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Diabetes Watch

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

   Treatment of ulcers plantar to metatarsal heads with resection of the metatarsal head, metatarsal osteotomies and partial foot amputation all have high complication rates, including frequent transfer ulcers and amputation of the entire foot.27,31,32 Tendon lengthening heals more ulcers with fewer complications including fewer transfer ulcers and fewer amputations.2,16-28

   Tendon lengthening appears to be an effective treatment and is my treatment of choice for diabetic toe ulcers and ulcers plantar to metatarsal heads and the midfoot.2,16-28 If ulcers recur, one can repeat tendon lengthening with good success.17,24,25 Tendon lengthening also helps heal transmetatarsal amputations and arterial forefoot wounds.18,38-47

Can Tendon Lengthening Have An Impact For Charcot Foot?

In one study on Charcot arthropathy, researchers noted that 36 percent of patients who had non-operative treatment had a progression of the deformity and 37 percent of patients treated with conservative care went on to ulceration.48 Tendon lengthening (gastrocnemius-soleus recession) heals most midfoot ulcers and frequently prevents recurrence and progression of the deformity of Charcot arthropathy.17

   For these reasons, the recommendation that one use tendon lengthening (gastrocnemius-soleus recession) as the initial offloading treatment for Charcot arthropathy seems reasonable.49 In the few patients in whom tendon lengthening via gastrocnemius-soleus recession does not heal midfoot ulcers, or if the foot is unstable or too deformed for custom shoes and inserts, then surgeons can still perform bony procedures (exostectomy or fusion) later.

Further Insights On Tendon Lengthening And Gastroc Recession

General contraindications to Achilles lengthening and gastrocnemius-soleus recession are plantar heel ulcers, extensive necrosis and/or infection that necessitates amputation of the entire foot.

   Increased stress in the foot can also cause deformity and foot pain including corns, calluses, clawtoes, plantar fasciitis, posterior tibial tendinitis, arch collapse, foot and ankle arthritis, Charcot arthropathy, Achilles tendinitis, metatarsalgia, and first metatarsophalangeal arthritis.4,6-8,11,12,17,50-57 Tendon lengthening can help address foot pain and deformity from these conditions.4,6,7,11,14,27,47,50-56 Patients with diabetes have a higher complication rate with foot and ankle surgery.58 Tendon lengthening via gastrocnemius-soleus recession has an advantage over most other surgeries for foot pain in patients with diabetes since it has a low complication rate and can also prevent foot ulcers from developing in the future.8,29,30

How Tendon Lengthening Stacks Up When It Comes To Evidence-Based Medicine

Most of the literature on the treatment of diabetic foot problems involves case series and personal opinion. The evidence for tendon lengthening for foot ulcers plantar to the metatarsal head includes a Level I study.19 There are also Level II studies as well as Level IV studies for tendon lengthening for ulcers plantar to the metatarsal head.2,16,21,23,24,26

   There is lower Level IV evidence for tendon lengthening on plantar ulcers on the toes, midfoot and the distal end of transmetatarsal amputation stumps.17,18,23,25,27 There is similar Level IV evidence for the use of tendon lengthening for pain from plantar fasciitis, Achilles tendinitis, metatarsalgia.11,51,52,54-56 Finally, there are Level V studies on tendon lengthening for arthritis and posterior tibial tendinitis, and for tendon lengthening for calluses, corns, clawtoes and Charcot arthropathy.4,7,8,17,27,46,47,49,50,53

Final Notes

In my opinion, tendon lengthening should be included in the initial treatment for diabetic foot ulcers. Tendon lengthening may also be a helpful treatment for Charcot arthropathy, calluses and foot pain in patients with diabetes from other causes listed above.

   Dr. Laborde is an Assistant Professor of Orthopaedic Surgery and Director of the Foot Clinic at the Louisiana State University Health Sciences Center in New Orleans.

