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J Reconstr Microsurg 2012; 28(04): 241-246
DOI: 10.1055/s-0032-1306372
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Prevention of Ulceration, Amputation, and Reduction of Hospitalization: Outcomes of a Prospective Multicenter Trial of Tibial Neurolysis in Patients with Diabetic Neuropathy

A. Lee Dellon
1   Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland
2   Dellon Institute for Peripheral Nerve Surgery, Peripheral Nerve Towson, Baltimore, Maryland
,
Vickie L. Muse
2   Dellon Institute for Peripheral Nerve Surgery, Peripheral Nerve Towson, Baltimore, Maryland
,
D. Scott Nickerson
3   Northeast Wyoming Wound Care Center, Sheridan, Wyoming
,
et al › Author Affiliations
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Publication History

13 August 2011

16 October 2011

Publication Date:
12 March 2012 (online)

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Abstract

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan–Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

Keywords

ulcers - amputation - diabetic neuropathy
 

  • References

  • 1 Dellon AL. Treatment of symptomatic diabetic neuropathy by surgical decompression of multiple peripheral nerves. Plast Reconstr Surg 1992; 89 (4) 689-697 , discussion 698–699
    CrossrefPubMedGoogle Scholar
  • 2 Wieman TJ, Patel VG. Treatment of hyperesthetic neuropathic pain in diabetics. Decompression of the tarsal tunnel. Ann Surg 1995; 221 (6) 660-664 , discussion 664–665
    CrossrefPubMedGoogle Scholar
  • 3 Hollis Caffee H. Treatment of diabetic neuropathy by decompression of the posterior tibial nerve. Plast Reconstr Surg 2000; 106 (4) 813-815
    CrossrefPubMedGoogle Scholar
  • 4 Aszmann OC, Kress KM, Dellon AL. Results of decompression of peripheral nerves in diabetics: a prospective, blinded study. Plast Reconstr Surg 2000; 106 (4) 816-822
    CrossrefPubMedGoogle Scholar
  • 5 Tambwekar DS. Extended neurolysis of the posterior tibial nerve to improve sensation in diabetic neuropathic feet. Plast Reconstr Surg 2001; 108 (5) 1452-1453
    CrossrefPubMedGoogle Scholar
  • 6 Wood WA, Wood MA. Decompression of peripheral nerves for diabetic neuropathy in the lower extremity. J Foot Ankle Surg 2003; 42 (5) 268-275
    CrossrefPubMedGoogle Scholar
  • 7 Biddinger KR, Amend KJ. The role of surgical decompression for diabetic neuropathy. Foot Ankle Clin 2004; 9 (2) 239-254
    CrossrefPubMedGoogle Scholar
  • 8 Lee CH, Dellon AL. Prognostic ability of Tinel sign in determining outcome for decompression surgery in diabetic and nondiabetic neuropathy. Ann Plast Surg 2004; 53 (6) 523-527
    CrossrefPubMedGoogle Scholar
  • 9 Aszmann O, Tassler PL, Dellon AL. Changing the natural history of diabetic neuropathy: incidence of ulcer/amputation in the contralateral limb of patients with a unilateral nerve decompression procedure. Ann Plast Surg 2004; 53 (6) 517-522
    CrossrefPubMedGoogle Scholar
  • 10 Rader AJ. Surgical decompression in lower-extremity diabetic peripheral neuropathy. J Am Podiatr Med Assoc 2005; 95 (5) 446-450
    CrossrefPubMedGoogle Scholar
  • 11 Valdivia JM, Dellon AL, Weinand ME, Maloney Jr CT. Surgical treatment of peripheral neuropathy: outcomes from 100 consecutive decompressions. J Am Podiatr Med Assoc 2005; 95 (5) 451-454
    CrossrefPubMedGoogle Scholar
