Gastrocnemius recession or tendo-achilles lengthening for equinus deformity in the diabetic foot?

Complications of Percutaneous Tendo-Achilles Lengthening for Treatment and Prevention of Diabetic Foot Ulcers: A Systematic Review

Percutaneous Achilles tendon lengthening is an effective surgical procedure to treat and prevent forefoot and midfoot ulcerations in patients with diabetes. Patients with diabetes are prone to plantar ulcerations due to a combination of factors, such as peripheral neuropathy, decreased tendon elasticity, peripheral vascular disease, and hyperglycemia. Complications such as re-ulceration and transfer lesion to the heel, associated with a calcaneal gait secondary to over-lengthening, are possible with percutaneous Achilles tendon lengthening. Although percutaneous Achilles tendon lengthening is well accepted, the overall incidence of complication has not been well described. A systematic review of the reported data was performed to determine the incidence of complication for percutaneous tendo-Achilles lengthening when used for the treatment and prevention of diabetic plantar ulcerations. Nine studies involving 490 percutaneous lengthening procedures met the inclusion criteria. The overall complication rate was 27.8% (8% with transfer heel ulcerations). Given the high rate of complications associated with a percutaneous Achilles tendon lengthening, careful patient selection and consideration of these risks should be considered prior to proceeding with this procedure. Additional prospective comparative analyses with standardization of surgical technique, degrees of lengthening achieved, and post-operative weightbearing and immobilization modalities are needed to decrease incidence of complication and achieve higher healing rates.

A 2-Stage Approach in Managing Diabetic Forefoot Ulcers

BACKGROUND

Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer.

METHODS

A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations.

RESULTS

Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion.

CONCLUSION

TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Management of the Charcot Foot and Ankle: Nonreconstructive Surgery

Diabetic neuroarthropathy is a complication of diabetes mellitus that results in instability of the foot, structural deformity, and soft-tissue breakdown. Commonly, midfoot collapse of the medial, lateral, or both longitudinal arches may result in increased plantar pressures and subsequent midfoot ulceration. Many of these wounds can be successfully managed with local wound care and off-loading; however, surgical intervention becomes necessary in cases of osteomyelitis or when the wound fails to heal despite conservative efforts. In cases where surgical reconstruction may not be indicated, nonreconstructive surgical efforts have shown effectiveness in resolving wounds and allowing patients to return to ambulatory lifestyles. This article serves as an update to current treatment recommendations for the nonreconstructive surgical management of Charcot neuroarthropathy.

NEMISIS: Neuropathic Minimally Invasive Surgeries. Charcot Midfoot Reconstruction, Surgical Technique, Pearls and Pitfalls

The last decade has seen a significant development in early surgical intervention for patients with or at risk of ulceration owing to deformity resulting from the sequalae of diabetic foot disease. Midfoot Charcot neuroarthropathy is the most common deformity; its correction is enabled by specialized surgical implants designed to maintain surgical corrections. There has also been an increasing number of orthopedic foot and ankle surgeons, with a specific interest in diabetic foot disease who provide early surgical correction in patients identified as high risk. Minimally invasive surgery using percutaneous incisions completes the triumvirate, facilitating earlier surgical intervention to decrease reulcerations.

A novel technique of isolated gastrocnemius recession: A cadaveric comparison with Strayer procedure

BACKGROUND

Strayer's gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically.

METHODS

Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques.

RESULTS

There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829).

CONCLUSIONS

Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Outcomes of Tendo-Achilles lengthening and weight-bearing total contact cast for management of early midfoot charcot neuroarthropathy

AIM OF STUDY

To report outcomes of tendo-Achilles lengthening (TAL) followed by weight-bearing total contact cast (TCC) in the out-patient setting for patients presented with midfoot Charcot neuroarthropathy (CN) and, develop a new classification system for midfoot CN based on this experience.

PATIENT AND METHODS

Published evidence suggests that tight Achilles-gastrocnemius-soleus complex is the deforming force in the initiation and progression of midfoot CN and TAL has shown to improve the range of ankle dorsiflexion and reduction of midfoot plantar pressures. We utilised this technique in the out-patient setting followed by weight-bearing TCC for all new patients who presented with a diagnosis of midfoot CN from February 2018.We report their outcomes after a 12 months follow-up and propose a new classification system based on the clinical and radiographic parameters.

