Surgical off-loading of the diabetic foot · postoperative infection in the foot and ankle, many previous studies have demonstrated the importance of neuropathy as a signiﬁcant

Surgical off-loading of the diabetic footRobert G. Frykberg, DPM, MPH,a Nicholas J. Bevilacqua, DPM,b andGeoffrey Habershaw, DPM,c Phoenix, Ariz; Los Angeles, Calif; and Boston, Mass

Surgical intervention for chronic deformities and ulcerations has become an important component in the management ofpatients with diabetes mellitus. These patients are no longer relegated to wearing cumbersome braces or footwear fordeformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individualsis not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this briefreview, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of
deformities that frequently lead to foot ulcers. ( J Vasc Surg 2010;52:44S-58S.)
Foot deformities, including contracture of thegastrocnemius-soleus complex, are clinically significantrisk factors that commonly lead to diabetic foot ulcer-ation.1-3 In fact, deformity in association with peripheralneuropathy and trauma were the three most commoncomponent causes in the pathway leading to foot ulcer-ation.3 Structural alterations in the architecture of thefoot often lead to abnormally high plantar foot pressures,as well as increased dorsal, medial, or lateral pressureswhen snugly fitting footwear is worn.4,5 These highpedal pressures consequently place the foot at risk forulceration.6-8

Although deformities such as hammer toes and bun-ions are quite common in the nondiabetic population, theyalso frequently develop in persons with diabetes but with-out significant consequence. It is the presence of peripheralneuropathy, however, that confers the attendant risk forulceration in diabetic individuals. A recent study of patientsundergoing foot and ankle surgery has shown that diabeteswithout complications imparts no greater risk for postop-erative infection than that for persons without diabetes.However, when diabetic patients with complications (in-cluding neuropathy) were compared with those withoutdiabetes, there was a tenfold risk for developing postop-erative infection.9 Although this study’s focus was onpostoperative infection in the foot and ankle, manyprevious studies have demonstrated the importance ofneuropathy as a significant predictor of foot ulcer-ation.3,7,10-12

From the Carl T. Hayden VA Medical Center, Phoenix;a Valley PresbyterianHospital, Los Angeles;b and Boston University Medical Center, Boston.c

Competition of interest: none.This article is being co-published in the Journal of Vascular Surgery® and the

Journal of the American Podiatric Medical Association.Correspondence: Robert G. Frykberg, DPM, Carl T. Hayden VA Medical

Center, 650 E Indian School Rd, Phoenix, AZ 85012-1892 (e-mail:[email protected]).

The editors and reviewers of this article have no relevant financialrelationships to disclose per the JVS policy that requires reviewers todecline review of any manuscript for which they may have a competi-tion of interest.

0741-5214/$36.00Published by Elsevier Inc. on behalf of the Society for Vascular Surgery

and the American Podiatric Medical Association.
doi:10.1016/j.jvs.2010.06.008
44S

Neuropathy not only predisposes to foot ulcer in thepresence of deformity and trauma but can also lead tothe development of deformity in the diabetic foot.4,8,13 TheCharcot foot is the most classic example of a deformityprimarily related to peripheral neuropathy of any cause.14,15

Neuropathy affects the sensory nerves of the lower ex-tremities and the motor as well as autonomic fibers.16-19

Consequently, motor neuropathy leads to muscle dys-function, dynamic contractures, and even paresis (ie,foot drop).

Ankle equinus, caused by a contracture of thegastrocnemius-soleus muscle complex and Achilles’ ten-don, is often found in patients with diabetes and has beenassociated with high forefoot plantar pressures.20-22 Theclinical effects of motor neuropathy are also seen in theform of intrinsic muscle atrophy.23 The “intrinsic mi-nus” foot is typified by such atrophy on the dorsalforefoot in concert with the development of hammertoes or claw toes (Fig 1).8,24 In severe cases, the intrinsicminus foot will develop a cavus appearance and associ-ated high plantar pressures under the prominent meta-tarsal heads.

Shoes are an important cause of trauma to the neuro-pathic foot, especially in individuals with structural defor-mity. Therefore, the provision of properly fitted therapeuticfootwear is considered a key component of an ulcer andamputation prevention program.13,25-27 Unfortunately,over-the-counter shoes often cannot accommodate severefoot deformities, including high plantar pressures. In somesituations, custom footwear is indicated to protect severelymisshapen feet.

