August 2003 - Some people with diabetes struggle with ulcers forming on the bottom of their feet; worse yet, many of these ulcers come back after treatment. A study at Washington University School of Medicine in St. Louis demonstrates that a surgical procedure to lengthen the Achilles tendons of patients with diabetes significantly reduces the risk of ulcer recurrence.
The findings appear in the August issue of the Journal of Bone and Joint Surgery.
"The return of ulcers has been a key concern for patients and their clinicians," says principal investigator Michael J. Mueller, Ph.D., associate professor of physical therapy. "If these wounds don't heal there's a greater risk that a patient will have to have a portion or all of the foot amputated. This study shows that lengthening the Achilles tendon can have a dramatic effect on the problem of ulcer recurrence."
According to the Centers for Disease Control and Prevention, 17 million Americans have diabetes. Many patients develop nerve damage as the disease progresses, making it difficult to feel a developing foot injury. Therefore, patients often don't recognize an injury until the skin breaks down and becomes infected, which may result in an ulcer.
An estimated 15 percent of people with diabetes develop foot ulcers. To treat them, clinicians put a cast on the infected foot to keep pressure off the wound and allow it to heal.
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Mueller and colleagues assigned 64 participants into one of two treatment groups. All patients had an ulcer on the ball of the foot and had no amputations. One group received a foot cast, while the other group received both a cast and the Achilles tendon lengthening procedure.
To lengthen the Achilles tendon, Jeffrey E. Johnson, M.D., associate professor of orthopaedic surgery, anesthetized the skin and made three nicks through the skin and into the tendon. The patient's foot was adjusted to stretch the tendon and then was immobilized for six weeks to heal.
After seven months, the group that received Achilles tendon lengthening surgery was 75 percent less likely to have an ulcer recurrence than the group who received only a cast; at two years, they were 52 percent less likely to have a returning ulcer.
"Lengthening the tendon causes some weakness in the calf muscles, which can cause unsteadiness, but can be improved with calf strengthening exercises," Johnson says. "Patients also must be cautioned about increased stress on their heel. Nonetheless, we believe the procedure is useful in preventing ulcer recurrence in patients at high risk for skin breakdown and foot amputation."
Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of achilles tendon lengthening on nueropathic plantar ulcers. Journal of Bone and Joint Surgery, August 2003. Funding from the National Institutes of Health supported this research. The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.
Source: Washington University School of Medicine
