Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

GUO Baofeng ¹ , ZHAO Wei ¹ , WU Hongfei ¹ , LIANG Xibin ¹ , XU Zhiyang ¹ , REN Longxi ¹ ,  QIN Sihe ^1,2

1. Department of Orthopaedics, Beijing Chui Yang Liu Hospital Affiliated to Tsinghua University, Beijing, 100022, P.R.China;
2. Department of Orthopaedics, Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids, Beijing, 100176, P.R.China;

Corresponding author：

QIN Sihe, Email: qinsihe@163.com

Keywords：

Diabetic foot; ulcer; metatarsal head; chronic osteomyelitis; metatarsal bone lengthening; Ilizarov technique

DOI：

10.7507/1002-1892.201911070

Video：

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Objective To explore the effectiveness of the first-stage debridement and Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.Methods Between January 2015 and October 2018, 8 cases (9 feet, 11 sites) of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head were treated by first-stage debridement and Ilizarov metatarsal bone lengthening. There were 3 males (4 feet, 5 sites) and 5 females (5 feet, 6 sites), with an average age of 57.5 years (range, 44-65 years). According to diabetic foot Wagner grade, 6 cases (7 feet) were grade 3 and 2 cases (2 feet) were grade 4. The chronic osteomyelitis located at left foot in 4 cases, right foot in 3 cases, and bilateral feet in 1 case. The duration of chronic osteomyelitis was 1-5 years (mean, 3.1 years). The chronic osteomyelitis site was the 1st metatarsal head in 3 feet, the 3rd metatarsal head in 1 foot, the 4th metatarsal head in 1 foot, and the 5th metatarsal head in 6 feet. Two patients had chronic osteomyelitis at 2 sites on 1 foot. The length of lengthened metatarsal bone, lengthening time, and the time of wearing external fixation frame were recorded, and the external fixation frame index was calculated. The healing conditions of foot ulcer and lengthening bone segment were observed, the healing time was recorded, and the healing index of lengthening bone was calculated. The ankle function was evaluated according to the American Orthopedic Foot and Ankle Society (AOFAS) score criteria.Results All patients were followed up 9-26 months with an average of 15.0 months. Except pin tract infection during the bone lengthening period, there was no complications such as skin necrosis and vascular or nerve injury occurred during treatment. The length of lengthened metatarsal bone was 12-35 mm with an average of 20.5 mm; the metatarsal bone lengthening time were 21-84 days with an average of 57.8 days. The average time of wearing external fixation frame was 14.6 weeks (range, 10.4-21.1 weeks) and the external fixation frame index was 54.3 days/cm (range, 42.9-59.2 days/cm). The ulcer wound healed with an average healing time of 30.5 days (range, 19-70 days) and no ulcer recurrence was observed during follow-up. Bone healing was obtained in all bone lengthening segments, and the average healing index was 42.5 days/cm (range, 37-51 days/cm). The average AOFAS score was 91.7 (range, 87-95); 5 feet were excellent and 4 feet were good. The excellent and good rate was 100%.Conclusion The metatarsal bone lengthening under Ilizarov law of tension-stress after debridement can promote diabetic foot ulcers healing and reconstructing the length of metatarsal to retain the function of metatarsal load and avoid amputation. This is an effective method for the treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.

Citation： GUO Baofeng, ZHAO Wei, WU Hongfei, LIANG Xibin, XU Zhiyang, REN Longxi, QIN Sihe. Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(8): 1000-1004. doi: 10.7507/1002-1892.201911070 Copy