RESULTS

TAL followed by weight-bearing TCC was performed in 33 feet. In 30 feet, the disease progression either stopped or receded to a lower stage on the new classification system. The procedure was well tolerated by patients in an out-patient setting and there were no reported complications such as wound healing, complete transaction of tendon or deep vein thrombosis. At 12 months follow-up, 30 of 33 pts returned to their pre-procedure level of mobilisation with their usual walking aids or customised shoes. The inter-observer agreement was k = 0.86 for read 1 and k = 0.96 for read 2; and intra-observer agreement ranged from 0.93 to 1.00 for the double read indicating excellent inter-observer and intra-observer agreement.

CONCLUSION

TAL followed by weight-bearing TCC is a safe and well tolerated procedure when performed in an out-patient setting. The Charcot disease of the midfoot slowed in the early stages of midfoot CN and in some cases, receded. The new classification system is easy to use, reliable, reproducible and sensitive enough to detect changes in the disease progression.

Charcot Reconstruction: Understanding and Treating the Deformed Charcot Neuropathic Arthropathic Foot

With worsening diet and increasing prevalence of diabetes, patient encounters with Charcot neuropathic arthropathy (CNA) are expected to increase. Without intervention, the pathology progresses with further subluxation/dislocation and fracture, placing soft tissues at risk of preulceration or formal ulceration, infection, and potentially major amputation. The need to avoid amputation is of paramount importance. Although a formal single eradicating tool for CNA is lacking, there is capacity to intervene in ways that may curtail the pace of destruction. This article reviews understanding of the disease process and provides guidance to surgical reconstruction of the deformity.

Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management

Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.

Evidence based review of literature on detriments to healing of diabetic foot ulcers

BACKGROUND

Diabetes mellitus places a substantial burden on society worldwide. Diabetic foot ulcers are a challenging problem for clinicians. Seven generally accepted detriments to healing of diabetic foot ulcers were identified: infection, glycaemic control, vascular supply, smoking, nutrition, deformity and offloading. The aim of this paper is to present a comprehensive evidence based review of the literature available on detriments to healing of diabetic foot ulcers.

METHOD

A research question was generated for each of the detriments to healing and a comprehensive review of the literature was performed using the Pubmed database in July 2014. All articles were assessed for relevancy and a level of evidence was assigned. An analysis of the total body of literature was used to assign a grade of recommendation to each detriment.

RESULTS

Grade A recommendation was assigned to offloading as there was good evidence supporting this intervention. Grade B recommendation was assigned to deformity as there was fair evidence consistent with the hypothesis. Infection and vascular supply had poor quality evidence supporting the research question and grade C recommendation was assigned. Grade I recommendation was assigned to glycaemic control, smoking and nutrition as there was insufficient and conflicting evidence available.

CONCLUSION

Our literature review revealed good evidence for some factors and insufficient literature on others. Further studies are needed to provide quality evidence regarding detriments to healing of diabetic ulcers.

A Wound Complication After Percutaneous Achilles Tendon Lengthening Requiring Surgical Excision: A Case Report

A percutaneous tendo-Achilles lengthening procedure corrects limited ankle joint equinus by decreasing the pull of the triceps surae complex. The standard technique using 3-incision hemisection described by Hoke is often used in patients with diabetes because of the minimal number of incisions and low risk of wound complications. We describe a patient who underwent percutaneous tendo-Achilles lengthening with a resultant open wound complication requiring staged surgical debridement.

Surgical Correction of the Achilles Tendon for Diabetic Foot Ulcerations and Charcot Neuroarthropathy

Achilles tendon pathologic conditions are implicated in contributing to the development of many diabetic foot complications including diabetic foot ulceration and Charcot neuroarthropathy. Surgical correction of the diabetic equinus deformity has been studied as an isolated or adjunctive treatment when dealing with difficult-to-close diabetic foot ulcerations or when surgically addressing the diabetic Charcot neuroarthropathy foot or ankle. This article reviews the most common indications, complications, and surgical procedures for equinus correction by either a tendo-Achilles lengthening or gastrocnemius recession for the management of diabetic foot conditions.

