Minimally invasive orthopaedic surgery for diabetic foot disease: A systematic review

Diabetic foot disease is a common life altering complication of diabetes mellitus that results from a combination of neuropathy, angiopathy, and structural deformities. Minimally invasive orthopaedic surgeries (MIOS) are known to shorten recovery time, reduced length of stay in hospital, reduce wound complications, all of which would benefit diabetic patients. Current evidence-based guidance on the use of minimally invasive orthopaedic surgeries (MIOS) in managing diabetic foot disease is limited.

To systematically review all studies on the use of MIOS in managing diabetic foot disease affecting various anatomical locations, and to compile data on ulcer healing, recurrence, complication rates.

A systematic literature search of Medline (PubMed), Embase, Scopus and Cochrane Library from inception until 31st October 2024, using the keywords 'diabetes', 'diabetic foot', 'minimally invasive surgery', 'minimally invasive procedure'. Articles were reviewed for demographic details and surgical outcomes. PRISMA guidelines were adhered to and reported.

Twenty-nine studies were included in the review: 13 reported on forefoot interventions, 4 on midfoot interventions, 3 on hindfoot interventions, and 9 on lower limb interventions. Forefoot MIOS, such as distal metatarsal osteotomies, phalangeal osteotomies and flexor tenotomies, showed significant improvements in ulcer healing times (mean 1.5-3.7 weeks) and reduced recurrence rates (0-21 %). Midfoot MIOS included Taylor Spatial Frame external fixator with percutaneous arthrodesis, solid bolt fixation and metatarsal ray resection. These interventions demonstrated promising outcomes with minimal complications, particularly in managing Charcot neuroarthropathy. MIOS techniques in hindfoot explored were tibio-talo-calcaneal arthrodesis, vertical contour calcanectomy and combination of subtalar arthroereisis with Achilles tendon lengthening. They showed favourable results in lowering post-operative infections (0-3 %) and raising functional scores (improved American Orthopaedic Foot & Ankle Society scores of 44.8). Lower leg MIOS, including percutaneous Achilles tendon lengthening, showed improved plantar forefoot ulcers healing (30-57.5 days) and lower recurrence rates (0-38 %) compared to total contact cast.

MIOS exhibits a promising role in the management of diabetic foot disease and ulcers, especially when paired with rigorous patient selection criteria and preoperative patient optimisation through a multidisciplinary team approach.