Hoffman procedure in the ulcerated diabetic neuropathic foot

Twelve diabetic patients with varying degrees of insensitivity of the foot presented with problems of forefoot ulceration beneath one or more metatarsal heads. This was associated with local abscess formation. Some of these patients had previously been subjected to surgical procedures such as ray resection or single metatarsal head resection for earlier problems and were left with areas of increased pressure in the weightbearing surface of the forefoot. Appropriate antibiotic therapy was started by the Infectious Diseases service in each case. Blood flow to the extremity was evaluated by pulse volume recordings and measurement of Doppler pressures at various levels down the extremity. Vascular reconstruction was indicated in two of these patients. After this reconstruction, circulation was deemed adequate to perform the Clayton (Clayton, M.L.: Surgery of the forefoot in Rheumatoid Arthritis. Clin. Orthop. 16:136-140, 1960) modification of the Hoffman (Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. 9:441-449, 1911) procedure. This procedure was also done on 10 other patients with more adequate circulation. Although the time of healing was prolonged in some instances, all feet healed and the patients were successfully graduated to full weightbearing with extra depth shoes with soft neoprene rubber insoles. This procedure should be considered instead of transmetatarsal amputation in some patients with problems of ulceration and abscess formation of the forefoot if circulation is adequate, or can be restored to adequate levels by vascular reconstruction.