Diabetic Foot Ulcers: Benefits of Metatarsal Head Resection, Transfer Lesions, and More

In this podcast, Robert J Klein, DPM, FACFAS, CWS, FFPM RCPS, clinical associate professor of surgery, University of South Carolina School of Medicine, Greenville, discusses his protocol for treating chronic or recurrent diabetic foot ulcers, highlights the benefits of metatarsal head resection, and provides major takeaways for clinicians treating this patient population.  

Podcast Transcript

Welcome back to another "ePlasty Podcast." On today's episode, we're joined by Dr. Robert Klein, clinical associate professor of surgery at the University of South Carolina School of Medicine in Greenville.

Dr. Klein discusses his protocol for treating chronic or recurrent diabetic foot ulcers highlights the benefit of metatarsal head resection and provides major takeaways for clinicians treating this patient population. Dr. Klein, can you tell us about your protocol for treating chronic or recurrent diabetic foot ulcers?

Dr. Robert Klein:  My protocol for treating chronic and/or recurrent diabetic foot ulcers is a multifactorial approach. I utilize aggressive offloading, total contact casting, removable CAM Walkers, preferably a high removable CAM Walker, knee's scooters anything that can get the weight off of the patient's foot.

For recurrent alterations that keep on coming back. I do take in consideration surgical offloading, and one of the ways that our surgical offload especially recurrent alterations in the metatarsal heads is through metatarsal head resection.

What are the benefits of using metatarsal head resection when treating chronic or recurrent diabetic foot ulcers? What are some of the risks and complications?

Dr. Klein:  The benefits of using metatarsal resection for chronic and recurrent diabetic frustrations is plentiful and it's documented in the literature. If you look at the International working group for diabetic foot, within their guidelines, they even talked about metatarsal head resection for recurrent or chronic diabetic foot ulcerations.

There's multiple articles in the literature as well that support using metatarsal head resection for recurrent diabetic foot ulcerations there are some drawbacks that you can have with metatarsal resection and one of those is a transfer ulceration or transfer illusion.

[inaudible 1:47] important when you think about using surgical offloading that you take into consideration that there could be problems down the road of either retransfer ulceration, or complications from the surgery itself.

Some of the risks and complications with metatarsal head resection for diabetic foot alterations include a transfer ulceration or transfer lesion, as with any type of surgery, wound dehiscence or delayed or non-healing of the wound, post-op hematoma, infection, even the possibility where there could be loss of toe, loss of foot basically amputation.

How do you address transfer lesions and/or alterations when performing an isolated metatarsal head resection?

Dr. Klein:  I address or I try to avoid transfer lesions or complications minute person resection. With the patient a lot of times it's talked with them preoperatively on an isolated fifth metatarsal head resection I find that the recurrence rate or transfer ulceration is relatively low within the literature that I reviewed somewhere between nine percent for fifth metatarsal resections.

For diabetic alterations and then the fifth metatarsal head next one that I'm very comfortable offering my patient as long as they've gone through the typical workup that we would do for any type of person that would have a surgery, appropriate blood flow, and infection control, things of that nature glycemic control.

For central rate metatarsus resection, those are a little bit more difficult because they do run a higher risk of transfer ulceration as well as taking up the first metatarsal head. Things that we can do to avoid. Hopefully, a transfer ulceration is a concomitant TAL, lengthening along with metatarsal head resection when we do a tendo case lengthening, it does decrease the peak pressures at the metatarsal heads.

That's one thing that we can do postoperatively if we do an isolated metatarsal head resection as well as sending the patient down to the prosthetics and orthotics department to have an appropriate custom insole made and possibly modifications to their shoes to help offload pressure in the forefoot.

What key takeaway messages would you like to give clinicians considering the use of metatarsal head resection?

Dr. Klein:  Key takeaways for using metatarsal head resection for diabetic foot ulcerations is that is a viable option for our patients who have diabetic foot ulcerations. As I shared a few minutes ago, isolated fits into metatarsal resections works extremely well at least in my hands. I do think metatarsal resection is a very viable option for us when we do treat diabetic foot alterations.

As long as we as providers and our patients go in understanding that there is a risk for a transfer ulceration, there's a risk for infection, there's a risk for wounded history, there's a risk for any type of surgery that we offer to our patients. Metatarsal resection is a very viable option for our patients with chronic recalcitrant DFTs.

Thanks for tuning in to another ePlasty podcast. For more like this, please visit our website. If you're interested in being a guest on our podcast, email us at eplastyeditor@hmpglobal.com.

More About Dr. Klein

Originally from Caldwell, New Jersey, Dr. Robert Klein, completed podiatric and surgical training in Chicago at Dr. William Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science. He holds an undergraduate degree from Florida Atlantic University in Chemistry.

Dr. Klein continued his education as the Chief Resident at Michigan Health Center in Detroit. He sustained lifelong learning taking post graduate courses at the University of Texas Health Science Center San Antonio and is currently completing a Strategic Healthcare Leadership program at Cornell.  Dr. Klein is a Diplomate of both the American Board of Foot and Ankle Surgery and American Board of Wound Management.

Dr. Klein practices wound care and limb preservation full time. He is a Clinical Associate Professor of Surgery, University of South Carolina School of Medicine - Greenville, and serves as the Chair, Division of Wound Care for Prisma Health Systems - Upstate. He has over 27 years of experience treating difficult to heal wounds, Dr. Klein demonstrates a strong passion and commitment to wound care, hard to heal wounds of the foot and ankle, and reconstructive surgery of the foot and ankle.

Dr. Klein has presented multiple scientific abstracts and posters and serves as a peer Reviewer on the Editorial Staff of Wounds: A Compendium of Clinical Research and Practice, as well as appearing on national television more than once.

In his spare time, he volunteers for the United State Naval Academy counseling and mentoring USNA Candidates while educating academic advisors in USNA career opportunities.