Equinus and Lengthening Techniques

Equinus is linked to most lower extremity biomechanically related disorders. Defining equinus as ankle joint dorsiflexion less than 5° of dorsiflexion with the knee extended is the basis for evaluation and management of the deformity. Consistent evaluation methodology using a goniometer with the subtalar joint in neutral position and midtarsal joint supinated while dorsiflexing the ankle with knee extended provides a consistent clinical examination. For equinus deformity with an associated disorder, comprehensive treatment mandates treatment of the equinus deformity. Surgical treatment of equinus offers multiple procedures but the Baumann gastrocnemius recession is preferred based on deformity correction without weakness.

Gastrocnemius fascia release under local anaesthesia as a treatment for neuropathic foot ulcers in diabetic patients: a short series

BACKGROUND

Diabetic foot ulceration is the leading cause of major amputation in the developed world. Plantar neuropathic ulcers at the forefoot can be managed conservatively with off-loading, but treatment is not invariably successful. Achilles tendon lengthening procedures aim at increasing dorsiflexion and decreasing forefoot pressure but can be associated with complications and require prolonged postoperative immobilization to prevent tendon rupture. We assessed the feasibility and clinical outcome of a comparative minimal invasive procedure: the gastrocnemius fascia release. This technique targets the same goals but is performed under local anaesthesia and allows immediate postoperative weight bearing and ambulation.

METHODS

Diabetic patients with plantar neuropathic ulcers Wagner grade 2 or 3 were recruited from our diabetic foot clinic. Patients with infected wounds or untreatable peripheral arterial disease were excluded from the study. Conservative treatment with off-loading and local wound care was attempted for six weeks and surgical procedure only contemplated upon failure. Primary end-points were improved range of dorsiflexion and time to healing. Secondary end-points were local ulcer recurrences, new plantar ulcers, and minor or major amputation. Post-operative follow-up was 12 months.

RESULTS

Seven patients were included in the study. An improvement in dorsiflexion of 10.4° (mean) was recorded post-operatively (p < 0.01). After 30 days, complete healing was accomplished in six of the seven patients. Long-term results were excellent as no ulcer recurrence or amputation was noted.

CONCLUSIONS

Gastrocnemius fascia release under local anaesthesia can be performed safely in diabetic patients with plantar neuropathic ulcers under the metatarsal heads. Clinical outcome is excellent and long-term results promising.

Preliminary Results of Primary Gastrocnemius-Soleus Recession for Midfoot Charcot Arthropathy

Background Treatment of Charcot arthopathy of the foot can be challenging. The goal of this investigation was to determine whether primary gastrocnemius-soleus recession could decrease rate of new ulcers, progression of deformity, and amputation in patients with Charcot arthropathy of the midfoot.Methods A retrospective chart review revealed 28 feet in 24 diabetic patients with radiographic evidence of Charcot arthropathy of the midfoot. They were treated with primary gastrocnemius-soleus recession. Eleven feet in 11 patients had concurrent plantar midfoot ulcers. Three feet in 3 patients were lost to follow-up. Twenty-five feet in 21 patients were followed for an average of 37 months postoperatively (range = 18-79).Results A favorable outcome was defined as healing of existing ulcers, no new ulcers, no obvious progression of deformity, and no amputation. Favorable outcomes were obtained in 22 of 25 feet (18 of 21 patients). Only one patient had a persistent ulcer after gastrocnemius-soleus recession. The other 10 patients with preexisting ulcers healed. Deformity of midfoot progressed in one patient, leading ultimately to transtibial amputation. Another patient developed a knee joint infection and had a transfemoral amputation at another institution.Discussion These preliminary data suggest that primary gastrocnemius-soleus recession is followed by a much lower rate of persistent, recurrent, and new ulceration than previously reported studies. Gastrocnemius-soleus recession seems to aid in the treatment of Charcot arthropathy of the midfoot.

LEVELS OF EVIDENCE

Level IV.

Soft Tissue Balancing After Partial Foot Amputations

Partial foot amputations have become common procedures for the foot and ankle surgeon as part of a limb salvage practice. These procedures are highly technique driven and there are many complex factors that affect the outcome and longevity. Appropriate surgical planning must be used with every partial foot amputation to ensure a plantigrade foot with the least potential for future breakdown. When performed appropriately, these amputations have great success with lower energy expenditure and decreased mortality compared with below-knee or above-knee amputations.