  • 12 Yao Y, Wang RZ. Peripheral Nerve Decompression (Dellon Procedure) and Diabetic Neuropathy. Chinese J Med 2005; 10: 1756-1758
    PubMedGoogle Scholar
  • 13 Siemionow M, Alghoul M, Molski M, Agaoglu G. Clinical outcome of peripheral nerve decompression in diabetic and nondiabetic peripheral neuropathy. Ann Plast Surg 2006; 57 (4) 385-390
    CrossrefPubMedGoogle Scholar
  • 14 Nelson SC, Little Jr ER. The 36-item Short-Form Health Survey outcome evaluation for multiple lower-extremity nerve decompressions in diabetic peripheral neuropathy: a pilot study. J Am Podiatr Med Assoc 2007; 97 (2) 121-125
    PubMedGoogle Scholar
  • 15 Karagoz H, Yuksel F, Ulkur E, Celikoz B. Early and late results of nerve decompression procedures in diabetic neuropathy: a series from Turkiye. J Reconstr Microsurg 2008; 24 (2) 95-101
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Dellon AL. The Dellon approach to neurolysis in the neuropathy patient with chronic nerve compression. Handchir Mikrochir Plast Chir 2008; 40: 1-10
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Dellon AL. Surgical treatment of chronic nerve compression in the patient with neuropathy. In: Zgonnis T, ed. Surgical Reconstruction of the Diabetic Foot and Ankle. Philadelphia: Lippincott Williams & Wilkins; 2009
    Google Scholar
  • 18 Dellon AL, Mackinnon SE, Seiler IV WA. Susceptibility of the diabetic nerve to chronic compression. Ann Plast Surg 1988; 20 (2) 117-119
    CrossrefPubMedGoogle Scholar
  • 19 Dellon ES, Dellon AL. Functional assessment of neurologic impairment: track analysis in diabetic and compression neuropathies. Plast Reconstr Surg 1991; 88 (4) 686-694
    CrossrefPubMedGoogle Scholar
  • 20 Dellon AL, Dellon ES, Seiler IV WA. Effect of tarsal tunnel decompression in the streptozotocin-induced diabetic rat. Microsurgery 1994; 15 (4) 265-268
    CrossrefPubMedGoogle Scholar
  • 21 Kale B, Yüksel F, Celiköz B, Sirvanci S, Ergün O, Arbak S. Effect of various nerve decompression procedures on the functions of distal limbs in streptozotocin-induced diabetic rats: further optimism in diabetic neuropathy. Plast Reconstr Surg 2003; 111 (7) 2265-2272
    CrossrefPubMedGoogle Scholar
  • 22 Siemionow M, Sari A, Demir Y. Effect of early nerve release on the progression of neuropathy in diabetic rats. Ann Plast Surg 2007; 59 (1) 102-108
    CrossrefPubMedGoogle Scholar
  • 23 Dellon AL. The four medial ankle tunnels: a critical review of perceptions of tarsal tunnel syndrome and neuropathy. Neurosurg Clin N Am 2008; 19 (4) 629-648 , vii
    CrossrefPubMedGoogle Scholar
  • 24 Dyck PJ. Peripheral neuropathy. Changing concepts, differential diagnosis and classification. Med Clin North Am 1968; 52 (4) 895-908
    PubMedGoogle Scholar
  • 25 Vinik AI, Mehrabyan A. Diabetic neuropathies. Med Clin North Am 2004; 88 (4) 947-999 , xi
    CrossrefPubMedGoogle Scholar
  • 26 Sinnreich M, Taylor BV, Dyck PJ. Diabetic neuropathies. Classification, clinical features, and pathophysiological basis. Neurologist 2005; 11 (2) 63-79
    CrossrefPubMedGoogle Scholar
  • 27 Tassler PL, Dellon AL. Cutaneous pressure thresholds in ulcerated and non-ulcerated diabetic feet, measured with the Pressure-specified Sensory Device. J Am Pod Med Assoc 1995; 85: 679-684
    PubMedGoogle Scholar
  • 28 Tassler PL, Dellon AL. Correlation of measurements of pressure perception using the pressure-specified sensory device with electrodiagnostic testing. J Occup Environ Med 1995; 37 (7) 862-866
