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J. Ceja Solorio and J. M. Giurini
should only be considered when more extensive surgery is
being planned or for longer procedures when it is critical that
patients remain immobile. This includes most major procedures of the hindfoot and ankle as occurs in reconstruction of
the Charcot foot. It should be remembered that either of
these techniques increases the perioperative morbidity and
mortality. Therefore, the nal choice of anesthesia should be
made following discussion with the anesthesiologist and the
patient’s primary medical doctor and with a clear understanding of the procedure being performed.
Surgical Approach
Prior to denitive surgery or correction of an underlying
deformity, the foot must be free of any acute infection. This
implies that any areas of undrained sepsis have been adequately drained and all necrotic tissue debrided to healthy
granular tissue. This may require staged, serial debridements. The proper technique for draining wounds is to incise
the wound in such a fashion to promote dependent drainage.
As the patient lies recumbent in bed with the extremity elevated, the wound will drain from distal to proximal (Fig.23.2)
[30]. Multiple stab incisions with the use of Penrose drains
should be avoided as they do not promote dependent drainage. Any tissue that appears infected or necrotic should be
sharply excised at this time, including any exposed or
infected bone. The wound is packed widely open and
inspected daily for the resolution of sepsis, cellulitis, and the
Fig. 23.2 An appropriate incision and drainage of infection should
allow dependent drainage as the patient lies recumbent in bed
development of healthy granulation tissue. The goal of the
initial surgical debridement is to convert an acute infection
into a chronic wound. While negative cultures following initial debridement are preferred, it is not a prerequisite for
denitive surgery and wound closure as additional surgical
debridement is performed at the time of wound closure.
Forefoot Procedures
First Ray
The plantar aspect of the rst ray (hallux and rst metatarsal)
is among the most common sites for diabetic foot ulcerations. The primary reasons for this are the increased weightbearing forces across this joint and abnormal biomechanics
[31–33]. Excessive pronation leads to medial transfer of
weightbearing forces through the medial longitudinal arch,
the rst metatarsal, and ultimately the hallux [34]. Common
sites of ulcerations include 1) plantarmedial aspect of the
hallux, 2) distal tip of the hallux, 3) directly plantar to the
interphalangeal joint (IPJ) of the hallux, 4) directly plantar to
the metatarsophalangeal joint (MTPJ), 5) directly plantar to
the rst metatarsal head, and 6) medial aspect of the rst
metatarsal head. Any structural deformity such as osteoarthritis, hallux limitus/rigidus, or severe plantarexion can
further alter the biomechanics of the joint and increase the
susceptibility of this joint to ulceration. Assessing the underlying structural or mechanical cause for the ulceration is vital
to understanding the etiology of the ulceration and for selecting the most appropriate procedure.
Ulcerations of the hallux, either plantarmedial or directly
plantar to the IPJ, are commonly related to abnormalities in the
rst MTPJ, either structural or mechanical. This is often manifested clinically by the presence of callus on the medial aspect
of the hallux (“medial pinch” callus) or limitation of motion at
the rst MTPJ (i.e., hallux limitus/rigidus) (Fig.23.3a,b). The
IPJ hyperextends to compensate for this lack of motion [35,
36]. Other less common causes for ulceration are an enlarged
medial condyle on the distal phalanx or the presence of an
interphalangeal sesamoid bone, in which case the ulceration is
typically directly plantar to the interphalangeal joint.
The choice of surgical procedure depends on the underlying cause. When the cause of the ulceration is related to lack
of adequate motion at the MTPJ, motion can be restored by
way of an arthroplasty of the hallux interphalangeal joint
(HIPJ) or of the rst MTPJ [37, 38]. Resection of the head of
the proximal phalanx relieves excessive plantar pressure,
increases motion, and allows for resolution of the ulceration.