Nonetheless, any footwear is only as good as the pa-tients’ adherence to wearing the shoes as prescribed. Tothis end, even in the ulcerated foot where strict adherenceto off-loading modalities are critical, one study showed thatpatients had poor compliance and wore the prescribedoff-loading devices only 28% of the time.28 Nonetheless,several studies have shown that patients fitted with thera-peutic footwear suffer significantly fewer primary or recur-rent ulcerations compared with diabetic patients who werenot given such footwear.29-32

Surgical intervention should be considered when recur-
rent ulceration or preulcerative lesions develop despite
mailto:[email protected]

JOURNAL OF VASCULAR SURGERYVolume 52, Number 12S Frykberg et al 45S

concerted efforts to prevent such lesions. Once consideredill-advised, corrective or reconstructive foot surgery hasassumed an important role in the management of pa-tients with chronic or recurrent foot ulcerations.13,33-38

Of course, such patients need to be carefully selected andevaluated to ensure that adequate vascularity is presentand that major comorbidities, including renal insuffi-ciency, unstable cardiovascular disease, and congestiveheart failure, are adequately controlled. Because periph-eral arterial disease (PAD) is often asymptomatic inpersons with diabetes, we follow the American DiabetesAssociation recommendation that an ankle-brachial in-dex (ABI) be measured in such persons who are aged�50 years.2,39 Furthermore, we routinely recommendobtaining a preoperative ABI (with toe pressures andwaveforms) in diabetic patients with foot ulcers in theabsence of clearly bounding pulses.

In 2003, Armstrong and Frykberg38,40 revised arisk-based scheme for classifying the types of foot surgeryperformed in diabetic patients largely depending on thepresence of open wounds and their acuity. Fundamen-tally, the classes of foot surgery are distinguished by theirprogressive risks for subsequent proximal levels of ampu-

Fig 1. Intrinsic minus foot. Note the high arched, thin foot withlittle muscle mass in this patient with advanced peripheral neurop-athy. Flexible hammer toes (claw toes) usually accompany thisdeformity as well.

Table. Classification of diabetic foot surgery40

● Class I: Elective. Reconstructive procedures on patients whodo not have loss of protective sensation (LOPS)

● Class II: Prophylactic. Reconstructive procedures performedto reduce the risk of ulceration or reulceration in patients whohave LOPS and do not have a wound present

● Class III: Curative. Procedures performed to assist in healingof open wounds

● Class IV: Emergent. Procedures performed to arrest or limitprogression of infection

tation (Table):

● Elective surgery (class I) represents reconstructive pro-cedures performed to correct deformities or high plan-tar pressures in persons without neuropathy.

● Prophylactic (class II) procedures are those performedin patients with neuropathy (loss of protective sensa-tion) to reduce the risk of ulceration or recurrentulceration when no open wounds are present.

● Curative surgery (class III) is often performed when openwounds are present to effect a cure by removing under-lying bony prominences (surgical decompression), osteo-myelitis, or by draining underlying abscesses. Obviously,such procedures are at higher risk for nonhealing orinfection than are the first two classes.

● Emergent procedures (class IV) are performed forsevere infections (wet gangrene, necrotizing fasci-itis, etc) to control the progression of infection. Asthe name implies, these procedures are performedemergently and often consist of open amputations atthe foot level combined with fasciotomies of the leg.

Armstrong et al41 later validated this classificationscheme in subsequent risk for proximal amputation andinfection. They found a significant trend toward increasingrisk of ulceration/reulceration, postoperative infection, all-level amputation, and major amputation with increasingclass of foot surgery (P � .01 for all complications). Aswould be expected, the greatest frequency of major ampu-tation was in class IV procedures.

