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Specialty Update   |    
What's New in Foot and Ankle Surgery
Randall C. Marx, MD1; Mark S. Mizel, MD, MBA2
1 Department of Orthopedics, University of Miami, P.O. Box 016960 (D-27), Miami, FL 33101
2 10130 North Lake Boulevard, #214 - #301, West Palm Beach, FL 33412. E-mail address: msmmdltjg@aol.com
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Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Apr 01;90(4):928-942. doi: 10.2106/JBJS.G.01289
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Extract

This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2006 and July 2007. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot and Ankle International, and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on February 17, 2007, in San Diego, California; and the summer meeting of the American Orthopaedic Foot and Ankle Society (AOFAS), held on July 13, 14, and 15, 2007, in Toronto, Ontario, Canada.
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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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    Randall C. Marx, M.D.
    Posted on May 11, 2008
    Dr. Marx & Dr. Mizel respond to Dr. Laborde
    University of Miami, Miami, FL

    We appreciate Dr. Laborde’s letter regarding statements made in our recent article “Specialty Update, What's New in Foot and Ankle Surgery”(1). We would like to respond to Dr. Laborde’s assertion of “the superiority of (Achilles) tendon lengthening over total contact casting” in the treatment of diabetic foot ulcers as well as lend support to our statement that total contact casting remains the “gold standard” treatment to offload grade 1 and 2 diabetic foot ulcers.

    Diabetic foot ulcers present an enormous clinical challenge to treat successfully. The pathway toward ulcer formation involves a complex interaction between macro- and micro-angiopathic systemic vasculopathy, diminished peripheral sensitivity and proprioception, and excessive plantar contact pressures on the forefoot which ultimately lead to breakdown of skin over bony prominences(2,3). Appropriate treatment of these ulcers involves a comprehensive approach including strict diabetic control, judicious use of surgical debridement and antibiotics when necessary, ostectomy of offending bony prominences, and some form of pressure relief of the ulcerated foot(2).

    A time honored approach to off-loading the foot afflicted with a diabetic pressure ulcer is with the use of a total contact cast (TCC). While a paucity of level I trials have been conducted TCC has become the most widely accepted treatment based on available evidence and its durable clinical track record(2,4). Multiple descriptive and controlled trials do exist demonstrating the relative safety and efficacy of TCC(3,5). The documented healing rates for primary diabetic foot ulcers following TCC is approximately 90% at 6 weeks(3,5,6). Despite its success in healing ulcers, however, the recurrence rates following this treatment are high which also makes this treatment an imperfect solution to a complex problem(3).

    There is a need for randomized controlled trials to directly compare Achilles tendon lengthening to TCC. The last Cochrane Database System Review on this subject underscored this need for more trials of high methodological quality in order to more confidently deliver treatment guidelines(2). The lone randomized clinical trial quoted by Dr. Laborde to support his assertions of the superiority of tendon lengthening over TCC does not, in actuality, compare the two treatment modalities. Meuller, et al. in 2003, a level I study, evaluates Achilles tendon lengthening used in conjunction with TCC in order to reduce the rate of re-ulceration of diabetic foot ulcers(3). This clinical trial is, to our knowledge, the only level I study evaluating Achilles lengthening in the treatment of diabetic foot ulcers. Meuller, et al. tempered the conclusions of their article stating that Achilles tendon lengthening “should be considered as an adjunct to treatment with a total-contact cast in patients with a neuropathic plantar ulcer of the forefoot and limited ankle dorsiflexion (≤5°) to decrease the rate of ulcer recurrence”(3).

    The concept of using Achilles tendon lengthening to offload diabetic foot ulcers in patients with concomitant ankle equinus contractures is compelling and may yet prove to be an invaluable adjunct to TCC. However, at this point, in our opinion, insufficient evidence exists to support Achilles lengthening in isolation to treat diabetic foot ulcers. Currently, only level III and IV studies evaluate the efficacy of tendon lengthening alone in the treatment of neuropathic ulcers(7, 8,9,10). While the authors' of “Specialty Update, What's New in Foot and Ankle Surgery” recognize that Achilles tendon lengthening may play a role in the treatment of select diabetic foot ulcers, at this point it does not have the clinical track record, nor evidence, to displace TCC as the “gold standard” treatment. The authors believe that any surgical procedure performed on these patients increases the possibility of the loss of the limb and any additional surgical intervention should be considered and applied cautiously.

    We appreciate the opportunity to clarify our statements and will continue to address the relative merits of all treatment modalities concerning diabetic foot ulcers as the literature and evidence dictates.