This procedure can also be employed when osteomyelitis is
isolated to the head of the proximal phalanx. In cases where
there are signicant degenerative changes at the level of the
rst MTPJ or complete lack of dorsiexion, resection of the
base of the proximal phalanx can restore motion at the joint
(i.e., Keller arthroplasty [39, 40]).
ab
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Fig. 23.3 (a) A common reason for ulcerations of the great toe is lack of dorsiexion at the rst MTPJ (hallux limitus/rigidus). (b) A common
location for ulcerations of the great toe is the plantarmedial aspect of the IPJ
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Fig. 23.4 Ulcerations under the rst metatarsal head are common due
to the weightbearing forces and function of the rst metatarsal
Fig. 23.5 The presence of synovial drainage from an ulceration is
Another common location of diabetic foot ulcerations is
indicative of joint involvement and requires resection of that joint
directly plantar to the rst metatarsal head (Fig.23.4). One
approach to resolving these ulcerations is by excising one or
both sesamoid bones. During the propulsive phase of gait,
the sesamoids migrate distally to be under the rst metatarsal
head, thus becoming more prominent. In patients with motor
neuropathy and an intrinsic minus foot, the sesamoids
become even more prominent serving as a potential pressure
point and site of ulceration. A tibial and/or bular sesamoidectomy may be indicated for a chronically recurrent ulceration that is directly plantar to the rst metatarsal head [34,
41]. Additionally, there should be no clinical or radiographic
signs of osteomyelitis of the rst metatarsal head. If osteomyelitis of the rst metatarsal head is suspected, this is best
treated with resection of the rst MTPJ. Additionally, the
presence of signicant degenerative changes of the rst
MTPJ is best treated with an arthroplasty of the rst MTPJ
(Keller procedure) [40, 42]. A relative contraindication to a
sesamoidectomy is a rigid plantarexed rst metatarsal. This
may require an adjunctive procedure (e.g., dorsiexory rst
metatarsal osteotomy).
It is critical to differentiate grade 2 ulcerations from grade
3 ulcerations with potential involvement of the rst
MTPJ. Ulcerations that probe directly into the joint or to
bone with a blunt stainless steel probe is considered to be
clinical evidence of osteomyelitis (Fig.23.5) [43–45]. In this
case the procedure of choice is one that completely resects
all infected bone. Joint resection can be performed through a
dorsal approach, leaving the plantar ulcer to heal by secondary intention. Alternately, the rst MTPJ may be resected
through a plantar approach by excising the ulcer followed by
primary closure with full thickness, nonabsorbable suture.
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This is often the authors’ preferred approach. There are clear
advantages to utilizing this approach. By excising the ulceration, all infected, nonviable tissue is removed. It also allows
for excellent exposure of all potentially infected tissues,
including the exor hallucis longus tendon and the sesamoid
bones which are commonly involved. Additionally, wounds
that are closed primarily heal more predictably and with less
scarring. As a rule, these wounds heal in 3–4weeks. The
healing rate of wounds which are allowed to heal by secondary intention cannot be predicted and is dependant on size
and depth. The longer these wounds remain open, the greater
the risk of secondary infection. Patient compliance diminishes the longer an ulceration remains open. It is also our
experience that patients with borderline blood ow do best
when wounds are closed primarily. While disadvantages
exist to closing these wounds primarily as well, it is our philosophy that the benets of primary closure outweigh the
risks.
Approaching the foot plantarly, an elliptical incision is
made excising the ulceration in toto. The ratio of incision
length to width should be at least 3:1 to allow for tension free
closure. This incision is full-thickness and is carried down to
the rst (Fig.23.6). All necrotic and infected tissue should be
excised at this time. At this point the exor hallucis longus
tendon will be visible. Typically focal necrosis within the
body of the tendon is visualized, indicating infectious involvement. It is therefore best to sacrice the tendon in order to
prevent recurrence of the infection. Removal of the long
exor tendon will often require an adjunctive procedure of
lengthening of the extensor hallucis longus tendon on the dorsum of the foot. Failure to perform this could result in an
extensus deformity of the great toe, making shoe t difcult.
