Is Tendon Lengthening The Best Treatment For Diabetic Foot Ulcers?
Diabetic neuropathy results in tendon imbalance and decreased protective sensation.1,2 Tendon imbalance, especially Achilles or gastrocnemius-soleus tightness, causes or aggravates most foot problems.3-7 Achilles tendon or gastrocnemius-soleus tightness causes increased stress in the foot.8,9 This stress can cause a callus and a subsequent forefoot ulcer.8 Increased stress in the foot less commonly leads to the progressive deformity of Charcot arthropathy, most often in the midfoot. Midfoot Charcot arthropathy progresses from arthritis, ligamentous instability and/or fracture to arch collapse and/or subluxation. This in turn may lead to a midfoot plantar bony prominence and the possible development of a midfoot ulcer.10
Multiple authors have stated that tendon imbalance correction, particularly Achilles or gastroc-soleus tightness correction, can help address most foot problems.3-7,11-14 Accordingly, let us take a closer look at tendon lengthening in comparison to other forms of treatment for diabetic foot problems.
Foot ulcers commonly become infected and lead to amputation. Approximately 85 percent of patients with diabetes who undergo amputation have foot ulcers.15 Healing foot ulcers and preventing their recurrence could prevent most amputations in patients with diabetes. Foot ulcer treatment consists of managing infection, arterial problems and high stress in the foot.
We can treat infection with antibiotics and debridement. If the patient lacks both pedal pulses, vascular evaluation and treatment are recommended. Tendon lengthening can decrease stress in the foot.8
Achilles tendon or gastrocnemius-soleus lengthening can be helpful in primary or adjunctive treatment for most foot problems and usually heals foot ulcers.2,7-28 Treatment of foot ulcers with tendon lengthening has good support in the literature, both for healing ulcers and preventing recurrence.2,16-28 I previously published a detailed literature review on tendon lengthening for diabetic foot problems.27
When it comes to plantar toe ulcers, one may perform percutaneous flexor tenotomies. Surgeons may perform a gastrocnemius-soleus recession to help address diabetic ulcers plantar to the metatarsal heads or midfoot. One would add posterior tibialis tendon lengthening to gastrocnemius-soleus recession for ulcers plantar to the fifth metatarsal, and add peroneus longus lengthening for ulcers plantar to the first metatarsal.
Gastrocnemius-soleus recession results in fewer new postoperative heel ulcers than Achilles tendon lengthening.27,29 Tendon lengthening in the calf has fewer complications than bony procedures in the foot and ankle, especially if the patient has diabetes and/or has no pedal pulses.17,30-34 Tendon surgery seems preferable to bony procedures in those with diabetes, smokers and patients with foot ulcers, infection and/or without pedal pulses.
Comparing The Efficacy Of Tendon Lengthening To Other Treatments
Tendon lengthening heals more ulcers than wound care and total contact casting (TCC).27,35,36 A meta-analysis revealed that “good” wound care healed only 31 percent (142/458) of diabetic foot ulcers in five months.35 Total contact casts healed an average of 80 percent of diabetic foot ulcers.36 According to a literature review, over 90 percent of ulcers heal after tendon lengthening.27
Tendon lengthening has fewer complications and a much lower recurrence rate than TCC.19,27,29,30,37 Guyton reported a 30 percent complication rate with TCC.37 Mueller reported an 81 percent (21/26) recurrence of diabetic foot ulcers in two years after healing with TCC.19