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

By J. Monroe Laborde, MD, MS

   Twenty ulcers were Grade 1 and 14 were Grade 2. Thirteen ulcers had associated cellulitis that was treated with antibiotics prior to surgery. Once the infection appeared to be under control, patients underwent TL. Five patients had one or more toes previously removed and three had one or more metatarsal heads removed. The ulcer duration prior to surgery ranged from one month to seven years (an average of 10 months in ulcer duration). Most patients had unsuccessful attempts to heal the ulcers with decreased weightbearing, debridement and shoe modification.

Strong Results, Little Recurrence

   Out of the 34 ulcers that were treated with TL procedures, 33 healed. All incisions healed primarily without any infections. Thirty-two of these ulcers healed within two months while the cuboid ulcer healed in five months. Pulses were not palpable in seven patients. One patient had no pulse, was on dialysis and the ulcer did not heal. He later developed gangrene of the foot and required a transfemoral amputation.

   There were four ulcer recurrences among the 33 healed ulcers. One patient with a recurrent toe ulcer agreed to undergo a toe TL and the ulcer healed. A transfer ulcer on the heel of another patient occurred when the patient got the cast wet and broke the heel of the cast and failed to return to the office immediately. This ulcer also healed. Two other patients had transfer ulcers in toes. Both healed after a toe tenotomy.

   No new deformities developed and no patient had development or progression of Charcot arthritis after the TL procedures. The follow-up ranged from 12 months to 81 months with the average follow-up being 36 months for the 34 ulcers. There were three complications in addition to the aforementioned ulcer recurrences. One patient had a pulmonary embolus more than three months after the first surgery but recovered completely. Another patient developed gangrene without a foot ulcer 12 months after surgery and had a transtibial amputation. Another patient had a traumatic open dislocation of her fifth toe and underwent a subsequent amputation.

What The Literature Comparison Reveals On Recurrence Rates And Complications

   Ulcer recurrence rates for all groups in this study were much lower than the previously reported recurrence rates in patients with no surgery and TCCs with and without subsequent Achilles lengthening.16,23

   Yosipovitch and Sheskin and Lin, et. al., previously reported the association of gastrocnemius-soleus contracture, neuropathy and chronic ulceration of the forefoot in this group of patients.11,18 The high rate of successful healing of forefoot ulcers after Achilles lengthening in these studies, seven of eight (88 percent) and 14 of 15 (93 percent) respectively, was similar to the success rate in our study: 33 of 34 (97 percent).11,18

   In regard to the ulcers that did recur in our study, three were on the first toes. The first toe ulcers may have recurred because the short flexors were not cut in a percutaneous tenotomy at the proximal phalanx in the first toe whereas both short and long toe flexors were cut in the other toes. Both short and long first toe flexors are now cut percutaneously with no recurrences thus far. Another patient experienced an ulcer recurrence at the third metatarsal head but this may have been partially related to a prior first ray amputation.

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