Once the tendon is removed, the sesamoids are visualized. They should be sacriced as they are intra-articular
structures and are in direct communication with the rst
MTPJ. The base of the proximal phalanx and the cartilage
of the rst metatarsal head are now resected. While it is
preferred to maintain as much metatarsal length as possible for weightbearing function, the goal should be to
resect enough metatarsal to remove all focus of
osteomyelitis.
Closure is achieved by using full thickness nonabsorbable sutures. Nonabsorbable, monolament 2–0 and 3–0
suture such as polypropylene is the authors’ preference.
J. Ceja Solorio and J. M. Giurini
Fig. 23.6 Osteomyelitis of the rst metatarsophalangeal joint is best
addressed by elliptical excision of the ulcer with resection of the joint.
Adequate resection of the rst metatarsal should be performed to assure
complete eradication of infected bone
Sutures are evenly spaced and used to coapt skin edges with
as little tension as possible. Closure of wounds under tension can be assisted by the use of assistive closure devices
(Fig.23.7) [46]. It is best to avoid deep sutures as they can
serve as a potential nidus of infection and can be difcult to
retrieve at a later date if necessary. One can consider packing the proximal 1.0cm of the wound with a 2×2 gauze
sponge to allow for drainage and avoid the development of
a hematoma. This is usually removed after 24–48 h and
allowed to heal by secondary intention. The postoperative
care mandates a period of total nonweightbearing of at least
4weeks. Early ambulation will result in wound dehiscence,
persistent drainage, postoperative infection, and possible
hypertrophic scar. The sutures are left in place for 4–6weeks.
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Fig. 23.7 Closure of wounds under tension can be assisted by newer
wound closure devices
Lesser Digits
In addition to biomechanical and muscular imbalances,
motor neuropathy in patients with diabetes can lead to intrinsic muscle atrophy resulting in increased risk of digital
deformities such as hammertoes and clawtoes. This association is not as straightforward as once believed and may, in
fact, be multifactorial [47, 48] (Fig.23.8). In the presence of
sensory neuropathy, ulcerations often develop over the proximal interphalangeal joint, at the distal tip of a toe or on adjacent sides of toes. With the exception of the second toe,
amputation of a lesser toe rarely results in long-term complications. Loss of the second toe can lead to a hallux valgus
deformity, but when an ulceration is discovered early and
treated aggressively, amputation of the toe can be avoided,
thus maintaining function as well as appearance.
Hammertoes can be classied as reducible or nonreducible. A reducible hammertoe implies the deformity is being
held by contractures of the soft tissues while a nonreducible
deformity suggests there has been bone and joint adaptation
as well as extensive soft tissue contractures. Reducible deformities can often be corrected by a tenotomy of the corresponding exor tendon. This can be performed in the ofce
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Fig. 23.8 Motor neuropathy is characterized by wasting of the instrinsic musculature in the arch of the foot. This typically results in deformities such as hammertoes, clawtoes, or plantarexed metatarsals
by making a small stab incision just proximal to the exor
crease of the affected toe with a #6100 Beaver blade. The
blade is advanced until the exor tendon can be palpated.
The blade is then used to transect the exor tendon in a transverse direction while applying a gentle dorsiexing force on
the toe. This puts the exor tendon under tension making it
easier to palpate. Once the tendon is released, the digit will
relax and straighten. The toe is then splinted for approximately 1week to maintain the correction.
Because of bone and joint adaptations, nonreducible
deformities require a more aggressive approach. Resection
of the phalangeal head along with release of soft tissue contractures is necessary to fully reduce the deformity. This may
be combined with excision of an ulceration if present.
In longstanding hammertoe deformities, there may be a
concomitant contracture at the level of the MTPJ, often with
subluxation or even dislocation at this level. When dislocated,
an area of high pressure can develop on the ball of the foot
under the corresponding metatarsal head. This manifests with
callus or even ulceration. Failure to recognize this fact can
lead to incomplete correction of the deformity and failure to
resolve the ulceration. In addition to a standard digital arthroplasty, the dislocation at the MTPJ needs to be corrected.
Correction of this deformity proceeds in a stepwise approach.
First, a tenotomy and capsulotomy at the MTPJ is performed.
