SLR - October 2012 - Deena Horn
Reference: Kim JY, Hwang S, Lee Y. Selective Plantar Fascia Release for Nonhealing Diavetic Plantar Ulcerations. J Bone Joint Surg Am. 2012; 94: 1297-302
Scientific Literature Review
Reviewed by: Deena Horn, DPM
Residency Program: Inova Fairfax Hospital
Podiatric Relevance:
Diabetic foot ulcerations secondary to neuropathy, vasculopathy and many other factors occur in approximately 15 percent of all patients with a diagnosis of diabetes over their lifetime. As podiatric physicians, it is our goal to prevent primary and further breakdown, by preventive medicine and aggressive wound measures. Many surgeons perform an Achilles tendon lengthening procedure in order to reduce plantar pressure. This article presents a new technique, selective plantar fascia release (SPFR), as an alternative to Achilles tendon lengthening to manage diabetic ulcerations.
Methods:
A preliminary cadaveric study was performed using five fresh frozen cadaveric feet in order to determine the best incision that was determined to be at the level of Lisfranc joint, due to the distance from the neurovascular bundle. Sixty feet met the inclusion criteria consisting of diabetics, prior nerve conduction test, plantar forefoot ulceration at the tip of the toe, IPJ or MTP joint. The dorsiflexion angle of the affected MTP joint was measured preoperatively and postoperatively. A paired T-test was used to assess differences between preoperative and postoperative passive dorsiflexion of the MTP joint.
Results:
The mean follow-up was 23.5 months. In six weeks, 67 percent of patients' forefoot ulcerations healed. However, 15 out of the 20 patients that did not heal showed anklyosis and destructive changes at the MTP joint. There was a significant difference in dorsiflexion range of motion, with an increase of 15 degrees after surgery.
Conclusion:
Achilles tendon lengthening, even though the recommended procedure for plantar ulcerations, do not heal 30 percent to 42 percent of ulcerations. It is believed that windlass effect of the selected toe is weakened after the SPFR, and the pressure under the metatarsal head and the digit is weakened. Selective plantar fascia release is a quick and simple procedure and found wound healing in 67 percent of patients. This procedure can be used in diabetic patients to heal neuropathic plantar forefoot ulcerations without complications, however an Achilles tendon lengthening procedure may still be optimal for patients with an arthritic MTP joint.