Tendon Lengthening: Is It A Viable Option For Forefoot Ulcers?

By J. Monroe Laborde, MD, MS

   When it came to metatarsal head ulcers, we performed lengthening of the gastrocnemius-soleus mechanism. Using the Vulpius technique, we transected the proximal tendon of the gastrocnemius muscle and underlying aponeurosis of the soleus muscle in the mid-calf.20 Peroneus longus (z-type) lengthening for first metatarsal ulcers and posterior tibial (intramuscular) lengthening for fifth metatarsal and cuboid ulcers improved varus-valgus alignment. We proceeded to place the patient’s ankle in a neutral position in a short leg walking cast for six weeks bearing full weight. The Vulpius procedure lengthens the gastrocnemius tendon and soleus aponeurosis proximal to the actual Achilles tendon. Both the Vulpius procedure and Achilles TL increase ankle dorsiflexion in a similar manner.

   For toe ulcers, the physicians in the study performed a toe flexor tendon tenotomy percutaneously at the proximal phalanx. Patients usually underwent toe tenotomy in the office whereas patients usually underwent the calf surgery on an outpatient basis. Due to a higher recurrence rate of first toe ulcers, physicians recommended both calf and toe procedures to patients with first toe ulcers. Patients bore full weight on the operated side and left the hospital the day of surgery unless they were in the hospital for another reason.

   The physicians involved in the study measured the amount of active ankle dorsiflexion with the knee in full extension preoperatively with a goniometer. They measured pulses via palpation of the dorsalis pedis and posterior tibial arteries. All patients without pulses received referrals for evaluation and treatment by a vascular surgeon but none of these patients were considered candidates for vascular surgery.

Using the Wagner classification, physicians graded ulcers as follows:

   Grade 1: superficial;
   Grade 2: deep, extending to ligament, tendon, joint capsule, fascia or bone;
   Grade 3: Grade 2 with infection (abscess, osteitis or osteomyelitis);
   Grade 4: gangrene of the toe or forefoot; and
   Grade 5: gangrene of the entire foot.

   Grade 3 to 5 ulcers were not included in the study unless the physicians could convert Grade 3 ulcers to Grade 1 or 2 ulcers with antibiotics.21 Some patients with prior ulcers and infections had been treated in the past by other physicians with amputation of toes and/or metatarsal heads but were not excluded from this study. If patients were unable to feel the 5.07 nylon monofilament in multiple areas without callus or ulcer on the plantar foot, researchers considered these patients neuropathic.22

   Employing the monofilament test, the researchers noted that all 24 patients who agreed to undergo the TL procedure had neuropathy. Twenty had diabetes mellitus, two had lumbar radiculopathy, one had hemiplegia and one had alcoholism. The patients’ ages ranged from 33 to 81 at the time of surgery with an average age of 60. There were 11 males and 13 females.

   Researchers treated 34 ulcers, which included 17 metatarsal ulcers (14 metatarsal head ulcers), 11 first toe ulcers, five lesser toe ulcers and one cuboid ulcer. All patients had calf tightness with inability to dorsiflex the ankle beyond 10 degrees with the knee extended and the average active dorsiflexion was -6 degrees for the 34 ulcers.

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