Outcomes of out-patient Tendo-Achilles lengthening and weight-bearing total contact casts for patients with diabetic forefoot ulcers

M. Tiruveedhula, A. Mallick, A. Graham, M. Mulcahy

Aim: To describe safety and efficacy of percutaneous Tendo-Achilles lengthening (TAL) in out-patient clinics for the management of diabetic forefoot ulcers.

Patients and methods: Consecutive patients, who presented to the Basildon Diabetic Foot clinic from 2018 with forefoot ulcers or a callosity, who underwent the TAL in the out-patient clinic and were followed for a minimum of 12m were included in the final analysis.
After a written consent, percutaenous Hoke hemisection were performed in the clinic followed by a weight-bearing plaster cast for 6-weeks in neutral ankle position, with one change of cast at week-2. At week-6, patients were advised to walk in an Aircast boot for further 4-weeks and referred to physiotherapy for rehabilitation. Forceful dorsiflexion of the ankle was avoided to prevent risk of over-lengthening.

Results: A total of 162 patients with 196 feet underwent TAL in the clinic by 3 consultants, of these 124 patients were followed for a minimum of 12m (12-36m). None had infection or wound related problems. Complete transaction of the tendon was noted in 3 patients and one-patient developed callosity in the heel, hence forceful dorsiflexion is avoided. In 118 patients, the forefoot ulcers healed within an average of 8 weeks (6-12weeks) with no further ulcer recurrence at 12m follow-up. The ulcer recurred in 4 patients, and in 2 patients, the ulcer did not heal. Radiological analysis of these patients showed plantar flexed metatarsals with joint subluxation. Ulcers healed following proximal dorsal closing wedge osteotomy in this subgroup of patients.

Conclusion: TAL is a safe procedure in the Out-patient clinic with no wound related complications. Patients were pleased with improved range of movements and early weight bearing status. Patients are however, cautioned about the weakness in leg following TAL which gradually improved with physiotherapy.