Specific types of operations or procedures are notrestricted to single classes of surgery as described above.To the contrary, many procedures are used in operationsperformed across multiple foot surgery categories. Forexample, a hammer toe repair might be performed as anelective, prophylactic, or a curative procedure dependingon the presence of neuropathy and the presence or

Fig 2. Acquired second hammer toe after great toe amputationwith dorsal ulcer. This is easily treated by a digital arthroplastyor joint resection with excision of the ulceration. A metatarso-phalangeal joint release is also usually required for rigiddeformities.

absence of an open wound (Fig 2) A tendo-Achilles’

JOURNAL OF VASCULAR SURGERYSeptember Supplement 201046S Frykberg et al

lengthening (TAL) would be indicated under the samesituations. A first ray amputation might be performed tocure chronic osteomyelitis even in the absence of an openwound (prophylactic), in the presence of a chronic drain-ing ulcer (curative), or as an emergent procedure tocontrol the spread of an acute necrotizing infection. Amidfoot osteotomy or arthrodesis of an ulcerated Char-cot deformity is commonly performed as a curative op-eration (class III), but is just as frequently performed toreconstruct a deformed nonulcerated foot and therebyoffer surgical decompression to reduce plantar pressures(class II; Fig 3).15,42,43

This review will focus on those procedures commonlyused by foot and ankle surgeons to address deformities thatare causing abnormal pressure gradients. As already noted,many of these procedures can be used in elective, prophy-lactic, or curative situations depending on the presence (orabsence) of neuropathy or ulceration. Although we will notdiscuss amputations or specific management of infection, abrief discussion of those procedures used to correct the

Fig 3. Reconstruction for correction of unstable Chardeformity. B, A preoperative radiograph shows osteolysitalectomy and fusion. D, Postoperative radiograph.

Charcot foot will be presented.

DIGITAL DEFORMITIES

Common digital deformities, such as hammer toe,claw toe, and mallet toe, are known to increase pres-sures and are associated with neuropathic ulceration.Correcting the structural deformity with a resectionarthroplasty may augment healing and reduce the risk ofulcer recurrence.44 Alternatively, a percutaneous flexortenotomy offers a less invasive approach and may affordthe necessary intrinsic pressure modulation to augmenthealing.

Distal tip ulcers, in a flexible hammer toe, maybe managed with a flexor digitorum longus tenotomy. Ablade or 18-gauge needle is introduced 1 cm proximal tothe proximal plantar flexural crease of the toe (Fig 4). Theankle is held in a dorsiflexed position with the patientactively holding all toes in a flexed position. The toe ismanually straightened, and the blade is moved across thetaught tendon, making ease of the tenotomy. The longextensor tendon will now hold the toe straight. A postop-

nkle. A, Preoperative clinical view demonstrates anklehe talar dome. C, Circular external fixator in place after

cot as of t

erative shoe can be used for limited ambulation. Overex-


tension of the toe can be managed with an extensor longustenotomy at a later date.

Laborde45 retrospectively reviewed 18 patients pre-senting with plantar toe ulcers treated with a flexor tenot-omy. All patients had a flexible claw toe deformity withulcers on the distal plantar aspect of the hallux or lesser toes.The incision and the ulcer healed in all patients. Twopatients underwent a repeat procedure for ulcer recurrenceand remained ulcer free at 17 and 34 months.

Tamir et al46 retrospectively reviewed the outcomes of14 patients (24 toes) treated with percutaneous flexortenotomies for a claw toe deformity to off-load the tip ofthe toe for ulcer healing. The authors performed an oste-oclasis in select patients to correct rigid contractures at theproximal interphalangeal joint. All patients healed with nosignificant complications noted.

Although the methodologic quality of both studies was

Fig 4. Flexor tenotomy. A, The toe is flexible and ulcethe patient is asked to dorsiflex the ankle and actively fleand can easily be tenotomized as shown here with a #61toes that have had flexor tenotomies. The fourth toe hadthe office setting.

poor, their results support the ability of a percutaneous

flexor tenotomy of the hallux and lesser toes to heal neu-ropathic toe ulceration secondary to toe contracture inpersons with diabetes.47

A rigid hammer toe is best treated with an arthroplastyat the level of the distal or proximal interphalangeal joint.However, a percutaneous flexor tenotomy may be at-tempted in the nonflexible deformity before resorting to anopen arthroplasty. On those occasions where a hallux ulceris not due to a limitation of motion at the metatarsopha-langeal joint (MTPJ), this same procedure can be used onthis digit (Fig 5).

