Decompressive Nerve Surgery Associated with Low Diabetic Foot Ulcer Rate and High-Risk Bias: A Systematic Review and Meta-Analysis.

Abstract

Diabetic sensorimotor polyneuropathy (DSPN) occurs in 50% of patients with diabetes mellitus (DM). Up to 70% of DM patients incur diabetic foot ulcers (DFUs). Of those with DSPN, 20% develop DFUs. Decompression nerve surgery (DNS) purportedly improves DSPN and DFU. As there is no accurate, pooled DFU incidence following DNS, the authors performed a systematic review and meta-analysis of DFU incidence following DNS. Given the 60% global DFU incidence, they hypothesized a lower, pooled DFU incidence following DNS. Two authors searched 6 databases from database inception to July of 2023 for DNS clinical studies. Primary tracked outcomes were new and recurrent DFU incidence following DNS. Included studies were clinical studies of adult patients with DM, DNS of the tibial nerve(s) at minimum, 3-month minimum follow-up, and reported new or recurrent DFU incidence following DNS. Nonclinical and nonhuman studies were excluded. The Grades of Recommendation, Assessment, Development, and Evaluation and Methodological Index for Non-Randomized Studies instruments were used to evaluate evidence. Using a random-effects model, a meta-analysis of DFU incidence was conducted. A total of 1074 studies were identified and 208 were screened. Thirteen studies yielded 2466 and 540 new and recurrent patients with DFU incidences of 1% and 5%, respectively. Primary studies had low-level evidence and high-risk bias, including selection bias. A subanalysis of sample size and follow-up length produced similar results. Further covariable analyses were precluded because of incomplete primary study data. Despite a low DFU incidence following DNS, clinical studies provide too low-level evidence and high-risk bias for any recommendations. Future randomized controlled trials may validate DNS for DFU management.