Foot surgery without anesthesia in diabetic patients with sensory neuropathy: A short series

Diabetic foot ulceration frequently involves foot surgery to accomplish wound healing. Anesthesia is invariably imposed, despite increased risks specific to diabetes. Conversely, debridements and wound explorations with firm tissue manipulation are regularly performed in diabetic foot clinics without anesthesia, as many patients are impervious to pain because of an insensate foot due to neuropathy.
In this study, we hypothesized that patients with advanced sensory neuropathy would be able to undergo anesthesia-free foot surgery with minimal pain or discomfort. Patients were deemed eligible only if they had not experienced any pain during prior debridement. Pain was assessed with a visual analog scale after debridement, in rest before surgery, during and after the operation. Patients agreed to commence surgery without anesthesia but that optional anesthesia would be provided if pain arose. Patient experience and satisfaction was assessed a posteriori by survey with closed and open questions.
Twenty-two patients underwent a variety of surgical procedures: amputations, metatarsal head resections, debridement, skin grafting, delayed primary closure and orthopedic corrections. Seventeen procedures went uneventful but five required additional local anesthesia. Patient satisfaction was high, and participants particularly appreciated early re-alimentation and mobilization, early transfer and discharge.
Our findings suggest that foot surgery without anesthesia is well tolerated in the insensate foot. Additional local anesthesia was rarely required to alleviate emerging discomfort or pain, and allowed all procedure goals to be met. All associated risks and side effects of high level anesthesia are effectively nullified when not resorting to anesthesia at all.

Publication year:2022

Keywords:anesthesia-free, diabetic foot, insensate, minor amputation, sensory loss, wound care