To The Editor:
I would like to comment on a portion of the Specialty Update "What's New in Foot and Ankle Surgery" (2008;90:928-42), by Marx and Mizel, which summarized research published in The Journal of Bone and Joint Surgery and Foot and Ankle International and presented at the American Orthopaedic Foot and Ankle Society (AOFAS) meeting between August 2006 and July 2007. The section on diabetes and peripheral neuropathy states: "Total contact casting remains the gold standard treatment with which to offload Wagner grade-1 and 2 diabetic foot ulcers." It is my opinion that articles published before and after the dates of the reviewed articles and presentations contradict this statement.
As early as 1996, Lin et al. reported a Level-III study in which ulcers that did not heal with use of a total contact cast were treated with Achilles tendon lengthening; 93% healed and did not recur1. More importantly, in a randomized controlled study (Level I) published in JBJS, Mueller et al. found that the healing rate after Achilles tendon lengthening combined with treatment in a total contact cast was higher than that associated with treatment with a total contact cast alone2. Especially dramatic was the difference in the recurrence rate, which was 81% at two years after ulcer healing in patients treated with a total contact cast alone compared with 38% in those treated with a total contact cast and Achilles tendon lengthening. These two studies, I believe, demonstrated the superiority of tendon lengthening over management with a total contact cast in terms of the rate of healing and especially the rate of recurrence of ulcers. Both before and after the review period in the Specialty Update by Marx and Mizel, additional studies (Level IV) with longer follow-up demonstrated that treating forefoot ulcers with tendon lengthening without the use of a total contact cast results in a higher rate of healing, a lower complication rate, and a much lower recurrence rate as compared with the results of treatment with a total contact cast alone3-6.
In my opinion, this literature indicates the superiority of tendon lengthening over a total contact cast for the treatment of diabetic forefoot ulcers. It is also my opinion that tendon lengthening, rather than a total contact cast, should now be considered the gold-standard treatment for diabetic forefoot ulcers. Even though diabetic foot problems are the most common problems that I treat, I have not had the occasion to use a total contact cast since I began performing tendon lengthening in 1995. I have found tendon lengthening to provide better results in terms of healing of foot ulcers with fewer complications and with much fewer recurrent problems. Hopefully, the next "What's New in Foot and Ankle Surgery" article will address the relative merits of treatment of diabetic foot ulcers with a total contact cast and tendon lengthening.