**5. Tendon lengthening treatment**

Patients with foot ulcers can be considered for tendon lengthening after vascular and infection have been treated. Diabetes mellitus and vascular disease are the most common co-morbidities with neuropathic foot problems [26, 29]. These patients frequently have complications. Tendon lengthening has less complications than bony procedures [1–6, 26, 29, 41]. Soft tissue procedures are usually performed first since they have lower complication rates, and then if they fail, bony procedures are done later.

Level I and level III studies have only been done for metatarsal head ulcers [25, 33, 36]. JBJS instructions for authors explains levels of evidence. There are however many level IV studies demonstrating effectiveness of tendon lengthening for foot ulcers [24, 26, 29, 34, 35, 41]. Level IV studies have advantages that the study populations are more likely to be representative of the population of interest, results are closer to those obtained in clinical practice, have a higher relevance and external validity and can be better applied to clinical practice [51]. Tendon lengthenings as the treatment of choice for diabetic forefoot ulcers seems to be supported by the above studies.

### **5.1 Metatarsal head forefoot ulcers**

If infection is present, patients with ulcers are treated with antibiotics then debridement and tendon lengthening [26]. The foot is covered with a sterile glove after the patient's skin is prepped in the operating room. Calf and ankle level tendon lengthening is done first and dressing applied. Glove is then removed for debridement of the foot and lengthening of toe tendons if needed. If gangrene of forefoot is present, debridement of gangrenous tissue and GSR are done to decrease pressure on the forefoot and to aid wound healing [41, 46, 48]. Vascular evaluation and wound care are also suggested. If forefoot wound healing is delayed after only debridement, transmetatarsal amputation [34], or Charcot arthropathy with or without ulcer [2], they are offered GSR. If gangrene of midfoot and/or hindfoot is present, transtibial or transfemoral amputation is suggested. Achilles lengthening to prevent ulcers is recommended for progressive metatarsal calluses [27].

GSR is used to treat all patients with ulcers plantar to metatarsal heads [24–26, 33, 35, 41]. With the patient supine the surgery is performed, while the knee is flexed and externally rotated. A stack of towels is placed under foot with the surgeon is seated on the opposite side. Vulpius technique [1, 26] is used, transecting the gastrocnemius tendon and underlying aponeurosis of the soleus just distal to the gastrocnemius muscle [44]. Ankle is dorsiflexed to 20–30°. Staples are used to close midcalf posterior longitudinal incision 5 cm. long after 3–0 absorbable suture closes the subcuticular layer. For recurrent ulcers and if patient can only tolerate local anesthesia percutaneous triple cut Achilles tenotomy can be used.

For first metatarsal ulcers peroneus longus (Z-type) lengthening is combined with GSR [26]. Incision is proximal to the ankle joint. The tendon repair is done with a 2–0 absorbable suture with no tension, with the first metatarsal is in maximum dorsiflexion and the foot is in maximum inversion. For fifth metatarsal ulcers posterior tibial lengthening is also performed [26]. Z-type lengthening is also performed through medial incision 5–10 cm. proximal to the ankle joint. Same technique is used to close these incisions. Repeat GSR or triple cut Achilles lengthening and percutaneous metatarsal osteotomy for recurrent metatarsal ulcers.

Full weight bearing is allowed immediately in a walking boot, which is worn for four to six weeks. Crutches or a walker is offered to the patient if needed for balance when surgery is bilateral. Ulcer treatment is clean dressings changed weekly. Skin staples are removed at two weeks. Diabetic-type shoes are recommended after six weeks. Double heel lift exercises are begun at 2 months and at 3 months single heel lift exercises. They can resume standing all day at work at 3 months. Running, jumping and climbing are allowed at 6 months.

## **5.2 Toe ulcer treatment**

Percutaneous toe flexor tenotomy at the proximal portion of the proximal phalanx is used for plantar toe ulcers [29, 52]. This can be done in the office, but can be done in the operating room if the patient is there for some other reason. Alcohol is used to prepare the toe, and then local anesthetic is given. Toe is extended so the tendons are palpable. Through a small (2 mm) transverse incision, both flexor tendons are transected. A sudden increase in extension of the distal and proximal interphalangeal joints of the lesser toes confirms division of both flexor tendons. After the flexor hallucis longus (FHL) is divided a sudden increase in extension of the interphalangeal joint of the hallux occurs. Suture is not used unless bleeding is excessive but incision is covered with sterile gauze. A postoperative shoe, sandal or extra-depth shoe can be used. Patients are allowed full weight-bearing. Patients return weekly until the ulcer heals.

