Researchers report that the addition of Achilles tendon lengthening to procedures for managing diabetic forefoot and midfoot ulceration seems warranted.
The results showed that Achilles tendon lengthening decreased the relative risk for ulcer recurrence by 94%, after taking into account factors such as ulceration type, the need for vascular intervention, and end-stage renal disease, cardiopulmonary disease, and osteomyelitis.
"The addition of Achilles tendon-lengthening surgery clearly benefited our patients, and we concluded that simply closing the wound, removing bony prominences, and performing tarsal tunnel release when indicated are not enough to prevent ulcer recurrence," say Lawrence Colen (Eastern Virginia Medical School, Norfolk, USA) and team.
They reviewed 149 diabetic patients who underwent wound closure surgery alone and 138 patients who underwent similar wound closure procedures plus Achilles tendon lengthening. The former group had a total of 179 ulcers, while the latter had 145.
Over an average follow-up period of 2.9 years, 25% of patients receiving wound closure surgery alone developed recurrent ulceration requiring reoperation, compared with only 2% of patients receiving additional Achilles tendon lengthening.
The researchers also assessed for transfer lesions, noting that overly lengthened tendons or tendon rupture can increase the risk for central heel ulcers, which are a much harder problem to manage than recurrent forefront ulcers.
But they found that only six (4%) patients undergoing Achilles tendon lengthening experienced transfer ulceration, and of these patients, only two (1.3%) developed heel ulceration. By comparison, 12% of patients receiving wound closure surgery only experienced transfer ulcers, all of which were in the forefoot.
"Once plantar ulceration occurs, reliable management of these wounds is imperative, as improper care often results in lower extremity amputation," the researchers comment in Plastic and Reconstructive Surgery.
Although their follow-up period may not have been long enough to assess long-term limb salvage rates, they expect that "the incidence of below-knee amputation would likely be higher in patients who required reoperation of recurrent ulcerations."
The team concludes that, as long as excessive Achilles lengthening is avoided, "it can help prevent forefoot and midfoot wounds, with an acceptable complication rate."
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