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Chronic diabetic ulcers under the first metatarsal head treated by staged
tendon balancing: A PROSPECTIVE COHORT STUDY
R. Dayer and M. Assal J Bone Joint Surg Br 2009;91-B 487-493
Quote:
We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.
The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.
We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.
BACKGROUND: Foot ulcers in patients with neuropathy are a common cause of hospital admission for infection sometimes resulting in amputation in patients with neuropathy. Tendon lengthening alone has been reported to be successful in treating neuropathic forefoot ulcers. Tendon lengthening has also been recommended as an adjunct to bony procedures (exostectomy or fusion) for treating midfoot ulcers. The author reports the results of gastrocnemius-soleus recession as the sole treatment of diabetic midfoot ulcers.
MATERIALS AND METHODS: This study evaluated the results of 11 patients with 11 neuropathic plantar midfoot ulcers who were treated primarily with gastrocnemius-soleus recession with an average followup of 39 months. Potentially risky bony procedures were done after tendon lengthening if ulcers did not heal or recurred.
RESULTS: Ten of the ulcers healed but one patient was lost to followup after his ulcer healed. One ulcer did not heal and one ulcer recurred but healed again after midfoot fusion. One patient later had a transfemoral amputation due to gangrene. Two patients later died from medical problems unrelated to their surgery. There were no incision problems, or transfer ulcers.
CONCLUSION: The author believes gastrocnemius-soleus recession as a primary treatment of diabetic midfoot ulcers is a low risk method of promoting ulcer resolution.
Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing
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