LESSER METATARSALS

Neuropathic ulcerations under the metatarsal heads area challenging problem and may lead to infection and am-

the tip. B, Lidocaine is injected at the site of entry, andhe toes. This makes the long flexor tendon very taught,r blade. No suture is needed. C, Shows all three middlection of osteomyelitis, 4 weeks postoperatively, done in

r is atx all tBeave

rese

putation.48 Various metatarsal procedures have been de-

y am


scribed, including metatarsal head osteotomies and resec-tions.38,49,50 An isolated metatarsal osteotomy should beconsidered for a chronic, nonundermining, nontunnel-ing, ulcer below a specific metatarsal head. It can beperformed through a dorsal incision with a double-action bone cutter or an oscillating saw. The osteotomycan be done at the surgical or anatomic neck of themetatarsal (Fig 6). A collar of bone may be removed ifshortening of the metatarsal is desired. Such proceduresare generally performed when the plantar ulceration doesnot penetrate to bone.

A tunneling ulcer should be appropriately débridedto remove all undermining. A metatarsal head resectionmay be performed to assist in healing by internallyoff-loading the ulcer (Fig 7). Armstrong et al51 evaluatedthe outcomes of an isolated fifth metatarsal head resec-tion for ulcerations beneath the fifth metatarsal head andcompared it with nonsurgical care. They reported morerapid healing and a lower recurrence rate in the surgicalgroup.

The surgeon must be cognizant of maintaining a nearlynormal metatarsal parabola. The second, third, and fourthmetatarsals function as a single unit and any disruption inmetatarsal length or height may result in a transfer callus orulceration. If an ulcer occurs, further metatarsal osteotomymay be necessary. Osteotomies should be performed on theremaining two metatarsals, and if not, additional ulcerationis likely to develop over the remaining metatarsal, necessi-

Fig 5. Arthroplasty of the hallux for surgical off-loadinghead of the proximal phalanx. B, Incision placement. Ctendon is repaired. D, The wound closed primarily. Earl

tating a third procedure. This scenario is especially likely to

occur after one of the metatarsal heads has been removeddue to infection.

Multiple metatarsal head resections or a panmetatar-sal head resection may be considered for nonhealingulcers in the presence of an abnormal metatarsal parabola(Fig 8).52 Hamilton et al48 proposed combining lessermetatarsal head resections with gastrocnemius recessionand a peroneus longus-to-brevis tendon transfer in pa-tients with chronic, neuropathic forefoot ulcerations. Allulcers were located beneath lesser metatarsal heads, al-lowing the authors to preserve the first MTPJ. Theyadjunctively managed the equinus deformity with a gas-trocnemius recession and alleviated pressure beneath thefirst metatarsal with the peroneus longus-to-brevis trans-fer. The authors reported ulcer healing in 10 patients(100%), with no ulcer recurrence at a mean 14.2 monthsof follow-up.48

KELLER ARTHROPLASTY

Limited range of motion at the MTPJ is a commonforefoot deformity that contributes to ulcer formationbeneath the hallux. This limitation in joint range ofmotion leads to increased pressure on the hallux duringambulation. Pressure reduction is essential and usuallyconsists of an external device to off-load the area.53 Thisdoes not correct the underlying deformity, however. Theassociated biomechanical abnormality still exists after theoff-loading device is removed, and ulcer recurrence may

chronic hallux ulceration. A, The ulcer is adjacent to thehead of the phalanx is removed, and the long extensor

bulation is possible with a postoperative shoe.

of a, The

occur. Identifying and correcting the underlying struc-


tural deformity may assist in healing and also reduceulcer recurrence.

Armstrong et al54 compared the safety and efficacy of afirst MTPJ arthroplasty (Keller-type procedure) with non-surgical management for wounds at the plantar aspect ofthe hallux interphalangeal joint (Fig 9). They included 41patients, with 21 undergoing a first MTPJ arthroplasty toaugment ulcer healing. Patients in the surgery group healedsignificantly faster than patients in the nonsurgery group.Care after healing was identical in both groups, and thesurgery group had fewer ulcer recurrences during the6-month follow-up. There was a very high prevalence ofpostoperative infections in the surgery group (40%), butthis was compared with the 38% of patients in the controlgroup who required treatment for infection during theperiod of therapy. The results of this study suggest that afirst MTPJ arthroplasty is a safe and effective procedure inthe treatment of noninfected, nonischemic wounds be-

Fig 6. Metatarsal osteotomy, now performed in the officbone cutter, hemostat, and freer elevator as a probe. A, Ta large hemostat. B, A double-action bone cutter is introat the metatarsal neck level. D, Multiple osteotomies shoand surgical neck of each metatarsal.

