Achilles tendon lengthening in the diabetic foot

NewsBot · Nov 20, 2007

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Podiatry Today has just published the full text of:
Tendo-Achilles Lengthening: Friend Or Foe In The Diabetic Foot?
Paul J. Kim, John S. Steinberg

While various researchers have implicated the equinus deformity as a major deforming force in a host of foot and ankle pathologies, the exact definition of equinus remains unclear.1-4 However, Root states that “the minimal range of ankle joint dorsiflexion that is necessary for normal locomotion is 10 degrees.”5 Subsequent studies report that the ankle joint range of motion for asymptomatic patients ranges from 0 to 13.1 degrees with the knee extended and from 5 to 22.3 degrees with the knee flexed.

The implication from these studies and other papers is that with a decrease in the range of motion at the ankle joint, it is more likely that pathologies will develop. Although other soft tissue and bony constraints may restrict ankle joint range of motion, the Achilles tendon appears to play the dominant role for this limitation.

Multiple factors are involved in the development of pathologies one sees in the diabetic foot. Some of these factors include neuropathy, ischemia and bony deformity. Soft tissue changes in the diabetic foot are particularly important. For example, there is a decrease in the soft tissue density on the plantar aspect of the diabetic foot, which is less tolerant of stress.10-12 We also know that patients with diabetes have less mobility available in their joints.
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Full text

Admin2 · Nov 20, 2007

Maybe related thread:
The windlass in diabetes

NewsBot · Mar 29, 2012

Prevalence of Equinus in Diabetic versus Nondiabetic Patients
Robert G. Frykberg, Joel Bowen, Jared Hall, Arthur Tallis, Edward Tierney, Denise Freeman
JAPMA March/April 2012 vol. 102 no. 2 84-88

Background: There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons.

Methods: A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion.

Results: Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28–8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58–10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11–7.09; P < .029).

Conclusions: Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration
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NewsBot · Jul 29, 2015

Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis
Sarah M. Dallimore and Michelle R. Kaminski
Journal of Foot and Ankle Research 2015, 8:33 doi:10.1186/s13047-015-0085-6

Introduction Diabetic foot ulcers have a devastating impact on an individual?s health-related quality of life and functional status. Additionally, diabetic foot ulcers impose a significant economic burden on our health care systems as a result of complications such as infection, hospitalisation and amputation. The current gold standard treatment for diabetic foot ulcers is total contact casting. However, the rate of ulcer recurrence is high, indicating the need for more effective long-term treatment options. Therefore, the aim of this study was to systematically identify, critique and evaluate all literature investigating the effectiveness of Achilles tendon lengthening, gastrocnemius recession and selective plantar fascia release in healing and preventing diabetic foot ulcers.

Review Searches were conducted in MEDLINE, CINAHL, AMED, EMBASE and The Cochrane Library from the earliest available date to November 2014. Methodological quality of included studies was assessed using the Downs and Black checklist. Data from randomised-controlled trials were analysed using random effects meta-analysis. For all other studies, data were analysed descriptively. Eleven studies (614 participants) were included in the review, with a median sample size of 29 participants. Meta-analysis of two randomised-controlled trials found that there was no statistically significant difference between Achilles tendon lengthening or gastrocnemius recession and total contact casting for time to healing of diabetic foot ulcers (mean difference, MD, 8.22 days; 95 % CI, −18.99 to 35.43; P = 0.55; I 2 = 34 %) and the rate of ulcers healed (risk ratio, RR, 1.06; 95 % CI, 0.94 to 1.20; P = 0.34; I 2 = 41 %). The rate of ulcer recurrence was significantly lower following Achilles tendon lengthening or gastrocnemius recession than total contact casting (RR, 0.45; 95 % CI, 0.28 to 0.72; P < 0.001; I 2 = 0 %).

