Latest / European Society for Vascular Surgery / #ESVS2025 - Basic DFU Biomechanics w/J. Pascual

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#ESVS2025 - Basic DFU Biomechanics w/J. Pascual · European Society for Vascular Surgery

• 0:12
  The toe and flow model with collaboration of
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  vascular surgery and podiatry has improved results
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  in diabetic foot ulcer healing. Vascular surgeons
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  provide assessment of foot perfusion and revascularization
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  when needed, and podiatrists contribute with
• 0:26
  assessment of the biomechanical factors causing
• 0:29
  or perpetuating the ulcer, and effective offloading.
• 0:33
  Hello, and welcome to the ESVS podcast. We're
• 0:37
  at the ESVS annual meeting held this time in
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  Istanbul, in Turkey. I'm sitting here with Professor
• 0:43
  Javier Pascual, podiatrist specialized in diabetic
• 0:46
  foot ulcer, and with whom I have the privilege
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  of working in the wound unit of the University
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  Hospital of Galdaca -Busanzalo in the Basque
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  Country, in the north of Spain. I convinced Javier
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  to come all the way to Istanbul to share his
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  knowledge in a session we have just held called
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  What the Vascular Surgeon Should Know About Basic
• 1:02
  Foot Biomechanics. The session was packed, the
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  audience was riveted, and of course... Us vascular
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  surgeons don't receive any specific training
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  on food biomechanics. And some basic knowledge
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  is key when dealing with diabetic foot ulcer,
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  isn't it? Yeah, yeah. Good morning. Nice to stay
• 1:21
  here. For me, it's a pleasure to attend your
• 1:24
  podcast. What you have told in the introduction
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  is true. Most ulcers we see in diabetic patients
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  have a mechanical origin or a mechanical component.
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  What we have learned in the past and recent years
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  is that probably reducing the mechanical stress
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  to the ulcers, it helps to the healing of the
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  ulcer. And not addressing that key issue can
• 1:49
  avoid the healing of the ulcer. Javier, you started
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  the session highlighting that most diabetic foot
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  ulcers are not located where we are usually told
• 1:59
  during residency that they are. Where do they
• 2:03
  happen? Yes. That is true, as the EURODIAL study,
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  which is the most important study performed here
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  in Europe, it showed that most foot ulcers do
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  not occur in the plantar area or the plantar
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  region, as they occur in the digits. So, 70 %
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  of ulcers that occur in the alveolar foot occur
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  in the digital area, also in the apex of the
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  toes, in the distal pump of the toe, in the dorsal
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  area, or in the digital leaf. Those are the lesions
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  that we see most in diabetic foot units. And
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  also plantar ulcers, they occur, but they are
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  only at 20 % of ulcers. In that sense, the aerodialysis
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  study broke with many previous beliefs we had
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  on diabetic foot. In the session, you next went
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  through three very specific clinical scenarios
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  that most vascular surgeons will encounter. and
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  that we often assess wrongly if we don't know
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  what you explained. Let's start with the first
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  one. An ulcer at the plantar tip of a toe. Why
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  do they happen? What should we look for? Ulcers
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  at the apex of the distal apex of the toe are
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  quite common in diabetic patients. They happen
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  because of the flexor tendon power. It contracts
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  in a stance phase of walking. So when we walk
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  or we stay in which varying situations on foot.
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  The flexotendons tend to contract. As long as
• 3:37
  the patient is getting more instability and older
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  patients are getting more and more instability,
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  flexotendon power, we know, is getting bigger
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  and bigger. And that's one of the reasons that
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  the patient develops a cloutal deformity, what
• 3:50
  we call a cloutal deformity, and also increase
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  the... stress on the tip of the toe. So in our
• 3:57
  experience this is one of the main reasons that
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  the patients develop an ulcer at the tip of the
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  toe. It can happen interestingly for me in ischemic
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  patients and in non -ischemic patients because
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  the mechanical problems also happens in the ischemic
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  patients. What should we do in those cases and
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  what shouldn't we do? Well Basically, the treatment
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  which nowadays we are implementing is to do what
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  we call a tenotomy, which is just to cut the
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  tendons. You can do it by an open approach or
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  a mini open approach or a mini invasive approach.
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  We do it in the office, usually with local anesthesia.
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  You don't need to go to the theater room. What
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  we do is to cut the tendon, both the flexor digitorum
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  brevis and flexor digitorum longus tendon in
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  that patient, that specific digit. It is quite
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  helpful measure to upload the digit. And results
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  are quite good. In the last year, several papers
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  have been published, six case series and one
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  randomized clinical trial showing its evidence.
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  Even international work in global diabetes will
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  recommend one of the new, in the last edition,
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  our recommendation is to perform that tenotomies
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  in those patients. So what we shouldn't do is
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  amputate those toes? Probably they can be avoided.
