When conservative modalities have been exhausted, you may consider over 20 surgical techniques, ranging from condylectomies to oblique osteotomies at the proximal, mid-shaft or distal metatarsal levels. Of these procedures, the Weil osteotomy has gained popularity, based upon the simple technique and stable fixation.”

This is another way of saying “If you are going to try something surgically try the easiest “something”.

“Try” is the operative word.

Is there a solution to my foot problem?

 

 

 

(Name withheld) Thanks again for your emails. In March this year, I had a Weil’s Osteotomy so as to correct my hammer toe which was the one next to my big toe and not the middle toe like the toe in your photograph. Since the first operation in March, then again in April, when they removed the screw as my body rejected it – it is now October, the toe is still very stiff and it is still floating (looking awful is the least). I saw a podiatrist a few times and he has now done a wedge on the middle toe next to the hammer toe which was operated on, he told me that all my body weight is now on the toe next to the operated toe, or something to that effect. The very worst of course for me is the hard lump/callous which is now underneath my foot, like a tight knot lump there and if I don’t wear an orthotic insole for walking, I’ve had it – even when I do wear one, the throbbing recurs. I can’t take pain tablets all the time, so I am just learning to live with it. After what I went through, if there is a solution?

Response: The Weil osteotomy is discussed in the pages

The patient in the picture which you refer to had four procedures before I got to see it. The second toe (next to the great) on the left had some kind of osteotomy, and was “floating” perhaps like yours. The third toe probably looks as your second toe did pre-operatively. The hard lump is a direct result of your toe abnormality, and can be predicted to worsen progressively unless surgically corrected. There is, very definitely, a solution. I look forward to seeing you and explaining the mechanism and background of your problem.