|2009 Annual Meeting Abstracts
Tendo-Achilles Lengthening: Friend or Foe in the Diabetic Foot
Lawrence Colen, M.D.1, Jiun-Ting Yeh, M.D.2, Theodore Uroskie, M.D.1, William Grant, D.P.M.3.
1Norfolk Plastic Surgery, Norfolk, VA, USA, 2Chang Gung Memorial Hospital, Taipei, Taiwan, 3Tidewater Foot and Ankle, Virginia Beach, VA, USA.
PURPOSE: While various researchers have implicated the equinus deformity as a major deforming force in the pathophysiology of the diabetic foot, the role of tendo-achillles lengthening surgery in preventing recurrence after forefoot and midfoot soft tissue repair for neurotrophic ulceration remains unclear. This study looks at the rate of recurrent ulceration in patients that have undergone soft tissue repair of the diabetic forefoot and midfoot with and without concomitant tendo-achillles lengthing procedures.
METHODS: Diabetic patients with plantar midfoot or forefoot ulceration that underwent soft tissue reconstruction to obtain a healed wound were included in our retrospective study. Chart review and review of our diabetic foot registry provided the necessary data for comparison. From 1983 to 1991 patients underwent wound closure procedures without simultaneous Achilles tendon lengthening surgery. From 1996 to 2004 all such patients were offered tendo-achilles lengthening as part of their reconstructive treatment plan provided their preoperative evaluation showed tightness of the Achilles. Patient demographics and comorbidities were identical in each of the two groups. Resection of bony prominences was performed in each of the two groups. All patients were followed an average of 2.9 years (range 1 to 7 years). Patients that had their Achilles tendon lengthened were evaluated with computerized gait assessment techniques before and after their surgery.
RESULTS: During the "early" timeframe 149 patients were operated upon. During the "later" timeframe 138 patients underwent similar wound closure techniques with the addition of Achilles tendon lengthening surgery. Local flaps were employed in 86% of patients, transmetatarsal/midfoot amputations in 7%, ray resections in 4% and free tissue transfer in 3%. Ninety-eight percent of patients during the "later" timeframe underwent tendo-achilles lengthening. Ulcer recurrence rates were 25% in the "early" group and 2% in the "later" group. Two patients in the "later" group developed plantar heel ulceration during the follow-up period.
CONCLUSION: Tendo-achilles lengthening significantly reduces the incidence of recurrent plantar forefoot and midfoot ulceration when performed at the time of soft tissue repair in the diabetic foot. It should be considered an integral part of the surgical treatment plan. Proper attention to operative technique is critical as over-lengthening of the Achilles tendon will contribute to "calcaneal gait" which may predispose the patient to future plantar heel ulceration.