Conservative Surgical Options for the Treatment of Forefoot Diabetic Ulcers and Osteomyelitis: An Evidence-Based Review and a Decision-Making Tool.

Diabetic foot ulcers cause higher rates of amputation and mortality; amputations yield even higher mortality rates than diabetic foot ulcers. Conservative excisional surgical procedures could be a suitable alternative to amputations, with comparable results with respect to wound-healing and infection control. Also, toe-sparing conservative surgical procedures offer good to excellent outcomes when compared with the nonoperative standard of care. Fourteen types of conservative surgical procedures were identified including bone excision with ulcerectomy, interphalangeal or metatarsophalangeal joint resection arthroplasty, internal pedal amputation of the phalangeal or metatarsal bone, distal Syme amputation, metatarsal osteotomy, metatarsal head resection, Achilles lengthening, gastrocnemius recession, selective plantar fascia release, percutaneous toe flexor tenotomy, and skin grafting. Depending on the location of the ulcer or osteomyelitis, a decision-making tree tool has been developed to assist surgeons for the indication of the different conservative operations. A striking underuse of the available conservative operations was noted. When indicated, the outcomes of conservative surgery were rated good to excellent; these procedures could be suitable alternatives to amputation.