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  What we have learned is probably most of them
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  can be avoided. The second scenario. was an ulcer
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  at the fourth interdigital space. Painful, small
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  on the surface, but deep down inside. What is
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  that? That is a common lesion we as podiatrists
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  see in many patients. It's a pressure ulcer that
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  happens because of a mechanical component of
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  pressure. The phalanx of the fifth toe usually
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  presses very forcefully with the phalanx of the
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  fourth toe, and they usually cause an ulcer lesion.
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  It has many mechanical reasons. It can be a bad
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  fitting shoe. It can be the flexor tendons that
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  pulls obliquely. It could be the way the basin
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  is walking that is pressing the lateral side
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  of the foot of the shoe. But the mechanical origin
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  is always present in this kind of lesions. And
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  it is an ulcer that happens because two bones
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  are together crossing and pressing. And how should
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  that be managed? Well, from a mechanical point
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  of view, you can have a conservative measure
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  that is to change the shoe, even to broke the
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  shoe, that we do a lot in diabetic patients.
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  You can do a tenotomy also, the fito, but one
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  measure that is working and more lasting in our
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  experience in the long run. is to do an ulcer
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  bone resection of the head. So if you look at
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  that ulcer, they usually have a bone which is
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  protruding, which is making the contact or pressing
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  the other bone. What we do is a trans -ulcer
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  resection of the bone. We take the bone off,
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  and that is an offloading treatment that works
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  nicely in those patients. As long as blood flow
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  is enough. Until they granulate and close. Yes.
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  And that also reduces recurrence because that
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  bone collision is no longer there. Yeah, that's
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  true. And the last scenario was recurrent plantar
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  ulcers at metatarsal heads. A nightmare, especially
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  when one has been resected and then you get an
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  ulcer of the neighbor metatarsal head and then
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  the next one. You described a fairly new procedure
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  that tries to deal with this. Can you briefly
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  describe it? Yeah, this is what is called now
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  internal amputation. What we basically do is
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  when there are more than one metatarsal head
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  you need to take, the mechanical construct of
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  the forefoot is no longer stable and it's no
• 7:59
  longer predictable. So what we do in those cases
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  is to take all the metatarsal heads out and we
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  maintain the digits, which is also something
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  that the patients love it because they maintain
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  the digits. What we now are doing is constructing
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  a new metatarsal parabola formula that is sound
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  biomechanically and it can last longer than if
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  you do just one metatarsal or just two metatarsals.
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  There are some exceptions to this. For example,
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  fifth metatarsal head resection, they can be
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  performed alone. The recurrence rate now in the
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  literature is 8 -10%, which could be acceptable,
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  but it doesn't happen in other metatarsal heads,
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  such as first, second, or fourth, with recurrence
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  rates higher, reaching 40 and 45%, which are
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  unacceptable. In those cases, a complete metatarsal
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  head resection or internal amputation of the
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  fourth is a more viable option. What are the
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  recurrence rates that you know so far that happened
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  with this procedure? Well, we don't have robust
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  numbers right now. In my experience, I have performed
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  29 procedures like that. I have had three recurrences.
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  For me now, it's a fairly acceptable rate of
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  recurrence. The session was full of images and
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  photos that unfortunately cannot be conveyed
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  through a podcast. The session has been recorded
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  and will be uploaded in the ESVS library in a
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  few weeks. Free access for ESVS members. So if
• 9:40
  you are not a member yet, make sure to become
• 9:42
  one. Just this recording is well worth it. To
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  finish off this podcast, I can heartily recommend
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  to put a podiatrist in your wound unit, in your
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  clinical practice, in your professional life.
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  He or she is a key member in any team treating
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  diabetic foot ulcer. And learn from them. because
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  all this knowledge they have and we don't, and
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  we can acquire at least the basics. Any final
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  take -home message from you as well? I would
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  like to say that most of ulcers in diabetic feed
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  has a mechanical component. They happen in ischemic
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  patients and in non -ischemic patients. The mechanical
• 10:23
  component is key for these patients. And mechanical
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  treatment is unquestionable and a treatment that
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  can help greatly to those patients to heal. I
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  think that the combination of vascular surgeon
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  and podiatrist in the flow and tone model explain
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  this very clearly. And as blood flow is enough,
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  mechanical treatments can be implemented. both
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  together can construct a very strong relationship
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  and a good treatment for patients. Well, thank
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  you so much for the session today and for this
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  extra time you have invested in the SBS podcast
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  and you have shared with our listeners. I hope
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  you enjoy the rest of your stay here in Istanbul
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  and safe travel back home. Thank you so much.
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  Thank you so much, Melina, to you. My pleasure,
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  absolutely. It was my pleasure. Thank you all
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  out there for listening. It has been a pleasure
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  as always. More to come soon. Have a great week
• 11:23
  and bye for now. Goodbye.