Willem D Rinkel1, Manuel Castro Cabezas2, Erwin Birnie3, J Henk Coert4. 1. Department of Plastic-, Reconstructive- and Hand Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, the Netherlands. Electronic address: w.d.rinkel@umcutrecht.nl. 2. Department of Internal Medicine/Centre for Diabetes, Endocrinology and Vascular Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands. 3. Department of Statistics and Education, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. 4. Department of Plastic-, Reconstructive- and Hand Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, the Netherlands.
Abstract
INTRODUCTION: Tibial nerve entrapment is highly prevalent in diabetic subjects, resulting in significantly more neuropathic complaints and concomitant sensory disturbances. The study aim was to assess the impact of tarsal tunnel syndrome (TTS) and sensory loss at baseline on incident diabetic foot ulceration (DFU) in diabetic patients, since decompressing the tibial nerve might change the natural history of the disease. METHODS: In this study, 113 subjects with TTS (69 bilateral, 23 left-sided and 21 right-sided) participating in the prospective Rotterdam Diabetic Foot Study were compared to 303 diabetic controls without TTS, regarding incident DFU. Kaplan-Meier analysis and Cox's regression analysis were used to determine the independent hazard of baseline variables for new DFU. RESULTS: The median observation period was 836.5 days (IQR, 459-1077.8). In bilateral TTS, 17.4% (95% CI: 8.4-26.3%) of subjects experienced DFU versus 8.3% (95% CI: 5.1-11.6%) in controls (left or right) during follow-up (p = 0.0036). In left-sided TTS, no subjects versus 6.2% (95% CI: 3.4-9.0%) in controls had DFUs (p = 0.243). Incident ulceration was seen in 14.3% (95% CI: -0.7% to -29.3%) of right-sided TTS subjects versus 4.1% (95% CI: 1.5-6.3%) in controls (p = 0.034). Besides HbA1c, diminished sensation at the hallux independently increased the risk of ulceration, in patients with (HR: 4.692, p = 0.003) and without (HR: 2.307, p = 0.002) prior DFU. DISCUSSION: Elevated sensory thresholds in TTS render diabetic patients at a higher risk for DFU. With effective surgery, TTS is likely to be an amenable factor to potentially prevent diabetic foot disease and thereby reduce amputation risk. LEVEL OF EVIDENCE: II.
INTRODUCTION: Tibial nerve entrapment is highly prevalent in diabetic subjects, resulting in significantly more neuropathic complaints and concomitant sensory disturbances. The study aim was to assess the impact of tarsal tunnel syndrome (TTS) and sensory loss at baseline on incident diabetic foot ulceration (DFU) in diabeticpatients, since decompressing the tibial nerve might change the natural history of the disease. METHODS: In this study, 113 subjects with TTS (69 bilateral, 23 left-sided and 21 right-sided) participating in the prospective Rotterdam Diabetic Foot Study were compared to 303 diabetic controls without TTS, regarding incident DFU. Kaplan-Meier analysis and Cox's regression analysis were used to determine the independent hazard of baseline variables for new DFU. RESULTS: The median observation period was 836.5 days (IQR, 459-1077.8). In bilateral TTS, 17.4% (95% CI: 8.4-26.3%) of subjects experienced DFU versus 8.3% (95% CI: 5.1-11.6%) in controls (left or right) during follow-up (p = 0.0036). In left-sided TTS, no subjects versus 6.2% (95% CI: 3.4-9.0%) in controls had DFUs (p = 0.243). Incident ulceration was seen in 14.3% (95% CI: -0.7% to -29.3%) of right-sided TTS subjects versus 4.1% (95% CI: 1.5-6.3%) in controls (p = 0.034). Besides HbA1c, diminished sensation at the hallux independently increased the risk of ulceration, in patients with (HR: 4.692, p = 0.003) and without (HR: 2.307, p = 0.002) prior DFU. DISCUSSION: Elevated sensory thresholds in TTS render diabeticpatients at a higher risk for DFU. With effective surgery, TTS is likely to be an amenable factor to potentially prevent diabetic foot disease and thereby reduce amputation risk. LEVEL OF EVIDENCE: II.
Authors: Neeraj Vij; Heather N Kaley; Christopher L Robinson; Peter P Issa; Alan D Kaye; Omar Viswanath; Ivan Urits Journal: Orthop Rev (Pavia) Date: 2022-09-05