Conclusions Achilles tendon lengthening and gastrocnemius recession appear to be effective surgical treatments for healing diabetic foot ulcers. The rate of ulcer recurrence was lower following Achilles tendon lengthening or gastrocnemius recession procedures compared to total contact casting treatment alone. Therefore, these surgical procedures may provide viable treatment options for the management and prevention of diabetic foot ulcers. Further rigorous randomised-controlled trials with longer follow-up are required to determine the long-term effectiveness and safety of these procedures.
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NewsBot · May 31, 2016

Gastrocnemius Fascia Release under Local Anaesthesia as a Treatment for Neuropathic Foot Ulcers in Diabetic Patients: a short series.
Kobe Van Bael et al
Acta Chirurgica Belgica

Background: Diabetic foot ulceration is the leading cause of major amputation in the developed world. Plantar neuropathic ulcers at the forefoot can be managed conservatively with off-loading but treatment is not invariably successful. Achilles-tendon lengthening procedures aim at increasing dorsiflexion and decreasing forefoot pressure, but can be associated with complications and require prolonged postoperative immobilization to prevent tendon rupture. We assessed the feasibility and clinical outcome of a comparative minimal invasive procedure: the gastrocnemius fascia release. This technique targets the same goals but is performed under local anesthesia and allows immediate postoperative weight-bearing and ambulation.
Methods: Diabetic patients with plantar neuropathic ulcers Wagner grade 2 or 3 were recruited from our diabetic foot clinic. Patients with infected wounds or untreatable peripheral arterial disease were excluded from the study. Conservative treatment with off-loading and local wound care was attempted for six weeks and surgical procedure only contemplated upon failure. Primary end-points were improved range of dorsiflexion and time-to-healing. Secondary end-points were local ulcer recurrences, new plantar ulcers and minor or major amputation. Postoperative follow-up was 12 months.
Results: 7 patients were included in the study. An improvement in dorsiflexion of 10.4? (mean) was recorded postoperatively (p < 0.01). After 30 days, complete healing was accomplished in 6 of the 7 patients. Long-term results were excellent as no ulcer recurrence or amputation was noted.
Conclusions: Gastrocnemius fascia release under local anaesthesia can be performed safely in diabetic patients with plantar neuropathic ulcers under the metatarsal heads. Clinical outcome is excellent and long-term results promising.
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NewsBot · Oct 26, 2016

Is there still a place for Achilles tendon lengthening?
Tagoe MT, Reeves ND, Bowling FL.
Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:227-31. doi: 10.1002/dmrr.2745.

Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.
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NewsBot · Jan 31, 2017

Association between ankle equinus and plantar pressures in people with diabetes. A systematic review and meta-analysis
A Searle, MJ Spink, A Ho, V Chuter
Clinical Biomechanics; 31 January 2017

Highlights
•We found a significant association between equinus and increased plantar pressures.
•Association present particularly in participants with a history of foot ulceration
•Potential for equinus to elevate plantar pressures independent of neuropathy
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Background
Diabetes is one of the most common chronic diseases in the world and is associated with a life-time risk of foot ulcer of 12–25%. Diabetes related restriction in ankle joint range of dorsiflexion is proposed to contribute to elevated plantar pressures implicated in the development of foot ulcers.

Methods
A systematic search of EBSCO Megafile Premier (containing MEDLINE, CINAHL, SPORTSdiscus and Academic Search Complete) and The Cochrane Library was conducted to 23rd November 2016. Two authors independently reviewed and selected relevant studies. Meta-analysis of study data were conducted where possible.

Findings
Fifteen studies met the inclusion criteria. Three studies were eligible to be included in the meta-analysis which found that equinus has a significant, but small, effect on increased plantar pressures (ES = 0.26, CI 95% 0.11 to 0.41, p = 0.001). Of the remaining studies, eight found evidence of an association between limited ankle dorsiflexion and increased plantar pressures while four studies found no relationship.