If the joint cannot be relocated following soft tissue release
alone, a shortening osteotomy of the metatarsal is performed
to relocate the joint and relieve the plantar pressure.
Lesser Metatarsal Procedures
The area under the lesser metatarsal heads is the next most
common location for diabetic foot ulcerations. Common
causes for high foot pressures and ulcerations in this loca-
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tion include abnormal foot mechanics, plantarexed metatarsals, limited joint mobility, and prior surgical intervention
[49–51]. While denitive studies on ulcer incidence and
location do not exist, it appears that the second metatarsal is
more susceptible to ulceration than the other lesser metatarsals. This is most likely due to the second metatarsal’s
dependence on the mechanics of the rst ray. When excessive pronation of the medial column occurs, there is
increased weight transfer and pressure to the lateral metatarsals especially in the presence of rst ray instability [34].
This is manifested by the development of callus under the
second metatarsal head. After the second metatarsal, the
typical order of ulcer development is the third metatarsal
then the fth followed by the 4th.
Selection of surgical procedures for ulcerations under the
metatarsal heads requires careful evaluation of the ulcer. As
with the rst metatarsal, a critical determinant in the surgical
management of these ulcerations is the presence or absence
of osteomyelitis. .
Lesser Metatarsal Osteotomy
J. Ceja Solorio and J. M. Giurini
A lesser metatarsal osteotomy can serve as a valuable adjunct
in the management and resolution of these ulcerations [52,
53]. The primary goal of these procedures is to alleviate
areas of high focal pressure. The presence of a chronically
recurrent ulceration under a metatarsal head without direct
extension into bone is the primary indication. The metatarsal
is approached through a dorsal incision. Dissection is carried
down to the surgical neck of the metatarsal. Once identied,
a through and through osteotomy is made at this level. A
variety of techniques have been described for this osteotomy.
Our preferred techniques are either the V-type osteotomy
with the apex directed toward the joint or the Weil osteotomy
with screw xation (Fig. 23.9). The dorsal to plantar
V-osteotomy provides a stable bone cut resistant to medial or
lateral dislocation. A small collar of bone can be resected
allowing for both shortening and elevation of the metatarsal
if necessary. This is often desired when the MTPJ is either
subluxed or dislocated. The metatarsal head is then elevated
to the same level of the adjacent metatarsals. Fixation of the
osteotomy with a.045 Kirschner wire is recommended.
However, in the presence of an open ulceration, the use of
internal xation should be used cautiously as this may
increase the risk for deep infection. Fixation and stability can
alternately be achieved by impacting the head onto the shaft.
The patient is kept nonweightbearing for 4–6weeks to allow
for primary bone healing.
Fig. 23.9 A dorsal to plantar V-osteotomy through the surgical neck of
the lesser metatarsal allows for adequate relief of plantar pressure overlying an ulceration. The medial and lateral wings of the “V” decrease
the risk of medial or lateral dislocation of the metatarsal head
The Weil osteotomy can also be performed in this clinical
situation [40]. In this approach, a dorsal-distal to plantarproximal osteotomy at a 45° angle is made at the level of the
surgical neck [54, 55] (Fig. 23.10). It can be xated with a
single 2.0 cortical screw (Fig.23.11a, b). The advantage of
the Weil osteotomy is that it can shorten the metatarsal with
little risk of dorsal dislocation. The Weil osteotomy works
well in patients with a relatively normal to atfoot. However,
in patients with a rigid anterior cavus foot, the amount of
proximal translocation may not be enough to resolve the
ulceration. In those patients, the V-osteotomy is the preferred
procedure.
Minimally invasive surgery (MIS) has been employed for
the treatment of neuropathic ulcerations [56–58]. This is a
reintroduction of the osteoclasis procedure performed in the
late 1970s and early 1980s. In MIS metatarsal osteotomy, a
small incision is made at the surgical neck of the metatarsal.
A 2.0mm Shannon burr is used to create a transverse osteotomy at this level. No xation is used. Incision placement
and osteotomy is performed under uoroscopic guidance.