1. Rosenbloom AL, Silverstein JH. Connective tissue and joint disease in diabetes mellitus. Endocrinol Metab Clin N Am. 1996; 25(2):473-83.
2. Lin SS, Lee H, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients; the effect of tendo-Achilles lengthening and total contact casting. Orthopaedics. 1996; 19(5):465-474.
3. McGlamry ED, Kitting RW. Equinus foot. J Am Pod Assoc. 1973; 63(5):165-184.
4. Anderson JG, Maskill D, Bohay DR, Conaway. Gastrocnemius recession: effective remedy for recalcitrant foot pain. AAOS Now. 2007, Oct, p.10.
5. Subotnick SI. Equinus deformity as it affects the forefoot. J Am Pod Assoc. 1971; 61(11):423-7.
6. Barrett SL. Understanding and managing equinus deformities. Podiatry Today. 2011; 24(5):58-65.
7. Digiovanni CW, Langer P. The role of isolated gastrocnemius and combined Achilles contractures in the flatfoot. Foot Ankle Clin N Am. 2007; 12(2):363-79.
8. Armstrong DG, Shea SS, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg. 1999; 81-A(4):535-8.
9. Lavery LA. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. J Am Pod Med Assoc. 2002; 92(9):479-832.
10. Pinzur MS. Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int. 2007; 28(8):952-59.
11. Maskill JD Bohay DR, Anderson JR. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-22.
12. Habbu R, Holthusen SM, Anderson JG, Bohay DR. Operative correction of arch collapse with forefoot deformity. Foot Ankle Int. 2011; 32(8):764-73.
13. Landsman A, Cook E, Cook J. Tenotomy and tendon transfer about the foot. Clin Podiatr Med Surg. 2008; 25(4):547-69.
14. Sgarlato TE, Morgan J, Shane HS, Frenkenberg. Tendo-Achilles lengthening and its effect on foot disorders. J Am Pod Assoc. 1975; 65(9):849-71.
15. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Diabetes Care. 1990; 13(5):213-21.
16. Yosipovitch Z, Sheskin J. Subcutaneous Achilles tenotomy in the treatment of perforating ulcer of the foot in leprosy. Int J Leprosy and Other Mycobat Dis. 1971; 39(2):631-632.
17. Laborde JM. Midfoot ulcers treated with tendon lengthenings. Foot Ankle Int. 2009; 30(9):842-6.
18. Barry DC, Sabacinski KA, Habershaw GM, Giurin JM, Chrzan JS. Tendo-Achilles procedure for chronic ulceration in diabetic patients with transmetatarsal amputations. J Am Pod Med Assoc. 1993; 83(2):96-100.
19. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers, a randomized clinical trial. J Bone Joint Surg. 2003; 85A(8):1436-1445.
20. Nishimoto GS, Attinger CE, Cooper PS. Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration. Surg Clin N Am. 2003; 83(3):707-726.
21. Holstein P, Lohman M, Birtsch M, Jorgensen B. Achilles tendon lengthening, the panacea for plantar forefoot ulcers? Diab Met Res Rev. 2004; 20(S1):S37-40.
22. Strauss MB. The orthopaedic surgeon’s role in the treatment and prevention of diabetic foot wounds. Foot Ankle Int. 2005; 26(1):5-14.
23. Laborde JM. Tendon lengthening for forefoot ulcers. Wounds 2005; 17(5):122-130.
24. Laborde JM. Neuropathic plantar forefoot ulcers treated with tendon lengthening. Foot Ankle Int. 2008; 29(4):378-384.
25. Laborde JM. Neuropathic toe ulcers treated with flexor tenotomies. Foot Ankle Int. 2007; 28(11):1160-64.
26. Dayer R, Assal M. Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing. JBJS. 2009; 91B(4):487-493.
27. Laborde JM. Tendon lengthening for neuropathic foot problems. Orthopedics. 2010; 33(5):319-26.
28. Kearney TP, Hunt NA, Lavery LA. Safety and effectiveness of flexor tenotomies to heal toe ulcers in persons with diabetes. Diabetes Res Clin Pract. 2010; 89(3):224-6.
29. Rush SM, Ford LA, Hamilton GA. Morbidity associated with high gastrocnemius recession. J Foot Ankle Surg. 2006; 45(3):156-160.
30. Takahashi S, Shrestha A. The Vulpius procedure for correction of equinus deformity in patients with hemiplegia. J Bone Joint Surg. 2002; 84B(7):978-980.
