**3. Results of foot ulcers treatment**

#### **3.1 Tendon lengthening**

Multiple authors reported the association of gastrocnemius-soleus contracture, neuropathy, and chronic ulceration of the forefoot [24–26]. The high rate of successful healing of forefoot ulcers after Achilles lengthening was reported in multiple studies [24–26, 33–36, 41]. Also a high rate of healing of midfoot and toe ulcers also occurred after tendon lengthening [2, 29].

The recurrence rate of foot ulcers after three years in diabetic patients treated without tendon lengthening, was 61% (286/468) [42]. After Achilles tendon lengthening, forefoot ulcer recurrence rates were much lower, 14% [41]. There is also a low rate of recurrence of toe ulcers treated with toe flexor tenotomy and with midfoot ulcers treated with tendon lengthening [2, 29].

Mueller et al. reported recurrence 10 of 26 ulcers 2 years after Achilles lengthening [33]. Adding peroneus longus and posterior tibial to gastrocnemius–soleus recession (GSR) yielded less recurrence, 3 of 18 at 45 months follow-up [26]. Dayer and Assal also had a low recurrence (1/22) by adding tendon procedures such as peroneus longus transfer to gastrocnemius recession [36].