The patient is placed in a controlled ankle motion (CAM)
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413
Fig. 23.10 The Weil osteotomy is an alternate osteotomy that allows
for plantar and proximal displacement of the metatarsal head, allowing
for correction of a subluxed or dislocated MTPJ. (Reprinted with per-
boot for 4weeks and allowed to ambulate. The concept is the
metatarsal will seek its own level and be on the same plane
as the remaining metatarsals (Fig.23.12a, b).
Complications following metatarsal osteotomies include
transfer calluses or ulcerations and stress fractures of adjacent metatarsals. These most commonly result when the
metatarsal head is elevated above the plane of the adjacent
metatarsals. The risk of transfer problems can be reduced if
the patient is tted with an accommodative custom orthosis
postoperatively. This will allow for more even distribution of
weightbearing forces across all metatarsal heads. Shoe gear
modication may also assist in this role, e.g., metatarsal
pads, rocker soles.
Lesser Metatarsal Head Resection
withUlcer Excision
An alternate approach for relieving plantar pressure is complete resection of the offending metatarsal head. While this
will result in resolution of the ulceration, this carries a high
mission from: Schuh R, Trnka HJ. Metatarsalgia: Distal Metatarsal
Osteotomies. Foot and Ankle Cl N.America. 16(4):583–95, 2011)
incidence of transfer lesion or ulceration. For this reason, it
is preferred to perform this procedure only when osteomyelitis of the metatarsal head is suspected and there is no
alternative but complete resection of the offending metatarsal head.
Resection of the metatarsal head can be approached
through a dorsal linear incision centered directly over the
metatarsal head. It should be remembered that it may be
necessary to resect the base of the corresponding proximal
phalanx as well as this structure is contiguous with the
metatarsal head and is most likely involved as well.
Therefore at minimum one should inspect the base of the
proximal phalanx. The ulcer is then allowed to heal by secondary intention.
Alternately, the metatarsal head may be resected through
a more direct plantar approach while excising the ulceration
at the same time (Fig.23.13). The advantage of this approach
is that all necrotic and infected tissue is excised and all tissue
can be directly inspected. Following resection of the metatarsal head, the wound is closed primarily as previously
described for rst MTPJ resection.
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a b
J. Ceja Solorio and J. M. Giurini
Fig. 23.11 (a, b) Weil osteotomy xated with a single 2.0 screw
Fig. 23.12 (a, b) Chronic
ulcerations under a metatarsal
head addressed with minimal
incision surgery (MIS)
technique
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Postoperatively, sutures are left in place for a minimum of
3weeks and the patient is maintained total nonweightbearing for 3–4weeks. It is recommended to continue antibiotics
until the sutures are removed and there is no drainage from
the surgical site. Long-term complications include possible
transfer lesions or ulcerations and stress fractures due to the
altered weightbearing surface. It is therefore recommended
that patients be tted with an appropriate orthotic device to
distribute pressures evenly.
Panmetatarsal Head Resection
Weightbearing forces are designed to be evenly dispersed
across all metatarsal heads. This interdependence between
the metatarsal heads has been previously described by
Fig. 23.13 An osteomyelitic lesser metatarsal head can be resected
through a plantar elliptical incision excising the ulceration in toto
Morton and later by Cavanagh. (32,33) Disruption of this
relationship will alter normal weight distribution and consequently peak pressures. Various factors can affect the weight
distribution across the metatarsals such as fractures resulting
in dorsiexed or shortened metatarsals, the atrophic form of
Charcot neuroarthropathy resulting in dissolution of metatarsal heads, or prior surgical resection of one or more metatarsal heads for osteomyelitis.
The recidivistic nature of diabetic foot disease makes
multiple metatarsal procedures common in this patient population. Osteomyelitis of the forefoot was previously treated
by transmetatarsal amputation. This procedure was
popularized by Dr. Leland McKittrick of the New England
Deaconess Hospital and was responsible for saving thousands
of limbs [59]. It is not without its complications however.