Interpretation
Limited ankle joint dorsiflexion may be an important factor in elevating plantar pressures, independent of neuropathy. Limited ankle dorsiflexion and increased plantar pressures were found in all the studies where the sample population had a history of neuropathic foot ulceration. In contrast, the same association was not found in those studies where the population had neuropathy and no history of foot ulcer. Routine screening for limited ankle dorsiflexion range of motion in the diabetic population would allow for early provision of conservative treatment options to reduce plantar pressures and lessen ulcer risk.
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NewsBot · Oct 13, 2017

The Effectiveness of Achilles Lengthening Plus Intralesional Human
Recombinant Epidermal Growth Factor to Prevent Recidivism of
Neuropathic Diabetic Forefoot Ulceration
Aristides I Garcia Herrera et al
Clin Res Foot Ankle 2017, 5:3

Objective: To assess the effectiveness and safety of the combination of z-plasty lengthening of Achilles tendon
plus intralesional administration of human recombinant Epidermal Growth Factor in the reduction of the recidivism of
neuropathic forefoot ulceration
Study Design: Sixty-two neuropathic forefoot ulceration in fifty-four diabetic subjects were included on this
prospective, Open, Uncontrolled, Non Randomized, Observational study. The eligibility criteria included normal
physical activity with no antecedent of minor amputation, and an ankle dorsiflexion range of motion (DF-ROM) minor
of 15 degrees measures with goniometer. Eligible patients were referred to the Vascular Surgery Service of the
Clinic Surgical Hospital “José R. Lopez Tabrane” in Matanzas, Cuba from January 2009 to May 2015. The follow-up
process ends in December 2016. Based on non-probability consecutive sampling thirty-one patients with thirty-five
neuropathic forefoot ulcerations (NFU) were included in the treatment group and twenty-three patients with twentyseven
NFU in the control.
Results: Sixty-two neuropathic forefoot ulceration in fifty-four diabetic subjects who met the eligibility criteria
(inclusion and exclusion) were included in this study. Groups were comparable according to demographic and
baseline characteristics. The recidivism of showed a 9 times reduction and the rate of new lesson was reduced in
3.1 times. Both findings of clinical relevance. The most frequent complications were Local pain 5.7% (n=3) in the
treatment group, and 14.8% (n=4) in the control group. There were not minor or major amputations reported as an
outcome of treatment.
Conclusion: Combination of z-plasty lengthening of Achilles tendon plus intralesional administration of Human
Recombinant Epidermal growth factor reduces the recidivism and the new lessons. This therapeutic association was
considered effectiveness and safety for the prevention of the recidivism and new lessons in the neuropathic
ulceration of the forefoot.
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NewsBot · Dec 20, 2017

Anatomic Evaluation of Percutaneous Achilles Tendon Lengthening.
Phillips S et al
Foot Ankle Int. 2017 Dec 1:1071100717745559. doi: 10.1177/1071100717745559.

BACKGROUND:
The objective of the study was to evaluate the accuracy of percutaneous Achilles tendon lengthening (TAL) using a triple hemisection technique and the improvement in ankle dorsiflexion.

METHODS:
Ten fresh-frozen above-knee cadaveric specimens were used. A percutaneous triple hemisection of the Achilles tendon (proximal, intermediate, and distal) was performed. Maximum ankle dorsiflexion was evaluated pre- and postprocedure with a digital goniometer. After proper dissection, the relative width of the cuts was noted. Following forced ankle dorsiflexion, displacement in the tensile gaps was measured in all 3 cuts with a precision digital caliper.

RESULTS:
The overall relative width of the percutaneous cut was 51.3% ± 16.3% of the Achilles tendon diameter, 44.3% ± 13.6% for the proximal cut, 50.3% ± 15.6% for the intermediate cut, and 59.3% ± 18.4% for the distal cut. Tendon excursion averaged 13.0 ± 3.8 mm for the proximal cuts, 12.5 ± 4.7 mm for the intermediate cuts, and 8.2 ± 3.7 mm for the distal cuts. One cadaver had a complete rupture of the Achilles tendon and was excluded from the excursion data analysis. The mean range of motion for ankle dorsiflexion was 8.1 ± 3.9 degrees preprocedure and 27.6 ± 5.3 degrees postprocedure. The dorsiflexion angle significantly increased ( P < .0001) at an average of 19.5 ± 5.0 degrees following TAL.

