Percutaneous Flexor Tenotomy--Office Procedure for Diabetic Toe Ulcerations

Nektarios Lountzis, MD; John Parenti, MD; Gerald Cush, MD; Maria Urick, CRNP, CWOCN; O. Fred Miller III, MD

Wounds. 2007;19(3):64-68. 

In This Article

Abstract and Introduction


Lesser toe deformities include, but are not limited to, hammertoes, mallet toes, and claw toes. In people with diabetes, these conditions can create pressure points and lead to callous and ulcer formation. Conservative treatment methods such as extra-depth toe box shoes, pads, inserts, and splints provide mixed results with inevitable recurrent ulcerations. Closed or percutaneous flexor tenotomy is a definitive corrective procedure for severe lesser toe deformities often complicated by ulceration in the insensate patient with diabetes. The authors illustrate this simple, office-based procedure in a step-by-step approach to correct these deformities and thereby offload pressures. The technique provides rapid healing and may prevent potential toe and lower extremity amputations.


Lesser toe deformities include, but are not limited to, hammertoes, mallet toes, and claw toes. These deformities are typically characterized by any combination of a plantarflexion deformity of the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints, and are commonly seen in adults with diabetes.[1] The pathophysiology appears to be multifactorial with a tendency to affect the second toe or less commonly the third toe.[2,3] The projection of the affected toe distal to the other digits can exert excess pressure and friction on either the toe pad and/or the DIP joints of the toe, especially in a shoe that has a narrow or short toe box. Over time, corns or callosities may form at these pressure points, and frequently in insensate patients with diabetes, subsequent ulceration.

Chronic nonhealing toe ulcerations often result in toe amputations. Postamputation foot dynamics are further altered and new pressure points lead to more ulceration and the possibility of subsequent foot or leg amputation. Typical conservative treatment methods, such as extra-depth toe-box shoes, pads, inserts, and splints must be continually employed and in the authors' experience in patients with diabetes, provide mixed results and recurrent ulcerations on these pressure points. Device expense, shoe wear compliance issues, and incorrectly applied techniques pose ongoing difficulties. Open flexor tenotomy has traditionally been the definitive corrective procedure used by many surgical sub-specialists for severe lesser toe deformities that are often complicated by ulceration when conservative treatment has failed.[4] This procedure not only corrects toe deformities, obviating the need for extra-depth shoes and orthotic devices, but also allows for rapid healing of the toe ulcerations after pressure has been relieved. Overall, the "percutaneous" procedure is simple, the outcomes are excellent, and the complications are minimal. The authors routinely perform closed or "percutaneous" flexor tenotomies in insensate patients with diabetes and the procedure—never described in an instructive fashion in the literature—can be performed during a routine office visit.


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