Addressing Tendon Balancing Concerns In Diabetic Patients

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Continuing Education Course #106 — March 2003

I am very pleased to introduce the sixth article, “Addressing Tendon Balancing Concerns In Diabetic Patients,” in our new CE series. This series, brought to you by HMP Communications, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

As Matthew J. Claxton, DPM and David G. Armstrong, DPM, point out, it can be a challenge to perform tendon balancing procedures in patients with diabetes. In this article, they discuss the etiology of muscle imbalances, key indications and a few pertinent pearls for performing various tendon balancing procedures.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications.

This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 64 and successfully answering the questions on pg. 70. Use the postage-paid card provided to submit your answers or log on to www.podiatrytoday.com and respond electronically.
ACCREDITATION: HMP Communications, LLC is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by HMP Communications, LLC are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Claxton and Armstrong have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by HMP Communications, LLC. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: March 2003.
EXPIRATION DATE: March 31, 2004.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• recognize the indications for tendon balancing in diabetic patients;
• employ tendon balancing in different amputation procedures;
• describe the impact of equinus and equinovarus deformities; and
• discuss key pearls for performing an Achilles tendon lengthening.

Sponsored by HMP Communications, LLC.

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Here is a close-up view of a plantar ulceration secondary to increased forefoot pressure.
The authors observed increased dorsiflexion in this patient after they completed an Achilles tendon lengthening.
Here the authors identify the peroneal tendons for a later transfer.
Here is a view of a completed Chopart amputation using peroneal tendons for transfer. As you can see, a medium hemovac has been placed into the dead space.
70
Author(s): 
By Matthew J. Claxton, DPM, and David G. Armstrong, DPM

Foot ulcers are the major risk factor for amputation among people with diabetes. Fifteen percent of people with diabetes will experience a foot ulcer. In this particular patient population, 14 to 24 percent will require lower extremity amputation.1 Loss of protective sensation and repetitive mechanical trauma (high foot pressures) are the major causes of diabetic foot ulceration.2,3
As per the ADA consensus report, the plantar forefoot is the most common location for foot ulcers.1 The underlying source of forefoot ulceration is increased forefoot pressure that results from pathologic gait patterns and structural deformity.4,5
So when it comes to prophylaxis of foot complications in the non-ulcerated neuropathic foot and for the cure in the ulcerated foot that cannot be appropriately accommodated externally by shoes and or braces, the goal is to control the foot deformity internally via reconstruction or amputation and accommodation.
The trend in recent years for any elective or non-elective foot surgery has been to focus upon osseous structures in order to maintain the correction. It is well known that soft tissue correction, such as tendon lengthening or transfer as an isolated procedure, will have a high rate of failure due to progressive contracture postoperatively. While osseous procedures are generally required for rigid deformity, it is also true that isolated osseous procedures that do not address soft tissue contractures in diabetic foot surgery will also lead to overall failure.5
While there are tendon balancing procedures that are recommended for the neurologically intact foot as well as the insensate foot, it’s important to have a strong understanding of the role of muscle imbalances as they relate to diabetic foot pathology.

How Muscle Imbalances Come Into Play
Diabetic polyneuropathy is a frequently encountered complication in the lower extremities.6 Polyneuropathy has sensory, autonomic and motor components. Anterior leg weakness and intrinsic muscle atrophy of the foot are the result of motor neuropathy. When peroneal nerve atrophy is present, be aware that is a contributing factor in allowing the posterior muscle groups to gain a mechanical advantage over the weak anterior muscles.7 You may also attribute gait and balance disturbances to the degradation of muscle proprioception.8 Van Gils, et. al., offer an in-depth discussion of the pathological biomechanics associated with the diabetic foot.7

Non-enzymatic glycosylation of soft tissues has also been implicated in diabetic complications, although this was not necessarily limited to the lower extremity.9-11 When researchers examined collagen fibers under electron microscopy, they found that the fibers had increased packing density, decreased diameter of fibers and abnormal morphology of fibrils in the Achilles tendons of diabetics who had concomitant gastroc-soleus equinus. These factors all contribute to tightening and contracture of the Achilles tendon.12 Glycosylation of the flexor tendons of the foot was reported by Ramirez, et. al.13
Cheiroarthropathy, a syndrome of limited joint mobility associated with diabetes, has been observed as a frequent and early complication of diabetes.7 This condition, which is more common in the upper extremities, has been described in the lower extremities as well.14-16 This syndrome has been associated with the other well-known complications of diabetes, including cardiovascular disease, retinopathy and nephropathy.17 Long-term glycemic control, as measured by hemoglobin A1C (HbA1C), demonstrates close correlation with limited joint syndrome. The risk of cheiroarthropathy increases by 250 percent for each 1 percent increase in HbA1C over 8 percent.18
While complications in the diabetic foot may be attributed to different tendinous and bony pathology, equinus and equinovarus foot position are two of the most important and commonly encountered pre- and post-surgical foot deformities. (See “Understanding The Impact Of Equinus And Equinovarus Deformities” on page 66)

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