SLR - September 2013 - Mieasha Hicks
Reference: Colen LB, Kim CJ, Yeh J, Hind B. Plast Reconstr Surg. 2013; 131:37e-43e.
Scientific Literature Review
Reviewed by: Mieasha Hicks, DPM
Residency Program: Grant Medical Center, Columbus, Ohio
Podiatric Relevance: Achilles tendon lengthening in diabetic patients with plantar ulcerations has been documented in the literature as a procedure to help reduce recurrence of these wounds. The authors here studied the rate of recurrence of diabetic forefoot and midfoot wounds in patients undergoing wound closure with or without concomitant Achilles tendon lengthening, and evaluated their methods and outcomes to previous published studies.
Methods: This study was a retrospective, non-randomized review of two groups of diabetic patients with plantar forefoot and midfoot ulcerations. The early group consisted of 179 wounds in 149 patients from 1983 to 1991 that underwent wound closure without simultaneous Achilles tendon lengthening. The late group consisted of 145 wounds in 138 patients from 1996 to 2004 that underwent wound closure with Achilles tendon lengthening. Lengthening was performed to obtain no more than zero to five degrees of ankle dorsiflexion by means of a two-stab percutaneous method or open Z-plasty in patients undergoing midfoot reconstruction. Passive ankle dorsiflexion and gait analysis for measuring plantar pressures were evaluated preoperatively and patients undergoing Achilles tendon lengthening had these measurements repeated in three months. Those individuals with positive Tinel’s sign also had tarsal tunnel release performed at the time of wound closure.
Results: Twenty-five percent of patients in the early group developed recurrent ulceration and 12 percent developed transfer ulcerations in the forefoot. In the late group, two percent of patients developed ulceration and a statistically significant four percent (six patients) developed transfer lesions, with two patients developing ulceration of the heel and the other four within the forefoot. Plantar sensation improved in 72 percent in the early group and 70 percent in the later group in those in which a tarsal tunnel was performed.
Conclusion: This study focuses on recurrence of wounds not just to the forefoot but also transfer lesions to the heel. Recurrent forefoot ulcerations are a much easier problem to manage than heel ulceration. Although recurrence has not been eradicated with the current methods used in this study, the authors described a 1 percent transfer lesion to the heel, which most likely correlates with the decision to achieve no more than zero to five degrees of ankle dorsiflexion in addition to using a two hemitransection of the tendon versus three. The addition Achilles tendon lengthening in diabetic patients with plantar ulcerations shows benefit in decreasing the rate of recurrence and with avoidance of excessive lengthening, calcaneal wounds can be minimized.