31. Weiman TJ, Mercke YK, Cerrito PB, Taber SW. Resection of the metatarsal head for diabetic foot ulcers. Am J Surg. 1998; 176(5):436-441.
32. Fleischli JE, Anderson RB, Davis WH: Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int. 1999; 20(2):80-85.
33. Weiman TJ, Griffiths GD; Polk HC. Management of diabetic midfoot ulcers. Ann Surg. 1992; 215(6):627-30.
34. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse. Foot Ankle Int. 1996; 17(60):325-30.
35. Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. Diabetes Care. 1999; 22(5):692-5.
36. Saltzman CL, Zimmerman MB, Holdsworth RL, Beck S, Hartsell HD, Frantz RA. Effect of weight-bearing in a total contact cast on healing of diabetic foot ulcers. JBJS. 2004; 86A(12):2714-19.
37. Guyton GP. An analysis of iatrogenic complications of total contact cast. Foot Ankle Int. 2005; 26(11):903-7.
38. Claxton MJ, Armstrong DG. Addressing tendon balancing concerns in diabetic patients, Podiatry Today. 2003; 16(3):63-70.
39. Lafontaine J, Brown D, Adams M, VanPelt. New and recurrent ulcerations after percutaneous Achilles tendon lengthening in transmetarsal amputation. J Foot Ankle Surg. 2008; 47(3):225-229.
40. Schweinberger MH, Roukis TS. Surgical correction of soft-tissue ankle equinus contracture. Clin Pod Med Surg. 2008; 25(4):571-85.
41. Roukis TS. Flexor hallucis longus and extensor digitorum longus tendon transfers for balancing the foot following transmetatarsal aamputation. J Foot Ankle Surg. 2009; 48(3)398-401.
42. Schade VL. Key insights on adjunctive procedures with transmetatarsal amputations. Podiatry Today. 2011; 24(3):22-28.
43. Pinzur M, Kaminisky M, Sage R, Cronin R, Osterman H. Amputations at the middle of the foot. JBJS. 1998; 68A(7):1061-4.
44. Sage R, Pinzur MS, Cronin R, Preuss HF, Osterman H. Comlications following midfoot amputation in neuropathic and dysvascular feet. J Am Pod Med Assoc. 1989; 79(6):277-280.
45. Lieberman JR, Jacobs RL, Goldstock L, Durham J, Fuchs MD. Chopart amputation with percutaneous heel cord lengthening. Clin Orthop Rel Res. 1993; 296:86-91.
46. Clark GD, Lui E, Cook KD. Tendon balancing in pedal amputations. Clin Pod Med Surg. 2005; 22(3):447-67.
47. Shizard K. Lesser toe deformities. JAAOS. 2011; 19(8):505-13.
48. Fabrin J, Larson K, Holstein PE. Long term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care. 2000; 23(6):796-800.
49. DeHeer P, Borer B. Managing equinus in patients with diabetes. Podiatry Today. 2012; 25(3):68-75.
50. Roven MD. Tenotomy and capsulotomy for lesser toes. Clin Podiatry. 1985; 2(3):471-5.
51. Anderson JG, Habbu R, Bohay DR. Gastrocnemius recession for heel pain. Techniques Foot Ankle Surgery. 2011; 10(20)71-75.
52. Abbassian A, Kohls-Gatzoulis J, Solan MC. Release in the recalcitrant plantar fasciitis. Foot Ankle Int. 2012; 33(1):14-19
53. Thomas JL, Huffman L. Charcot foot deformity: surgical treatment options. Wounds. 2008; 20(3):67-73.
54. Gentchos CE, Bohay DR, Anderson JG. GSR as treatment for refractory Achilles tendinopathy. Foot Ankle Int. 2008; 29(6):620-3.
55. Laborde JM. Achilles tendon pain treated with gastrocnemius-soleus recession. Orthopedics. 2011; 34(4):289-91.
56. Duthon VB, Lubbeke A, Duc SR, Stern R, Assal M. Noninsertional Achilles tendinopathy treated with gastrocnemius lengthening. Foot Ankle Int. 2011; 32(4):375-9.
57. Kirane YM, Michelson JD, Sharkey NA. Contribution of the flexor hallicis longus to loading of the first metatarsal and the first metatarsophalangeal joint. Foot Ankle Int. 2008; 29(4):367-77.
58. Myers TG, Lowery NJ, Frykberg, Wukish DK. Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int. 2012; 33(1):20-28.

Diabetes Watch
J. Monroe Laborde, MD, MS
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