Ulcerations at the distal stump and equinovarus contractures
are common long-term complications (Fig.23.14a, b). It is
often necessary to revise these TMA’s or perform tendon balancing procedures to correct these deformities [60, 61].
Additionally, patients have difculty psychologically accepting this procedure at times because it will often require special shoe gear that draws attention to the fact they have had
an amputation.
The panmetatarsal head resection (PMHR) and its variations were originally described for the treatment of painful
lesions in patients with rheumatoid arthritis [62–65]. Jacobs
rst described the use of the PMHR in patients with diabetes
for the successful treatment of chronic neuropathic ulcerations [66]. This report was subsequently followed by a
report by Giurini etal. where a larger series of patients were
studied with similar results. Additionally, an alternate technique was described [67]. Over the years, the PMHR has
replaced the TMA as the procedure of choice in patients with
ab
Fig. 23.14 (a) A common complication following transmetatarsal
amputation is contracture of the Achilles tendon and subsequent equinus deformity. This can lead to characteristic lesions at the distal end of
the TMA. (b) A distal lateral ulceration of a TMA with an underlying
equinovarus deformity
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J. Ceja Solorio and J. M. Giurini
recurrent ulcerations following prior surgical resection of
metatarsal heads [68].
The PMHR is rarely a procedure of rst choice. The primary indication is the presence of chronically recurrent neuropathic ulcerations on the plantar aspect of the foot following
prior metatarsal head resections or ray amputations. It is our
belief that if two or more metatarsals have already been
resected or need to be resected to eliminate osteomyelitis, the
patient would be best served by a PMHR (Fig.23.15). At rst
this may appear to be a drastic, aggressive approach. However,
experience has shown that this approach may actually spare
patients additional trips to the operating room for transfer
ulcerations.
Various surgical approaches have been described for the
PMHR. Dorsal approaches, plantar approaches or a combination of the two have been performed with equal success [69].
Our preferred approach is the four incision dorsal approach:
one incision directly over the rst metatarsal, one between the
second and third metatarsals, one directly over the fourth
metatarsal, and one directly over the fth metatarsal. This
approach allows for adequate exposure of all metatarsal heads,
decreases the potential for retraction injury on the skin edges,
and maintains adequate skin islands so as not to affect vascular
supply. An alternate approach is to combine a dorsal incisions
with a plantar incision that excises the ulceration. The plantar
wound and all necrotic tissue is excised, the involved metatarsal head(s) is resected, and the wound is closed primarily as
previously described.
The surgical technique for resection of the metatarsal heads
has already been described. The most important technical
point to remember in performing this procedure is to maintain
the metatarsal parabola. This typically means that the rst and
second metatarsals are left approximately the same length
while the third, fourth, and fth metatarsals are each sequentially shorter (Fig.23.16a–c). Failure to maintain this relationship can lead to recurrent ulceration. This may be difcult to
Fig. 23.15 Prior resection of two metatarsal heads and the presence of
osteomyelitis of a remaining metatarsal head is indication for panmetatarsal head resection
abc
Fig. 23.16 (a–c) An alternative to the TMA is the panmetatarsal head resection (PMHR). When possible fusion of the rst MTPJ with stabiliza-
tion of the lesser MTPJ’s with K-wires is the preferred technique
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417
achieve if there has been a prior metatarsal head resection. In
that case the metatarsal parabola should be recreated with the
remaining metatarsals. The extensor tendons dorsally or the
exor tendons plantarly are identied and are retracted. This
maintains the function of these tendons during the gait cycle
affording this procedure the prime advantage over the TMA.A
concomitant tendoachilles lengthening (described later) can
also be performed as there is often an equinus deformity contributing to the development of the ulceration. This should be
assessed at the time of surgery.