What's new in wound treatment: a critical appraisal

With the growing demand for the specialized care of wounds, there is an ever expanding abundance of wound care modalities available. It is difficult to identify which products or devices enhance wound healing, and thus, a critical and continual look at new advances is necessary. The goal of any wound regimen should be to optimize wound healing by combining basic wound care modalities including debridement, off-loading, and infection control with the addition of advanced therapies when necessary. This review takes a closer look at current uses of negative pressure wound therapy, bioengineered alternative tissues, and amniotic membrane products. While robust literature may be lacking, current wound care advances are showing great promise in wound healing.

Chronic leg pain in athletes

Chronic leg pain is commonly treated by orthopaedic surgeons who take care of athletes. The sources are varied and include the more commonly encountered medial tibial stress syndrome, chronic exertional compartment syndrome, stress fracture, popliteal artery entrapment syndrome, nerve entrapment, Achilles tightness, deep vein thrombosis, and complex regional pain syndrome. Owing to overlapping physical examination findings, an assortment of imaging and other diagnostic modalities are employed to distinguish among the diagnoses to guide the appropriate management. Although most of these chronic problems are treated nonsurgically, some patients require operative intervention. For each condition listed above, the pathophysiology, diagnosis, management option, and outcomes are discussed in turn.

What risk factors predict usage of gastrocsoleus recession during tibial lengthening?

BACKGROUND

Tibial lengthening is frequently associated with gastrocsoleus contracture and some patients are treated surgically. However, the risk factors associated with gastrocsoleus contracture severe enough to warrant surgery during tibial lengthening and the consistency with which gastrocsoleus recession (GSR) results in a plantigrade foot in this setting have not been well defined.

QUESTIONS/PURPOSES

We compared patients treated with or without GSR during tibial lengthening with respect to (1) clinical risk factors triggering GSR use, (2) ROM gains and patient-reported outcomes, and (3) complications after GSR.

METHODS

Between 2002 and 2011, 95 patients underwent tibial lengthenings excluding those associated with bone loss; 82 (83%) were available for a minimum followup of 1 year. According to our clinical algorithm, we performed GSR when patients had equinus contractures of greater than 10° while lengthening or greater than 0° before or after lengthening. Forty-one patients underwent GSR and 41 did not. Univariate analysis was performed to assess independent associations between surgical characteristics and likelihood of undergoing GSR. A multivariate regression model and receiver operating characteristic curves were generated to adjust for confounders and to establish risk factors and any threshold for undergoing GSR. Chart review determined ROM, patient-reported outcomes, and complications.

RESULTS

Amount and percentage of lengthening, age, and etiology were risk factors for GSR. Patients with lengthening of greater than 42 mm (odds ratio [OR]: 4.13; 95% CI: 1.82, 9.40; p = 0.001), lengthening of greater than 13% of lengthening (OR: 3.88; 95% CI: 1.66, 9.11; p = 0.001), and congenital etiology (OR: 1.90; 95% CI: 0.86, 4.15; p = 0.109) were more likely to undergo GSR. Adjusting for all other variables, increased amount lengthened (adjusted OR: 1.05; 95% CI: 1.02, 1.07; p < 0.001) and age (adjusted OR: 1.02; 95% CI: 0.99, 1.05; p = 0.131) were associated with undergoing GSR. Patients gained 24° of ankle dorsiflexion after GSR. Self-reported functional outcomes were similar between patients with or without GSR. Complications included stretch injury to the posterior tibial nerve leading to temporary and partial loss of plantar sensation in two patients.

CONCLUSIONS

Dorsiflexion was maintained and/or restored similarly among patients with or without GSR when treated under our algorithm. Functional compromise was not seen after GSR. Identification of patients at risk will help surgeons indicate patients for surgery. Acute dorsiflexion should be avoided to minimize risk of injury to the posterior tibial nerve.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The gastrocnemius: a new paradigm for the human foot and ankle

A silent gastrocnemius contracture can gradually do so much harm when left undetected and unattended. The calf is a common source of a majority of acquired, nontraumatic adult foot and ankle problems. When it comes to surgical lengthening procedures, whether at the Achilles, at the musculotendinous junction, or more proximal, the search must move on to find the safest, most accurate, and quickest recovery method possible. Addressing the calf contracture as definitive treatment and, better yet, as prevention will no doubt become a mainstay of the treatment of many foot and ankle problems.