Percutaneous extensor and flexor tenotomy can be used for a dorsal ulcer of PIP joint. Percutaneous capsulotomy dorsal metatarsal-phalangeal (MP) and volar (PIP) are also performed if needed. Percutaneous phalangeal osteotomy is performed if correction is insufficient.

For interdigital ulcers of the first web space, patients are offered percutaneous adductor tenotomy, and lateral capsule release of the first MP joint. An interdigital ulcer of the lessor toes may also have percutaneous MP capsular release in the lessor toe in addition to first toe surgery. Percutaneous phalangeal osteotomy or removal of prominent bone is performed if ulcer persists or recurs. Toe amputation is usually performed for osteomyelitis in the toe which is not controlled with antibiotics.

### **5.3 Charcot foot**

Midfoot ulcers can develop plantar to the bony prominence in the area of arch collapse from Charcot neuropathic arthropathy (Charcot foot). Exostectomy or fusion have recommended to be combined with Achilles lengthening [53–56]. Good preliminary results have been found with tendon lengthening (GSR) alone as the initial

### *Tendon Balancing for Diabetic Foot Ulcers, Foot Pain and Charcot Foot DOI: http://dx.doi.org/10.5772/intechopen.105938*

treatment for midfoot ulcers: 9/10 ulcers healed, 1/9 recurred with less complications than bony procedures [2, 5, 6]. Tendon lengthening (GSR) seems to heal these ulcers, prevent progression of bony deformity and promote consolidation of fragmented midfoot bone [2, 57]. The lack of progression of deformity and low recurrence rate of GSR also compare favorably with the 41/140 (36%) deformity progression and 43/140 (37%) ulceration after non-operative treatment [56, 57].

Removal of plantar bony prominence percutaneously with a burr is now routinely added to GSR. Posterior tibial lengthening can be added for lateral midfoot ulcers and peroneal tendon lengthening for medial midfoot ulcers. GSR results in much fewer heel ulcers than does Achilles tendon lengthening [1, 41, 58, 59]. If the ulcer fails to heal or recurs, then tendon lengthening and percutaneous removal of the midfoot bony prominence (exostectomy) can be repeated [5, 41]. If the ulcer fails to heal or recurs, if there is no bony prominence and the foot is unstable, then midfoot fusion can be performed [6]. Soft tissue surgery is advantageous because diabetic patients have a higher complication rate with foot and ankle surgery [60].

Lengthening the Achilles in Charcot arthropathy was recommended by Thomas and Huffman [55]. Tendon lengthening is recommended for early stage Charcot foot to relieve pain, promote consolidation, prevent progression of deformity and heal or prevent midfoot ulceration from arch collapse [2, 57]. Bony procedures are less commonly done if tendon lengthening fails. Amputation is kept as a last resort**.**

#### **5.4 Results of tendon lengthening**

A 47% decrease in major amputations in Medicare patients with diabetic foot ulcers between 2000 and 2010 has been reported [61]. In the same period Achilles tendon lengthening increased 89% and gastrocnemius recession increased 575%. The authors felt the main cause of decrease in major amputations was the increase in tendon lengthening. Recently performed a literature review on diabetic foot ulcer treatment and gave the highest recommendation (supported by strong evidence) to tendon lengthening [62].

Available evidence seems to indicate that tendon lengthening is the most effective treatment for plantar diabetic foot ulcers with the least complications [41, 57]. Tendon lengthening can also relieve foot pain, prevent ulcers and Charcot foot, and stop progression of Charcot arch collapse to rocker bottom foot, midfoot ulceration and amputation [57, 63]. Tendon lengthening may be combined with other modalities but should be done as soon as possible to promote rapid healing before the ulcer gets infected and to better prevent new, recurrent and transfer ulcers, progression of deformity and amputation [41, 57].

Yammine and Assi noted underuse of tendon lengthening which offered excellent outcomes with more ulcers healed faster with less recurrence, transfer ulcers, infection and amputation than nonsurgical treatment [64, 65]. This author recommends tendon lengthening as part of initial treatment for diabetic plantar forefoot and midfoot ulcers and Charcot of the midfoot [41, 57].
