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

Monroe Laborde, MD

   Postoperatively, I allowed patients full weightbearing in a removable cam walking boot for six weeks with a subsequent transition into diabetic shoes. Diabetic shoes are extra-depth, oxford-type shoes with custom inserts. Only patients with midfoot ulcers had a custom-molded insert inserted into the boot for six weeks prior to the diabetic shoe.

   I reviewed the charts in a retrospective fashion. If I had not seen the patients for more than two years after surgery, I asked them to return for follow-up. If they returned, I observed their gait and examined their feet for recurrent ulcers, deformity, amputation or other problems. If the patients would not return, I questioned them on the phone regarding recurrence and complications. Phone questioning included whether they had any problems after tendon surgery and ulcer healing such as ulcer recurrence, other wounds or subsequent surgery, amputation, deformity, weakness or gait problems.

A Closer Look At The Retrospective Study Results

I lost 30 patients to follow-up, leaving 100 ulcers in 75 patients. The last follow-up was for a person who had 14 toe ulcers, 15 metatarsal head ulcers and five midfoot ulcers. The last follow-up on the remaining patients was by phone. All patients had over two years follow-up unless they died or had an earlier amputation. Patients who died or had an amputation before two years of follow-up were included in the calculation of average follow-up. There were 46 toe ulcers, 44 metatarsal ulcers and 10 midfoot ulcers. Six patients had more than one type of ulcer.

   The average follow-up for 46 toe ulcers in 31 patients was 39 months. Pedal pulses were palpable in 27 patients and 26 patients had diabetes. All ulcers healed in less than two months (see Figure 1). No lesser toe ulcers recurred. Three first toe ulcers recurred but healed again after repeat tenotomy for the ulcer recurrence. Two patients had major amputations for gangrene and four patients died. These patients were included in the average follow-up.

   The average follow-up for 44 ulcers plantar to metatarsal heads in 40 patients was 38 months. Pedal pulses were palpable in 34 patients and 37 patients had diabetes. Only one of these ulcers did not heal. The ulcers that healed did so in less than two months. Seven ulcers recurred but healed again if patients had repeat tendon lengthening for ulcer recurrence. There were eight forefoot transfer ulcers, four toe ulcers and four metatarsal head ulcers, all of which healed after tendon lengthening. One patient had a major amputation for gangrene, four patients died and three patients developed heel ulcers. Two of the heel ulcers were posterior and one was a plantar heel ulcer. The superficial plantar heel ulcer healed with a few weeks of wound care.

   The average follow-up for 10 midfoot ulcers in 10 patients was 31 months. Pedal pulses were usually not palpable because of swelling from Charcot arthropathy. Nine patients had diabetes. Nine ulcers healed in less than four months and none recurred. In addition to tendon lengthening, one patient had an exostectomy and one patient had a midfoot fusion. If those two patients were excluded, seven of eight ulcers healed and none recurred. Two patients had amputation for gangrene and one died. They were included in the average follow-up.

   The overall results of this study, at an average follow-up of 38 months, revealed that a total of 98 percent (98/100) ulcers healed, 10 percent (10/98) ulcers recurred, 11 percent (11/98) transfer ulcers including 2 posterior heel ulcers, 1 percent (1/98) plantar heel ulcer, 7 percent (5/75) of the patients had amputation, and 12 percent ( 9/75) died. All amputations were for gangrene, which developed after ulcer healing because of ischemia. None of these amputations were due to infection from ulcers. Deaths were caused by medical problems but were not due to post-operative complications. There were no incision problems, no new foot wound infections, no new Charcot arthropathy and no progression of midfoot deformity after tendon lengthening.

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