Tendon Lenthenings for Forefoot Ulcers

J. Monroe Laborde, MD, MS

Disclosures

Wounds. 2005;17(5):122-130. 

In This Article

Abstract and Introduction

The objective of this study was to determine if plantar forefoot ulcers would heal and not recur if treated with tendon lengthenings. Patients with neuropathy (usually from diabetes mellitus) and plantar forefoot ulcers were treated with tendon lengthening and followed. Of 34 forefoot ulcers treated with tendon lengthenings, 1 did not heal, and 4 recurred at the same location by 36 months average follow-up. Three patients developed transfer ulcers at other locations on the foot. Two patients subsequently required leg amputation for gangrene (1 transfemoral and 1 transtibial). No amputations were completed for progressive infection from ulcers. Tendon lengthening appears to be an effective treatment for neuropathic plantar forefoot ulcers.

Approximately 3% of the United States population have diagnosed diabetes mellitus.[1] Diabetic foot problems, however, are the leading cause of amputation.[2,3] The risk of amputation is 15 times greater in patients with diabetes than other people.[2] Up to 15% of patients with diabetes will require amputation.[1,3] Over 50,000 amputations in patients with diabetes occur annually in the US.[4] In 1 study of patients with diabetes mellitus, 84% of lower-extremity amputations (67/80) were preceded by foot ulcers.[2]

Among people with diabetes, about 15% will eventually have foot ulcers.[1,5] In the absence of large-vessel disease, diabetic forefoot ulcers result from the combination of neuropathy and abnormal mechanical stress.[1,6,7] Deformity that increases stress on a portion of the foot can instigate ulceration in a patient with diabetic neuropathy.[1,6,7] Peripheral neuropathy results in the loss of protective sensation and a lack of recognition of repetitive mechanical stress, which often cause forefoot ulcers in patients with diabetes.[1,7]

Diabetic motor neuropathy[7,8] and glycosylation of collagen[7] may contribute to calf tightness and decreased dorsiflexion of the ankle, which increase pressure on the forefoot. The high forefoot pressure is consistent with the most common locations of foot ulcers, which are the plantar surface of the metatarsal heads and the hallux.[7,8]

Foot ulcers can cause deep spreading infection, which can result in leg amputation.[5,9] Prevention and cure of foot ulcers should prevent most leg amputations in patients with diabetes.[8]

Patients who have experienced previous foot ulceration have abnormally high pressures at healed ulcer sites.[10] Plantar foot ulcers occur at sites of high pressure.[7,11] The combination of neuropathy and decreased ankle dorsiflexion has been implicated in the cause of forefoot ulcers.[7,12,13] Reducing the risk of neuropathic ulceration of the forefoot should be accomplished by decreasing pressure on the forefoot.[10] Pressure relief has been accomplished by shoe modification, total contact casts, and Achilles tendon lengthening (TL).[9,14]

Total contact casting (TCC) is an effective technique for healing diabetic neuropathic foot ulcerations.[5,15,16] However, 20% (20/102) to 81% (21/26) of the ulcers healed by TCC have recurred in 2 years.[15,16]

Achilles TL promotes healing of chronic foot ulcers in patients with neuropathy (Figures 1 and 2).[12,17,18] Healing occurred in patients who did not heal by TCC and with fewer ulcer recurrences than ulcers healed by TCC.[17] Dorsiflexion metatarsal osteotomy also is effective in healing chronic neuropathic forefoot ulcers but has a much higher complication rate.[19]

Typical neuropathic forefoot ulcer before tendon lengthening (gastrocnemius-soleus and posterior tibial).

Same patient's foot 2 months after tendon lengthening.

Healing of forefoot ulcers and prevention of ulcer recurrence and amputation caused by ulcers are important objectives for those who manage patients with neuropathic forefoot ulcers. This report describes the results of a group of patients who had forefoot ulcers treated with TLs.

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