A 46-year-old man with type 2 diabetes of 12 years' duration, documented peripheral neuropathy with loss of protective sensation and history of a chronic non-healing ulcer on the plantar medial aspect of his right hallux inter-phalangeal joint, had limited joint mobility in the 1st metatarsophalangeal joint, with approximately 10° of hallux dorsiflexion (Fig. 8.9). Quantitative plantar pressure measurements revealed markedly elevated peak plantar pressure, 95 N/cm2, beneath the great toe (Fig. 8.10). The maximum peak pressure corresponded to the precise location of his ulcer. Radiographs revealed no evidence of osteomyelitis. Conservative treatment consisted of local wound care, total-contact casting, a walking brace
and extra-depth shoes with total-contact orthoses. Over a period of several months the ulcer showed some improvement with off-loading: however, it never completely healed. The ulcer became infected on two occasions with Staphylococcus aureus. The infections resolved prompdy with oral antibiotics.
It became clear that the ulcer would not heal without surgical intervention, and that he was at high-risk for future infections and amputation of his hallux. Keller resectional arthroplasty of the 1st metatarsophalangeal joint was proposed as a salvage procedure and the patient consented. Within 4 weeks following the procedure, the hallux ulcer was completely healed. A complication occurred on postoperative day 18, with development of pain and swelling at the base of the right 2nd toe. The patient indicated that his foot began to hurt as he was walking to his car. X-rays revealed a non-displaced fracture of the proximal phalangeal base of the 2nd toe. The 2nd and 3rd toes were splinted, the patient was placed in a walking brace, and the foot healed without further complications.
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