neath the hallux.54

FIRST MTPJ RESECTION

The excision of the first MTPJ should be consideredif the metatarsal head has osteomyelitis, after failed sesa-moidectomy, or for a chronic ulcer probing to the jointbut with a viable hallux.38 The incision may incorporateand excise the ulcer or be placed dorsally to avoid theulcer altogether. The incision is made directly to bone,with no undermining of the soft tissue. The dissection isat the level of the ligaments and periosteum. The meta-tarsal is cut and beveled plantarly to reduce any boneprominences. The base of the phalanx is removed as in aKeller bunionectomy. Both sesamoids should be re-moved because a fibrous union to the metatarsal stumpmay occur if they are left and become a future source ofulceration (Fig 10). This is also necessary in cases of openjoint involvement or infection, wherein the infected orcontaminated sesamoids will become a source for con-

ing when possible, can be done with simple instruments:gh a dorsal incision, the metatarsal neck is grasped withadjacent to the hemostat. C, The bone is osteotomized

ere are all in the proper location, between the anatomic

e setthrou

ducedwn h

tinued infection.


TAL LENGTHENING

Limited ankle joint mobility, as seen clinically as a tightAchilles’-gastrocnemius-soleus complex, is a deformingforce and a causative factor in plantar forefoot ulcer-ations.21 During normal gait, 10° of dorsiflexion at theankle is required, and anything less will increase plantarpressures in the forefoot and impede healing of the wound.To alleviate the pressure, several authors have suggestedpercutaneous TAL.55-58 Armstrong et al21 confirmed that

Fig 7. A, Undermining ulceration that probes into dstandard metatarsal osteotomy. B, The ulcer is excised ana proximal drain is acceptable as long as there is no activenon-weight bearing for 4 weeks.

plantar pressures are reduced after percutaneous TAL. Lin

et al59 reported results of percutaneous TAL in 15 patientswith plantar forefoot ulcers that did not heal despite 9weeks of total contact casting. All but one ulcer healed(93%), with no ulcer recurrence noted after a mean 17.3-month follow-up.

Mueller et al22 conducted a randomized control trialcomparing the combined treatment of total contact castand percutaneous TAL against a total contact cast alone.Initial healing rates were similar in both groups, but the

issues (including bone or joint) is not appropriate foradjacent metatarsal is removed. C, Primary closure with

s. The drain is pulled in 24 hours, and the patient is kept

eep td thesepsi

significant difference was noted when the ulcer recur-


rence rate was compared. After 2 years, the ulcer recur-rence rate was 81% in the group treated with a total contactcast alone compared with 38% in those treated with a totalcontact cast and TAL. A gastrocnemius recession may beused as an alternative for relief of forefoot pressure60 andhas also been described as an effective treatment for mid-foot ulcers (Fig 11).60,61

CHARCOT FOOT

Charcot arthropathy, perhaps the most characteristicdeformity attributed to the diabetic foot, occurs in only1% of the diabetic population as a whole and in approx-imately 30% of individuals with peripheral neuropa-thy.62-64 Originally described by Charcot as the piedtabétiques in persons with tertiary syphilis,65 the Charcot

Fig 8. Pan metatarsal head resection. A, Failed metatarsamputation could be done, but the toes are viable. Surgicapproach; here, a dorsal approach is planned. C, Excisionseveral months after procedure.

foot is now most commonly encountered in persons with

diabetes.66 Several studies have indicated that diabeticpatients with Charcot foot deformities have an increasedrisk for ulceration and subsequent amputation andhigher mortality compared with diabetic persons with-out this complication.67-69