CONCLUSION:
Our cadaveric study demonstrated that the percutaneous triple hemisection of the Achilles was an accurate technique that provided successful lengthening of the tendon and increased ankle dorsiflexion. Complete ruptures are possible complications.

CLINICAL RELEVANCE:
Our cadaveric study showed that in a clinical situation, triple hemisections of the Achilles tendon can be performed reliably, with significant improvement of the ankle dorsiflexion, mainly through increased tendon excursion at the proximal and intermediate cuts, and with low risk of complete ruptures.
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NewsBot · Sep 5, 2018

Diabetic foot ulcers and isolated gastrocnemius tightness
Edson Augusto de Jesus Constante Pignata et al
Sci J Foot Ankle. 2018;12(2):150-3.

Objective: To determine the prevalence of isolated gastrocnemius tightness (IGT) in diabetic patients with plantar ulcers in the forefoot using
the Silfverskiöld test.
Methods: This prospective cohort study consecutively evaluated 50 diabetic patients with Wagner grade I or II ulcers in the forefoot treated
conservatively on an outpatient basis and assessed them for IGT using the Silfverskiöld test.
Results: The prevalence of IGT was 66.7%. There was no significant correlation between IGT and the ulcer’s area or depth (Wagner’s classification)
or the patient’s insulin use.
Conclusion: The prevalence of IGT in diabetic patients with plantar ulcers is high, suggesting that this complicationmay contribute to the
development of plantar ulcers.
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NewsBot · Oct 9, 2018

Prevalence of ankle equinus and correlation with foot plantar pressures in people with diabetes
A.Searle M.J.Spink V.H.Chuter
Clinical Biomechanics Volume 60, December 2018, Pages 39-44

Highlights
•We found a high prevalence of ankle equinus in a low risk cohort of adults with diabetes.
•Adults with an equinus were more than twice as likely to have at risk in-shoe peak plantar pressures.
•Significantly more males and people with neuropathy or elevated HbA1c levels displayed an equinus.
•Ankle equinus diagnosis may help identify adults at increased risk of diabetic foot complications.
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Background
An association between equinus and plantar pressure may be important for people with diabetes, as elevated plantar pressure has been linked with foot ulcer development. To determine the prevalence of equinus in community dwelling people with diabetes and to examine any association between presence of equinus and forefoot plantar pressures.

Methods
Barefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, non-weight bearing ankle range of motion and neuropathy status were assessed in 136 adults with diabetes (52.2% male; 47.8% with neuropathy; mean (standard deviation) age and diabetes duration: 68.4 (11.5) and 14.6 (11.1) years respectively).

Findings
Equinus, when measured as ≤5° dorsiflexion, was present in 66.9% of the cohort. There was a significant correlation between an equinus and barefoot (r = 0.247, p = 0.004) and in-shoe forefoot pressure time integrals (r = 0.214, p = 0.012) and in-shoe forefoot alternate pressure time integrals (r = 0.246, p = 0.004). Significantly more males (p < 0.01) and people with neuropathy (p = 0.02) or higher glycated haemoglobin levels (p < 0.01) presented with an equinus.

Interpretation
Community dwelling adults with diabetes have a high rate of ankle equinus which is associated with increased forefoot pressure time integrals and a two-fold increased risk of high in-shoe peak pressures. Clinical assessment of an ankle equinus may be a useful screening tool to identify adults at increased risk of diabetic foot complications.
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NewsBot · Jul 10, 2019

Calf muscle stretching is ineffective in increasing ankle range of motion or reducing plantar pressures in people with diabetes and ankle equinus: A randomised controlled trial
AngelaSearle et al
Clinical Biomechanics 5 July 2019

Highlights
•Ankle equinus is associated with increased plantar pressure in people with diabetes.
•Adults with diabetes and ankle equinus undertook 8 weeks of static calf stretching.
•No significant increase in ankle dorsiflexion was seen following the intervention.
•Additionally no significant reduction in plantar pressures was noted.
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Background
Limited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may increase ankle dorsiflexion and reduce plantar pressures in people with diabetes.