    References:

    1. Marx RC, Mizel MS. What’s New in Foot and Ankle Surgery. J Bone Joint Surg Am. 2008;90:928-942.

    2. Spencer S. Cochrane Database of Systematic Reviews. 2008; 1: 00075320-100000000-01633.

    3. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers. A Randomized Clinical Trial. J Bone Joint Surg Am. 2003;85A(8):1436-1445.

    4. Coughlin MJ, Mann RA, & Saltzman CL (Eds). Surgery of the Foot and Ankle; (8th Edition) Vol 2. Philadelphia, PA. Mosby Inc. Pgs. 1281–1368.

    5. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkeless LB. Off-loading the diabetic foot wound. A randomized clinical trial. Diabetes Care 2001;24: 1019–1022.

    6. Mueller MJ, Diamond JE, Sinacore DR, Delitto A, Blair VP 3rd, Drury DA, Rose SJ. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care. 1989;12:384–8.

    7. Laborde JM: Treatment of Forefoot Ulcers with Tendon Lengthenings. Jrnl of Southn Orthopaedic Assoc. 2003;12(2):60–65.

    8. Laborde JM. Tendon Lengthening for Forefoot Ulcers. Wounds. 2005;17(5):122–130.

    9. Laborde JM. Neuropathic Toe Ulcers Treated with Flexor Tenotomies. Foot and Ankle International. 2007: 28 (11):1160–64.

    10. Laborde JM: Neuropathic Plantar Forefoot Ulcers Treated with Tendon Lengthening. Foot and Ankle International. 2008;29(4):378-384.

    James Laborde, M.D., M.S.
    Posted on April 26, 2008
    Regarding "What's New in Foot and Ankle Surgery"
    Tulane Medical Center, New Orleans, LA

    To The Editor:

    I would like to comment on a portion of the article entitled "Specialty Update, What's New in Foot and Ankle Surgery"(1). This review summarized research published or presented in JBJS, Ankle & Foot International and AOFAS meetings 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 grade 1 and 2 diabetic foot ulcers"(2). It is my opinion that articles published before and after the dates reviewed contradict this statement.

    As early as 1996, Lin et al. published a level III study in which ulcers that did not heal with total contact casting (TCC) were treated with Achilles lengthening and 93% healed and did not recur(3). More importantly, Mueller et al. published a randomized controlled study (level I) in JBJS which showed a higher healing rate when Achilles lengthening was combined with TCC compared to TCC alone(4). Especially dramatic was the difference in recurrence, which was 81% in two years follow-up after ulcer healing with TCC alone, compared to 38% after adding Achilles lengthening. These two studies, I believe, demonstrated the superiority of tendon lengthening over TCC in rate of healing and especially in rate of recurrence of ulcers. Both before and after the review period, additional studies (level IV) with longer follow-up have demonstrated that treating forefoot ulcers with tendon lengthenings without TCC has a higher rate of healing, lower complication rate and a much lower recurrence rate than TCC(5,6,7,8).

    In my opinion, this literature indicates the superiority of tendon lengthening over TCC in the treatment of diabetic forefoot ulcers. It is also my opinion that tendon lengthening should now be considered the gold standard treatment for diabetic forefoot ulcers, rather than TCC. Even though diabetic foot problems are the most common problem I treat, I have not had the occasion to use a TCC since I began performing tendon lengthening in 1995. I have found tendon lengthening more effective in healing foot ulcers with fewer complications and with much fewer recurrent problems. Hopefully the next article in "What's New in Foot and Ankle Surgery" will address the relative merits of TCC and tendon lengthening for diabetic foot ulcers.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family 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, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References:

    1. Marx RC, Mizel MS. What's new in foot and angle surgery. J Bone Joint Surg Am. 2008;90:928-942.

    2. Marx RC, Mizel MS. What's new in foot and angle surgery. J Bone Joint Surg Am. 2008;90:933.

    3. Lin SS, Lee H, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients; the effect of tendo-Achilles lengthening and total contact casting. Orthopaedics 1996;19(5):465-474.

    4. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers, a randomized clinical trial. JBJS 2003;85A(8):1436-1445.

    5. Laborde JM: Treatment of forefoot ulcers with tendon lengthenings. J of Southern Orthopaedic Assoc. 2003;12(2):60-65.

    6. Laborde JM. Tendon Lengthening for Forefoot Ulcers. Wounds. 2005;17(5):122-130.

    7. Laborde JM: Neuropathic toe ulcers treated with flexor tenotomies. Foot & Ankle Int. 2007;28(11):1160-64.

    8. Laborde JM: Neuropathic plantar forefoot ulcers treated with tendon lengthening. Foot & Ankle Int. 2008;29(4):378-384.

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