The classic “rocker-bottom” deformity (Fig 12) is theresult of a collapse of the midfoot architecture generally dueto injury and continued weight bearing on the insensatefoot. With the continued stress of weight bearing, a viciouscycle ensues that exaggerates local inflammation and leadsto more fractures, dislocations, and deformity.14,70 Abnor-mally concentrated pressures develop in the midfoot duringambulation on the deformed foot, and ulceration fre-quently ensues.71 When the ankle joint is the primary site ofinvolvement (Sanders-Frykberg pattern V),14 instability

geries with transfer ulcer subsecond. B, Transmetatarsalloading can be accomplished through a dorsal or plantaretatarsal head through a dorsal incision. D, Radiograph

al sural off-of m

and deformity become the most difficult problem to man-


age and all too frequently fails conservative therapy withbracing.15,64,72

Conservative care for Charcot arthropathy has been thetraditional mainstay of treatment for this limb-threateningdisorder,14,64,72,73 but surgical management for Charcotjoints is not a recent evolution in our understanding of howthis entity can be approached. Although his report dealtprimarily with Charcot joints due to tabes dorsalis, Stein-dler74 presented a series of surgical cases including subtalararthrodesis as early as 1931. Several other important surgi-cal case series were published in the ensuing decades thatillustrated the efficacy of a surgical approach to this arthrop-athy as well as its inherent difficulties and complica-tions.75,76

Numerous descriptive studies have been published inthe last 20 years detailing various surgical techniques for the

Fig 9. A, Keller arthroplasty used as a curative procedurshows the resection of the base of the proximal phalanxnoted 3 weeks after a Keller arthroplasty was performed.

management of the deformed Charcot foot.15,43,77-82 The

indications for surgery are generally to provide a moreeffective management strategy when conservative measureshave failed. Specifically, surgery is recommended for thosepatients with recurrent ulceration (with or without infec-tion), severe instability, or severe deformities not amenableto footwear therapy alone.83 Many surgical techniques havebeen described, including simple plantar exostectomy withor without TAL, midfoot realignment arthrodeses, hind-foot arthrodeses, and ankle arthrodeses (Fig 13). A combi-nation of procedures is most often required because Char-cot deformities are usually multilevel. Although arthrodesisusing internal fixation is most often practiced, multipla-nar external circular fixation using Ilizarov techniques (Fig14) has been used with increasing frequency in recentyears.43,82,84 Regardless of technique, the goals of surgeryremain the same: establish a stable, plantigrade foot miti-

ulcer under a rigid hallux. B, A postoperative radiographllow for unrestricted dorsiflexion. C, Healed ulceration

e forto a

gating focal areas of increased pressure and shearing forces.


By reducing plantar prominences and their attendant highpressures, healing of open ulcers can be augmented and therisk of subsequent skin breakdown will be reduced.77 Thereader is referred to the referenced citations for specifictechniques of interest.

CONCLUSION

Surgical management of diabetic foot disorders is nolonger considered an unwarranted practice. To the con-trary, surgery on the ulcerated or deformed foot hasassumed an increasingly important role in the manage-

Fig 10. First metatarsophalangeal joint resection. AB, The joint is resected through a dorsal incision. Thejoint. C, A radiograph shows the resection of the mphalanx.

ment of such disorders both in the United States and

abroad. Nonetheless, these patients are indeed at ahigher risk for complications than their nondiabeticcounterparts, especially in those with peripheral neurop-athy or ischemia. Careful patient selection and thoroughevaluation of the foot as well as attendant comorbiditiesare the cornerstones of achieving successful results inotherwise very complicated patients. Early and ostensiblyaggressive surgical intervention on the deformed footcan obviate many months of unsuccessful conservativecare, especially when ulcer recidivism becomes the pri-mary challenge. Although virtually all the procedures

chronic deep ulcer under the first metatarsal head.or illustrates that the plantar ulcer penetrated into thersal head, both sesamoids, and the base of proximal

, Aelevatetata

used in this setting are not exclusive to diabetic foot

deformity.


Fig 11. A, A gastrocnemius recession performed to augmenthealing of a plantar forefoot ulceration. B, An image taken 2 years
postoperatively demonstrates long-term ulcer healing.
Fig 12. A rocker-bottom Charcot foot is shown with soft tissuevisualization of large plantar midfoot ulcer under the apex of the


Fig 13. A, This chronic midfoot ulcer was treated with a simple exostectomy with tendo-Achilles’ lengthening.B, Postoperative image shows a plantar incision that was closed primarily and reinforced with tape strips (tendo-
Achilles’ lengthening incision not shown).


surgery, great care (with close follow-up) is necessary inthe postoperative period to ensure optimal outcomes inthese high-risk patients.

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Documents

Surgical off-loading of the diabetic foot · postoperative infection in the foot and ankle, many previous studies have demonstrated the importance of neuropathy as a signiﬁcant