Methods
Two arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention.

Findings
68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:−0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:−2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:−10.0 to 12.9, p = 0.803) or barefoot peak pressures (−19.1 kPa, 95% CI:−96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up.

Interpretation
Our data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus.
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NewsBot · Aug 31, 2020

Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening
Dean H. Meshkin et al
JFAS: August 28, 2020

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.
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NewsBot · Oct 31, 2020

The use of Percutaneous Achilles’ Tendon Lengthening as an
Adjunct Procedure in Foot and Ankle Surgery: A Review
Gabriel Santamarina, George Zislis
Arch Orthop. 2020

Diabetic foot and ankle reconstruction is a difficult area of surgery in which to achieve ideal outcomes. The goal for a majority of
cases in this surgical field is to achieve a plantigrade foot that can function throughout the gait cycle in shoes with or without a brace.
There are multiple biomechanical, biochemical, neurological, vascular, infectious, and social factors that can influence the likelihood
of achieving those goals. The effect of the Achilles’ tendon on the gait cycle, through its effects on joint function, is the greatest
determinant of non-rigid deformity in diabetic feet. In order to improve the chance of a desired outcome, the Achilles tendon should
be assessed for any possible pathologies. For many patients, the addition of the simple technique of a percutaneous Achilles’ tendon
release to a surgical case is powerful enough to address multiple biomechanical issues and prevent below-knee amputations.
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NewsBot · Feb 23, 2021

Diabetic foot: Which one comes first, the ulcer or the contracture?
Raden Andri Primadhi, Herry Herman
World J Orthop. 2021 Feb 18;12(2):61-68

Diabetic foot is among the most common complications of patients with diabetes. One of the known causes of foot ulceration is ankle equinus, which increases the pressure on the plantar surface during ambulation. Conversely, equinus contracture can be caused by a complicated wound, and it may be due to prolonged immobilization. In this paper, we reviewed the pathogenesis of both conditions and their clinical considerations. Poor glycemic control in patients with diabetes may result in angiopathy and neuropathy as an underlying condition. An ulcer can be precipitated by an injury, improper foot care, or increased biomechanical loading as seen in elevated plantar pressure following equinus contracture. Equinus contracture may be a direct effect of hyperglycemia or can arise in combination with another pathway, for example, involving the activation of transforming growth factor β. Static positioning resulting from any prior foot wound may develop fibrotic changes leading to contracture. Wound healing promoting factors can also result in overhealing outcomes such as hypertrophic scarring and fibrosis. The body's repair mechanism during the healing cascade activates repair cells and myofibroblasts, which also serve as the main producers and organizers of the extracellular matrix. Considering this intricate pathogenesis, appropriate interventions are essential for breaking the vicious cycle that may disturb wound healing.
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NewsBot · Mar 22, 2021

Does a weight bearing equinus affect plantar pressure differently in older people with and without diabetes? A case control study
Sean G.Sadler et al
Clinical Biomechanics; 15 March 2021, 105324

Highlights
•We matched older adults with and without diabetes.
•A high prevalence of ankle equinus was detected with no difference between groups.
•Equinus significantly increased plantar pressure in both groups.
•Clinicians should screen for equinus in older adults regardless of diabetes status.
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Background

A weight bearing ankle equinus has adverse effects on forefoot plantar pressure variables in older adults with diabetes, but it is unclear if this is also the case in older adults without diabetes.

