What A New Study Reveals About Tendon Lengthening For Diabetic Plantar Foot Ulcers

Monroe Laborde, MD

Presenting the results of a recent retrospective study and offering a review of the related literature, this author says tendon lengthening compares favorably to other modalities in terms of efficacy and reduced complications.

Foot ulcers are a common cause of infection and amputation in patients with neuropathy. Diabetes is the most common cause of neuropathy.1 The treatment of foot ulcers with tendon lengthening has good literature support.2-15 Ulcers from types of neuropathy other than diabetes seem to respond in the same way to tendon lengthening.2,12,13

   Pecoraro and colleagues reported that 84 percent (67/80) of amputations in patients with diabetes were preceded by foot ulcers.16 The prevention or cure of foot ulcers could potentially prevent most of these amputations.

   The treatment of foot ulcers from diabetes and other causes of neuropathy consists of managing infection, arterial insuffiency and high plantar pressure in the foot. Neuropathy causes decreased sensation and tendon tightness.2,4,6 Increased pressure from tendon tightness causes foot ulcers.4,5

   Tendon lengthening decreases plantar pressure in the foot.5 Various researchers have demonstrated that tendon lengthening is successful in healing and preventing recurrence of forefoot and midfoot ulcers with a low complication rate.2-15 With this in mind, let us take a closer look at a retrospective study of tendon lengthening for patients with diabetic neuropathic ulcers of the forefoot and midfoot. This study involves a larger number of patients and longer follow-up in comparison to previously reported studies.

Reviewing The Methodology And Protocol Of The Study

Between 1995 and 2006, I performed tendon lengthening for 105 consecutive patients with 130 plantar foot ulcers. The ulcers were months to years in duration with patients receiving previous non-operative treatment elsewhere. For this study, I included all plantar foot ulcers (from diabetes and other causes of neuropathy without gangrene (Wagner types I, II and III).17 The most common type of diabetic foot ulcer in this study was a Wagner type II. Most patients had a pedal pulse. I did include in the study patients who didn’t have a pedal pulse and sent them for vascular evaluation. No patients had vascular surgery either because their disease was too mild or it was not correctable.

   Patients with toe ulcers underwent a percutaneous toe flexor tenotomy at the level of the proximal phalanx. Those with ulcers plantar to metatarsal heads had a gastrocnemius-soleus recession. I cut the gastrocnemius tendon and soleus fascia transversely in the mid-calf just distal to the gastrocnemius muscle. I subsequently stretched the soleus muscle about 2 cm. in the operating room by dorsiflexing the ankle. Usually, I did not debride the ulcers and only removed bone for osteomyelitis in two patients with metatarsal head ulcers. I usually changed dry sterile dressings on a weekly basis.

   I added peroneus longus tendon lengthening for first metatarsal ulcers and posterior tibial tendon lengthening for fifth metatarsal ulcers. I cut the peroneus longus tendon in a Z fashion to lengthen it about 2 cm, and subsequently repaired it with 0 suture. The incision was vertical and 2 inches long, 2 to 4 inches proximal to the tip of the lateral mallelous. I lengthened the posterior tibial tendon about 1 cm. by cutting fascia over the muscle and everting the foot to stretch the muscle. The incision for this was vertical and 2 inches long, 4 to 6 inches proximal to the tip of the medial mallelous. I also performed a gastrocnemius recession for patients with midfoot ulcers.

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