1.	Mauricio D, Jude E, Piaggesi A, et al. Diabetic foot: status and future prospects. J Diabetes Res, 2016, 2016: 5691305.
2.	Mutluoglu M, Sivrioglu AK, Eroglu M, et al. The implications of the presence of osteomyelitis on outcomes of infected diabetic foot wounds. Scand J Infect Dis, 2013, 45(7): 497-503.
3.	Acharya S, Soliman M, Egun A, et al. Conservative management of diabetic foot osteomyelitis. Diabetes Res Clin Pract, 2013, 101(3): e18-e20.
4.	Johnson JE, Anderson SA. One stage resection and pin stabilization of first metatarsophalangeal joint for chronic plantar ulcer with osteomyelitis. Foot Ankle Int, 2010, 31(11): 973-979.
5.	镇普祥, 陈炎, 高伟, 等. 应用 Ilizarov 技术胫骨横向骨搬移术治疗合并全身性炎症反应综合征的重度糖尿病足. 中国修复重建外科杂志, 2018, 32(10): 1261-1266.
6.	Yan Chen, Xiaocong Kuang, Jia Zhou, et al. Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers. Clin Orthop Relat Res, 2019. doi: 10.1097/CORR.0000000000001075.
7.	中华医学会糖尿病学分会, 中华医学会感染病学分会, 中华医学会组织修复与再生分会. 中国糖尿病足防治指南 (2019版). 中华糖尿病杂志, 2019, 11(2): 92-108.
8.	Wukich DK, Armstrong DG, Attinger CE, et al. Inpatient management of diabetic foot disorders: a clinical guide. Diabetes Care, 2013, 36(9): 2862-2871.
9.	徐波, 杨彩哲, 吴石白, 等. 糖尿病足患者截肢相关危险因素分析. 中华内科杂志, 2017, 56(1): 24-28.
10.	Bus SA, Lavery LA, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev, 2020, 36(Suppl 1): e3269.
11.	Patel VG, Wieman TJ. Effect of metatarsal head resection for diabetic foot ulcers on the dynamic plantar pressure distribution. Am J Surg, 1994, 167(3): 297-301.
12.	Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med, 2017, 376(24): 2367-2375.
13.	Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care, 1995, 18(11): 1460-1462.
14.	郭保逢, 赵巍, 徐执扬, 等. 无植骨 Ilizarov 外固定技术治疗股骨萎缩性骨不连. 中国修复重建外科杂志, 2019, 33(8): 940-946.
15.	秦博泉, 吴仕舟, 解慧琪, 等. 病灶清除联合 Ilizarov 技术治疗第一跖趾关节痛风石合并骨缺损. 中国修复重建外科杂志, 2020, 34(2): 168-172.
16.	张磊, 王新卫, 陈雨声, 等. 应用 Ilizarov 技术治疗骨髓炎出现复杂软组织问题的处理技巧探讨. 中国修复重建外科杂志, 2018, 32(10): 1286-1291.
17.	Guizar-Cuevas S, Mora-Ríos FG, Mejía-Rohenes LC, et al. Elongation with callotaxis for congenital brachymetatarsia. Acta Ortop Mex, 2010, 24(6): 395-399.

1. Mauricio D, Jude E, Piaggesi A, et al. Diabetic foot: status and future prospects. J Diabetes Res, 2016, 2016: 5691305.
2. Mutluoglu M, Sivrioglu AK, Eroglu M, et al. The implications of the presence of osteomyelitis on outcomes of infected diabetic foot wounds. Scand J Infect Dis, 2013, 45(7): 497-503.
3. Acharya S, Soliman M, Egun A, et al. Conservative management of diabetic foot osteomyelitis. Diabetes Res Clin Pract, 2013, 101(3): e18-e20.
4. Johnson JE, Anderson SA. One stage resection and pin stabilization of first metatarsophalangeal joint for chronic plantar ulcer with osteomyelitis. Foot Ankle Int, 2010, 31(11): 973-979.
5. 镇普祥, 陈炎, 高伟, 等. 应用 Ilizarov 技术胫骨横向骨搬移术治疗合并全身性炎症反应综合征的重度糖尿病足. 中国修复重建外科杂志, 2018, 32(10): 1261-1266.
6. Yan Chen, Xiaocong Kuang, Jia Zhou, et al. Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers. Clin Orthop Relat Res, 2019. doi: 10.1097/CORR.0000000000001075.
7. 中华医学会糖尿病学分会, 中华医学会感染病学分会, 中华医学会组织修复与再生分会. 中国糖尿病足防治指南 (2019版). 中华糖尿病杂志, 2019, 11(2): 92-108.
8. Wukich DK, Armstrong DG, Attinger CE, et al. Inpatient management of diabetic foot disorders: a clinical guide. Diabetes Care, 2013, 36(9): 2862-2871.
9. 徐波, 杨彩哲, 吴石白, 等. 糖尿病足患者截肢相关危险因素分析. 中华内科杂志, 2017, 56(1): 24-28.
10. Bus SA, Lavery LA, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev, 2020, 36(Suppl 1): e3269.
11. Patel VG, Wieman TJ. Effect of metatarsal head resection for diabetic foot ulcers on the dynamic plantar pressure distribution. Am J Surg, 1994, 167(3): 297-301.
12. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med, 2017, 376(24): 2367-2375.
13. Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care, 1995, 18(11): 1460-1462.
14. 郭保逢, 赵巍, 徐执扬, 等. 无植骨 Ilizarov 外固定技术治疗股骨萎缩性骨不连. 中国修复重建外科杂志, 2019, 33(8): 940-946.
15. 秦博泉, 吴仕舟, 解慧琪, 等. 病灶清除联合 Ilizarov 技术治疗第一跖趾关节痛风石合并骨缺损. 中国修复重建外科杂志, 2020, 34(2): 168-172.
16. 张磊, 王新卫, 陈雨声, 等. 应用 Ilizarov 技术治疗骨髓炎出现复杂软组织问题的处理技巧探讨. 中国修复重建外科杂志, 2018, 32(10): 1286-1291.
17. Guizar-Cuevas S, Mora-Ríos FG, Mejía-Rohenes LC, et al. Elongation with callotaxis for congenital brachymetatarsia. Acta Ortop Mex, 2010, 24(6): 395-399.

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Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head

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