Methods
40 older adults with diabetes (88% type 2, mean diabetes duration 17.6 ± 14.8 years) and 40 older adults without diabetes, matched for age (±3 years), sex and BMI (±2 BMI units) were included (63% female, mean age 72 ± 4 years, BMI 30 ± 4 kg/m2). Primary outcomes were prevalence of a weight bearing equinus and evaluation of barefoot forefoot plantar pressures in older adults with and without diabetes.

Findings
A weight bearing equinus was present in 37.5% and 27.5% of the diabetes and non-diabetes group respectively with no significant difference between groups (p = 0.47). People with diabetes and equinus displayed higher peak pressure (808 versus 540 kPa, p = 0.065) and significantly higher pressure-time integral (86 versus 68 kPa/s, p = 0.030) than people with diabetes and no equinus group. The non-diabetes equinus group had significantly higher peak pressure (665 versus 567 kPa, p = 0.035) than those with no diabetes and no equinus, but no difference in pressure-time integral.

Interpretation
A high prevalence of a weight bearing equinus was detected in older adults with and without diabetes, with associated increases in plantar pressures. As an equinus has been associated with many foot pathologies this study's findings suggest that clinicians should check for the presence of a weight bearing ankle equinus in all older adults.
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NewsBot · Feb 3, 2022

Internet of Things and Artificial Intelligence-Enabled Privacy Preserving Systems for Smart Healthcare
Fan Zhang et al
Volume 2022 |Article ID 4866240 | https://doi.org/10.1155/2022/4866240

To our best knowledge, no study investigated the utility of the combination of high-frequency US and real-time shear wave elastography (RTSWE) in the evaluation of Achilles tendon (AT). Our study aimed to evaluate AT in patients with diabetic foot ulcers using high-frequency US and RTSWE. We retrospectively reviewed 100 patients who visited our hospital due to diabetes. Patients were divided into the study group (those with diabetic foot ulcers) and the control group (those without diabetic foot ulcers). Patients’ demographics, basic medical records, and laboratory tests were reviewed. High-frequency ultrasound and RTSWE were performed in both AT for all 100 patients. Young’s modulus was measured at the upper, middle, and lower parts of each AT by RTSWE. There were 50 patients with diabetic foot ulcers. Patients in the study group had older age, a higher incidence of insulin use, and a higher level of cholesterol than those in the control group. However, thickness and Young’s modulus of AT were comparable in two groups, when evaluated by the combination of high-frequency ultrasound and RTSWE. There was no significant difference in thickness and elastic modulus of AT in patients with and without diabetic foot ulcers when evaluated by the combination of high-frequency ultrasound and RTSWE.
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NewsBot · Feb 4, 2022

Surgical treatment of chronic Achilles tendon rupture results in improved gait biomechanics
Anna Nordenholm et al
J Orthop Surg Res. 2022 Feb 2;17(1):67

Background: Chronic Achilles tendon rupture is associated with persistent weakness at push-off with the affected foot and poor balance, resulting in significant alterations to normal gait. Surgical repair is the most common treatment for improving gait in patients with a Chronic Achilles tendon rupture, but, to date, the outcomes have not been quantified in the literature.

Methods: A total of 23 patients with a Chronic Achilles tendon rupture (mean age 61 ± 15 years) underwent three-dimensional gait analysis according to a standardized protocol using an optical tracking system. Data of spatiotemporal, kinematic and kinetic variables were collected preoperatively and one year postoperatively. In addition, the postoperative gait biomechanics were compared with the gait biomechanics of a control group consisting of 70 healthy individuals (mean age 49 ± 20 years). The prospectively collected data were analyzed by an independent t test.

Results: Postoperatively, increments were found in gait speed (mean difference - 0.12 m/s), stride length (- 0.12 m), peak ankle moment (- 0.64 Nm/kg), peak ankle power (- 1.38 W/kg), peak knee power (- 0.36 m) and reduced step width (0.01 m), compared with preoperative gait biomechanics (p < 0.014). Compared with the control group, patients with a Chronic Achilles tendon rupture exhibited slower postoperative gait speed (mean difference 0.24 m/s), wider step width (- 0.02 m), shorter stride length (0.16 m), longer relative stance phase (- 2.15%), lower peak knee flexion (17.03 degrees), greater peak knee extension (2.58 degrees), lower peak ankle moment (0.35 Nm/kg), peak ankle power (1.22 W/kg) and peak knee power (1.62 W/kg), (p < 0.010).

