Scientific Article   |    
Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers* A Randomized Clinical Trial
Michael J. Mueller, PT, PhD; David R Sinacore, PT, PhD; Mary Kent Hastings, MS/PTATC; Michael J. Strube, PhD; Jeffrey E Johnson, MD
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Investigation performed at the Washington University School of Medicine, St. Louis, Missouri

Michael J. Mueller, PT, PhD
David R. Sinacore, PT, PhD
Mary Kent Hastings, MS/PT, ATC
Program in Physical Therapy, Box 8502, 4444 Forest Park Boulevard, St. Louis, MO 63018. E-mail address for M.J. Mueller: muellermi@msnotes.wustl.edu

Michael J Strube, PhD
Department of Psychology, Washington University, Campus Box 1125, #1 Brookings Drive, St. Louis, MO 63130

Jeffrey E. Johnson, MD
Department of Orthopedic Surgery, Barnes-Jewish Hospital at Washington University School of Medicine, 660 South Euclid Avenue, Box 8233, St. Louis, MO 63110

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Center for Medical Rehabilitation Research and the National Institutes of Health RO1 HD 36802. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

*Read at the Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, July 12, 2002, in Traverse City, Michigan, by Jeffrey E. Johnson, MD. Recipient of the Roger A. Mann, MD, Award for outstanding clinical paper.

J Bone Joint Surg Am, 2003 Aug 01;85(8):1436-1445
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Background: Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with and without an Achilles tendon lengthening. Our primary hypothesis was that the Achilles tendon lengthening would lead to a lower rate of ulcer recurrence.


Sixty-four subjects were randomized into two treatment groups, immobilization in a total-contact cast alone or combined with percutaneous Achilles tendon lengthening, with measurements made before and after treatment, at the seven-month follow-up examination, and at the final follow-up evaluation (a mean [and standard deviation] of 2.1 ± 0.7 years after initial healing). There were thirty-three subjects in the total-contact cast group and thirty-one subjects in the Achilles tendon lengthening group. There were no significant differences in age, body-mass index, or duration of diabetes between the groups. Outcome measures were time to healing of the ulcer, ulcer recurrence rate, range of dorsiflexion of the ankle, peak torque (strength) of the plantar flexor muscles, and peak plantar pressures on the forefoot.

Results: Twenty-nine (88%) of thirty-three ulcers in the total-contact cast group and all thirty ulcers (100%) in the Achilles tendon lengthening group healed after a mean duration (and standard deviation) of 41 ± 28 days and 58 ± 47 days, respectively (p > 0.05). (One patient in the Achilles tendon lengthening group died before treatment was completed.) In the first seven months of follow-up, sixteen (59%) of the twenty-seven patients in the total-contact cast group who were available for follow-up and four (15%) of the twenty-seven patients in the Achilles tendon lengthening group who were available for follow-up had an ulcer recurrence (p = 0.001). At the time of the two-year follow-up, twenty-one (81%) of the twenty-six patients in the total-contact cast group and ten (38%) of the twenty-six patients in the Achilles tendon lengthening group had ulcer recurrence (p = 0.002). Compared with the group treated with the total-contact cast, the group treated with Achilles tendon lengthening had increased dorsiflexion and it remained increased at seven months (p < 0.001). Plantar flexor peak torque also decreased after Achilles tendon lengthening (p < 0.004), but it returned to baseline after seven months. Peak plantar pressures on the forefoot during barefoot walking were reduced (p < 0.0002) following Achilles tendon lengthening yet returned to baseline values within seven months after treatment.

Conclusions: All ulcers healed in the Achilles tendon lengthening group, and the risk for ulcer recurrence was 75% less at seven months and 52% less at two years than that in the total-contact cast group. Achilles tendon lengthening should be considered an effective strategy to reduce recurrence of neuropathic ulceration of the plantar aspect of the forefoot in patients with diabetes mellitus and limited ankle dorsiflexion (=5°).

Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Michael J. Mueller
    Posted on August 28, 2003
    Dr. Mueller responds to Dr. Kaspar
    Washington University School of Medicine

    In response to Dr. Kaspar's questions, the first pertains to the difference in weight-bearing instructions after the respective treatments. Those in the total contact casting (TCC) group were allowed to weight-bear immediately while those in the Achilles tendon lengthening (ATL) group were instructed to remain partial weight bearing for one week. Although not clearly described in the Methods section, both groups were advised to limit activities as much as possible. We agree that this difference in weight-bearing instruction is a potential, but in our view probably minimal, confounding variable to the interpretation of the results.

    A greater confounding variable is the use of a walking boot by the ATL group as they transitioned from a cast to shoes. This boot was needed because of the instability that some subjects showed during walking, and this variable was discussed in the paper.

    The second question relates to the actual risk of the procedure. We agree that one could consider the appearance of heel ulcers as either a recurrence or as a complication. Prior to the start of the study, we defined ulcer recurrence as being limited to the forefoot.We did not change this definition when heel ulcers developed.

    The risk of infection is always a potential complication with a surgical procedure, although we have experienced only one infection in what is now a series of several hundred ATL procedures.

    We do not believe there was a meaningful difference in primary wound healing. It was excellent in both groups. We believe the results of the study suggest that an ATL should be considered as an adjunct to treatment with a total contact cast in patients with a recurrent neuropathic forefoot ulcer and limited ankle dorsiflexion to reduce the rate of ulcer recurrence. The serious risk of ulcer recurrence is wound infection and lower extremity amputation.

    We encourage readers to consider all benefits and risks to this procedure and discuss them with each prospective patient. Additional research is needed to help determine optimal methods to prevent ulcer recurrence without the risks of a surgical procedure.

    Sarkis (Sam) Kaspar
    Posted on August 23, 2003
    Achilles lengthening for preventing recurrence of plantar ulcers: A bit of a stretch?
    Johns Hopkins

    The article by Mueller et al on achilles lengthening to help forefoot ulcers to heal reports that even though the surgical group had non-statistically-significant trends towards longer healing times (57.5 surgical vs 40.8 days non-surgical) a larger number of ulcers healed in the surgical group (33 of 33 surgical vs 29 of 33 non-surgical),and the recurrence rate was lower in the surgical group (4 of 27 recurred vs 16 of 27 in the non-surgical group.

    My first question pertains to the role of protected weight-bearing post operatively. In the Methods section, the authors state that the casting group was allowed to take full weight immediately, whereas the surgical group was protected for a week then gradually allowed to bear weight but advised to limit their activity. Doesn't this introduce a confounding variable because of the different treatment of the two groups?

    Secondly, the study’s entire pool of neuropathic-foot-ulcer patients would clearly be at risk for wound complications about the ankle, a not-insignificant risk even in healthy patients undergoing achilles tendon repair. While the tenotomy style procedure likely limited this, there was one deep infection requiring surgical débridement, plus 4 cases of heel ulcers developing only in the surgical group, suggesting that the benefits may be more modest than proposed (for example, the heel ulcers should be counted as “plantar ulcers” and not excluded as separate complications). Hence, rather than a risk ratio of 59% to 15% (3.9, with reported 95% CI of 1.8 to 8.9 for “forefoot ulcers”), the true ratio is likely 59% versus 33% (9/27 rather than the 4/27 reported). Also, if the surgical patient who died during treatment was to be considered a peri- operative mortality, then the risk to benefit ratio is again higher.

    While this is a very interesting and extensive piece of research, the full set of data in the article does lead one to become concerned over wound healing, the paper’s inclusion of heel ulcers, deep infection, and peri-operative mortality as issues separate from the recurrence rate (in the complication section for the surgical group), and the differences in weight-bearing status allowed in the two groups.

    I would be grateful to the authors for their response to these comments.

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