Achilles tendon lengthening, the panacea for plantar forefoot ulceration?

Background: Recent reports on Achilles tendon lengthening (ATL) have documented rapid healing of chronic plantar neuropathic forefoot ulcers.

Methods: Sixty-eight patients with 75 ulcerated neuropathic feet (63 patients with diabetes with 69 ulcerated feet) underwent ATL and were retrospectively studied for chronic plantar ulceration in the forefoot and reduced dorsiflexion range of motion at the ankle. Median duration of ulcers was 48 months (range 11-84 months) in 16 forefoot amputation stumps and 11 months (range 3-84 months) for the rest of the patients.

Results: Healing of the ulcers was obtained in 68/75 feet (91%). At a median follow-up of 12 months (3-26 months), 4 had never healed, 5/10 recurrent ulcers and 6/11 transfer ulcers (localized to the heel) had not healed, that is, a healing rate of 60/75 (80%). Acute transfer ulcers to the heel occurred in 47% of patients with complete anaesthesia of the heel pad. Late heel ulceration occurred in 14% of those with extreme ankle dorsiflexion (>15 degrees). Failure to heal or ulcer recurrence occurred more frequently at dorsiflexion <10 degrees (33%). Rupture of the Achilles tendon occurred in 7 feet (10%). Charcot event was experienced in 3 (4%).

Conclusion: Lengthening of the Achilles tendon is effective in healing plantar neuropathic ulceration. Patients with complete anaesthesia of the heel pad should not undergo this procedure and extreme dorsiflexion should be avoided because of the risk of heel ulceration. Moreover, the procedure should be performed only in a multidisciplinary setting for immediate dealing with complications and for surveillance and treatment of future ulceration.