    PubMedGoogle Scholar
  • 29 Dellon AL. Computer-assisted sensibility evaluation and surgical treatment of tarsal tunnel syndrome. Adv Pod 1996; 2: 17-40
    PubMedGoogle Scholar
  • 30 Tassler PL, Dellon AL. Pressure perception in the normal lower extremity and in the tarsal tunnel syndrome. Muscle Nerve 1996; 19 (3) 285-289
    CrossrefPubMedGoogle Scholar
  • 31 Vinik AI. Advances in diabetes for the millennium: new treatments for diabetic neuropathies. MedGenMed 2004; 6 (3, Suppl) 13-19
    PubMedGoogle Scholar
  • 32 Rathur HM, Boulton AJ. Recent advances in the diagnosis and management of diabetic neuropathy. J Bone Joint Surg Br 2005; 87 (12) 1605-1610
    CrossrefPubMedGoogle Scholar
  • 33 Palumbo JP, Melton LJ. Peripheral vascular disease and diabetes. In: Harris M, Jamman R, eds. Diabetes in America. Washington, DC: U.S. Govt. Printing Office; 1985
    Google Scholar
  • 34 Moss SE, Klein R, Klein BE. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med 1992; 152 (3) 610-616
    CrossrefPubMedGoogle Scholar
  • 35 Resnick HE, Valsania P, Phillips CL. Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, 1971-1992. Arch Intern Med 1999; 159 (20) 2470-2475
    CrossrefPubMedGoogle Scholar
  • 36 Frykberg RG. Epidemiology of the diabetic foot: ulcerations and amputations. Adv Wound Care 1999; 12 (3) 139-141
    PubMedGoogle Scholar
  • 37 Centers for Disease Control. Diabetes Surveillance, 1993. Atlanta, GA: U.S. Department of Health and Human Services; 1993
    Google Scholar
  • 38 Bloomgarden ZT. American Diabetes Association 60th Scientific Sessions, 2000: the diabetic foot. Diabetes Care 2001; 24 (5) 946-951
    CrossrefPubMedGoogle Scholar
  • 39 Centers for Disease Control and Prevention (CDC). History of foot ulcer among persons with diabetes—United States, 2000-2002. MMWR Morb Mortal Wkly Rep 2003; 52 (45) 1098-1102
    PubMedGoogle Scholar
  • 40 Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293 (2) 217-228
    CrossrefPubMedGoogle Scholar
  • 41 Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. QJM 2007; 100 (2) 65-86
    PubMedGoogle Scholar
  • 42 Crawford F, McCowan C, Dimitrov BD , et al. The risk of foot ulceration in people with diabetes screened in community settings: findings from a cohort study. QJM 2011; 104 (5) 403-410
    CrossrefPubMedGoogle Scholar
  • 43 Bartus CL, Margolis DJ. Reducing the incidence of foot ulceration and amputation in diabetes. Curr Diab Rep 2004; 4 (6) 413-418
    CrossrefPubMedGoogle Scholar
  • 44 Witsø E, Lium A, Lydersen S. Lower limb amputations in Trondheim, Norway. Acta Orthop 2010; 81 (6) 737-744
    CrossrefPubMedGoogle Scholar
  • 45 Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes Care 2010; 33 (12) 2592-2597
    CrossrefPubMedGoogle Scholar
  • 46 Al-Wahbi AM. Impact of a diabetic foot care education program on lower limb amputation rate. Vasc Health Risk Manag 2010; 6: 923-934
    PubMedGoogle Scholar
  • 47 Rogers LC, Bevilacqua NJ. Organized programs to prevent lower-extremity amputations. J Am Podiatr Med Assoc 2010; 100 (2) 101-104
    PubMedGoogle Scholar
  • 48 Nickerson DS. Low recurrence rate of diabetic foot ulcer after nerve decompression. J Am Podiatr Med Assoc 2010; 100 (2) 111-115
    PubMedGoogle Scholar
  • 49 Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006; 29 (6) 1288-1293
    Google Scholar