Can Curative Foot Surgery Facilitate The Healing Of Diabetic Foot Ulcers?
Up to 25 percent of people with diabetes will develop a foot ulceration at some point during their lifetimes.1 There are a number of component causes that interact to complete the causal pathway to foot ulceration. However, the most frequent component causes are peripheral neuropathy, deformity and trauma.2,3
Deformity leads to increased plantar pressures and when these are combined with sensory neuropathy, ulcer formation is likely. Therefore, one must consider foot deformities as a possible cause for all foot ulcers.
There have been many new, exciting advances in the treatment of diabetic foot ulcerations. However, it is the fundamentals of care that one must prioritize. The basic, fundamental aspects of care include infection control, debridement and offloading. It is also important to ensure adequate limb perfusion and determine if there is an ischemic component to the wound.
Proper offloading is an essential component in the overall care of patients with diabetes but this is often overlooked. Adequate offloading starts with recognition of underlying deformities and subsequent implementation of a pressure reduction plan. Adequate pressure reduction may occur extrinsically through casts or specialized boots, or intrinsically through surgery.4 The gold standard for non-surgical offloading of the foot is the total contact cast.5 When it comes to the non-infected, non-ischemic, plantar neuropathic foot ulcer, researchers have reported the effectiveness of total contact casting with healing rates ranging from 72 to 100 percent.6
However, a total contact cast does not correct the underlying fixed deformity and one study showed an 81 percent ulcer recurrence rate after two years.7 In situations in which there is a deformity that prevents the efficacy of short and long-term solutions, surgical intervention is warranted. Researchers have described various surgical procedures to assist in ulcer healing. These “curative”-type procedures are designed to augment healing and reduce the risk of ulcer recurrence.8
Limited ankle joint mobility, as one may see clinically as a tight Achilles-gastrocnemius-soleus complex, is a deforming force that physicians must consider as a causative factor in plantar forefoot ulcerations. During normal gait, 10 degrees of dorsiflexion of the foot is required. Less than this will increase plantar pressures in the forefoot and impede healing of the wound.
Weighing The Pros And Cons Of Percutaneous TAL And Gastrocnemius Recession
To alleviate the forefoot pressure, several authors have suggested percutaneous tendo-Achilles lengthening (TAL).9-12 Armstrong and co-workers confirmed that plantar pressures are reduced after percutaneous TAL.13
Lin and colleagues performed a percutaneous TAL on 15 patients with foot ulcers that were resistant to healing with conservative care. All but one ulcer healed and there was no ulcer recurrence after a mean 17.3-month follow-up.14
Mueller and colleagues conducted a randomized control trial of 64 patients, comparing the combined treatment of total contact cast and percutaneous TAL against a total contact cast alone.7 Healing rates were higher in the tendon lengthening group (100 versus 88 percent). However, the dramatic difference was in the recurrence rate. After two years, there was an 81 percent ulcer recurrence rate in the group treated with a total contact cast alone in comparison with 38 percent in those treated with a total contact cast and TAL.7