Tendon Lengthening: Is It A Viable Option For Forefoot Ulcers?
- Volume 18 - Issue 7 - July 2005
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I chose the Vulpius technique because of prior favorable experience using this technique in children with cerebral palsy. This technique allows immediate full weightbearing in a cast with less over-correction and incision problems.20 Takahashi and Shrestha successfully used the Vulpius procedure to correct equinus deformity of the ankle in 230 adults after cerebrovascular accident.27 The average age was 68 and 98 patients had diabetes. They had no wound or tendon problems and allowed standing in a brace (ankle foot orthosis) the next day.
When it comes to determining the TL technique for treating forefoot ulcers, it is up to the surgeon’s discretion. The addition of peroneus longus or posterior tibial and/or toe flexor lengthening may have been the reason for the lower ulcer recurrence rate (12 percent) in this study as compared to the 38 percent recurrence rate reported by Mueller, et. al.
The purpose of TL procedures is to decrease stress on the area of ulceration. Tenotomy of the toe flexor tendons decreases stress on the plantar surface of the toe. Peroneus longus lengthening should decrease pressure on the first metatarsal head and the posterior tibial lengthening should decrease pressure on the fifth metatarsal.
Lengthening the gastrocnemius-soleus mechanism should decrease stress on the entire plantar forefoot. Armstrong, et. al., confirmed that Achilles lengthening decreases pressure on the forefoot, recommending the procedure as an adjunctive therapeutic and prophylactic measure to reduce the risk of neuropathic ulceration.14 Performing TL prophylactically on these and other patients with prior ulcers, impending ulcers or progressive callus has shown no recurrences thus far.
Another study should determine if daily calf stretching can prevent calf tightness and progression to forefoot callus, forefoot ulceration and Charcot arthritis in patients with diabetes. Since calf stretching might help and probably would not harm patients with diabetes, it now seems reasonable to recommend prophylactic calf stretching to these patients.
The results of this series of patients suggest that lengthening of the tendon-muscle units is effective treatment for neuropathic forefoot ulcerations. Tendon lengthenings would not be expected to prevent amputation in patients with severe peripheral vascular disease and gangrene. However, by healing most forefoot ulcerations and lowering their recurrence rate, this procedure appears to lower the incidence of progression of forefoot ulceration to infection and subsequent amputation. A follow-up study to document these findings better with more patients and larger groups of different ulcer locations is underway.
Dr. Laborde is a Consulting Surgeon in the Department of Orthopedic Surgery at Touro Infirmary. He is a Clinical Assistant Professor of Orthopaedic Surgery at the Tulane University School of Medicine. Dr. Laborde is affiliated with the Louisiana State University Health Sciences Center in New Orleans, La.
Dr. Steinberg (pictured) is an Assistant Professor in the Department of Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.
This article was adapted with permission from the May 2005 issue of WOUNDS: A Compendium Of Clinical Research And Practice.