Midfoot Procedures
The midfoot encompasses the area from the tarsometatarsal
(TMT) joints to the talonavicular (TN) joint. Surgery in this
region is most commonly necessary following deformities
resulting from neuroarthropathy (Charcot joint disease). The
most common location of Charcot joint disease involves the
TMT (Lisfranc’s) joints but other joints in the midfoot may also
be affected [70, 71]. Instability at Lisfranc’s joint often results in
a rockerbottom deformity of the midfoot resulting in a plantarmedial ulceration. This is most often due to subluxation of the
rst metatarsal and medial cuneiform creating a plantar prominence. Ulcerations on the plantar and lateral aspect of the foot
are not uncommon. These result from plantar extrusion of the
cuboid from a Charcot process at the calcaneocuboid joint and
actually pose a more signicant management problem [70].
These are typically recalcitrant to conservative measures.
There is no single surgical procedure that can be applied
to all ulcers in this location. Therefore, a exible approach to
these lesions is required. Surgical approaches may involve
simple ostectomy with or without fasciocutaneous ap or
primary arthrodesis of unstable joints [72].
Ostectomy
This is the simplest approach to chronic plantar ulcerations
of the midfoot. This is reserved for those deformities that
have their apex directly plantar to the rst metatarsal-medial
cuneiform joint and where the midfoot is not hypermobile.
The depth of the ulceration dictates the best surgical
approach. A direct medial incision centered over the joint is
preferred when the ulceration is supercial and does not
probe bone. This allows for excellent visualization of the
joint and the prominent bone. The prominence is resected
from medial to lateral either with an osteotome or with a saw.
The goal should be to remove an adequate amount of bone to
alleviate the plantar pressure and not create a new bony
prominence which may lead to a new source of irritation and
ulceration, thus negating the benets of this procedure.
Ulcerations which communicate with bone and show
signs of osteomyelitis clinically are best managed by exci-
sion of the ulceration with bone resection and primary closure of the ulceration. In addition to removing the infected
bone, the ability to close the ulceration primarily without
tension is an additional goal. This approach is best employed
when the ulcer is located either plantar central or plantar lateral in the midfoot. The most likely etiology for these ulcerations is plantar displacement of the cuboid. Ulcerations that
measure less than 2.5cm in diameter are amenable to this
approach. The use of closed suction irrigation is also
recommended in order to prevent hematoma formation
which can lead to wound dehiscence or infection.
One of the more difcult ulcerations to manage is an
ulcer located centrally in the midfoot secondary to plantar
subluxation of the cuboid bone. This is the type 5in the
Harris and Brand classication of Charcot joint disruption
(pattern II in the Sanders classication) and has been
described as being very resistant to conservative care [70].
Resolution of these ulcerations often require surgical intervention of some type.
Exostectomy withFasciocutanous Flap
Ulcerations that measure 2.5 cm in diameter or more are
typically difcult to close primarily without tension. In these
cases alternate techniques for wound closure should be
sought. These ulcerations are typically excised circumferentially to the level of the cuboid bone. This allows removal of
all necrotic, infected tissue as well as any hyperkeratotic
margins bordering the ulcer. The joint capsule and periosteum of the cuboid are next encountered which are reected
off the underlying bone, the cuboid. This exposes the peroneal groove of the cuboid bone which is usually the culprit in
these ulcerations. The peroneus longus runs through this
groove. When possible this tendon should be retracted out of
harm’s way. On rare occasions, however, it may be necessary
to sacrice the peroneus longus in order to gain adequate
exposure of the bony prominence. The peroneal groove is
next resected with the use of an osteotome and mallet. Once
completed, the wound should be carefully inspected for any
remaining bony prominence or bone spicules which can
serve as a new point of pressure and possible ulceration.
This procedure often leaves a relatively large dead space
which can serve for the collection of a hematoma. It is best
to ll this dead space with a muscle ap which will serve two
purposes: 1) it will decrease the dead space following the
bony resection; 2) it will provide a layer of soft tissue
between the underlying bone and the overlying skin
(Fig. 23.17). The exor digitorum brevis muscle is well
suited for this purpose because of its anatomic proximity to
the resected bone and ease of dissection. The muscle is
rotated laterally to cover the cuboid. A full thickness fasciocutaneous ap based on the medial plantar artery is rotated
from medial to lateral to cover the actual ulcer site. A split
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