Conclusion: Surgical intervention and postoperative rehabilitation can be an effective treatment for alterations in gait after a Chronic rupture of the Achilles tendon. However, at one year postoperatively, patients still exhibit impairments in spatiotemporal variables and knee and ankle power compared with healthy controls.
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NewsBot · Feb 7, 2022

Radiographic correction of Achilles tendon lengthening in diabetic patients with high risk for foot ulceration
Gregory A.FooteDPM, AACFAS Andrew M.BelisDPM, FACFAS
Foot & Ankle Surgery: Techniques, Reports & Cases; Volume 2, Issue 1, Spring 2022, 100146

Highlights
•Midfoot collapse in patients with neuropathy greatly increases the risk for ulceration.
•Isolated tendoachilles lengthening provides significant improvement in arch height for relief of plantar midfoot pressures.
•This minimally invasive technique allows for accelerated return to function with protected weight bearing.
•A significant improvement in radiographic parameters shows the effectiveness of this method over a short patient series.
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In the diabetic population, abnormal radiographic findings in sagittal plane alignment of the foot has been well documented as a significant risk factor for ulceration. The purpose of this study is to investigate the effects of an isolated Achilles tendon lengthening on the various radiographic foot angles and how this procedure may have a significant impact on the architecture of the foot, thus reducing the risk for complications.

A total of 10 diabetic patients in this study were evaluated following isolated tendoachilles lengthening with protected weight bearing immediately post-operatively. Radiographic measures of equinus, sagittal deformity and arch height were evaluated on pre-operative weight-bearing lateral radiographs, immediate post-operative radiographs and at the 3-month follow-up. There was an average increase in calcaneal inclination angle of 50.04% and improvement in Meary's angle and talar declination angle of 74.39% and 23.95%, respectively. The results also showed an increase in medial column height of 35.95% and a 77.22% improvement in cuboid height. Loss of correction at the 3-month follow-up was insignificant on all measurements.

Our results showed that an isolated tendoachilles lengthening procedure led to statistically significant improvement of sagittal plane radiographic alignment of the foot translating to a decreased risk for plantar ulceration in diabetic patients. This procedure has utility in a high-risk population to delay disease progression and prevent deformity until aggressive surgical intervention can be safely performed.
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NewsBot · Jul 20, 2022

Overlapping Repair and Epitenon Healing are More Stable Biomechanically Than Side to Side Repair and Endotenon Healing in Achilles Tendon Lengthening with Z Plasty
DenizAkbulut et al
Foot and Ankle Surgery; 20 July 2022

Backround
The current study aimed to compare biomechanical stability and healing process of side-to-side repair with overlapping repair after Achilles tendon lengthening with Z-plasty.

Methods
In our study, 22 Sprague Dawley male rats were used. Side-to-side repairs were classified as group 1 and overlapping repairs as group 2. The left and right legs of seven rats were used to compare early group 1 and early group 2 biomechanical test results at day 0. Seven rats were used to compare late group 1 and late group 2 biomechanical test results at day 28. Both the right and left tendons were tested from the four rats examined in the biomechanically in the untreated control group. The last remaining four rats were used for histopathological evaluation of tendon repair, at 28-days from the index procedure.The ultimate load to failure was compared between groups.

Results
At time 0, there were no measurable differences between group 1 (3.8±1.4 N) and group 2 (3.7 ± 1.1 N), and both could endure less than one-tenth of the untreated control (49 ± 12). At 28 days, ultimate load to failure improved significantly in both group 1 (16.2 ± 3.5 N) and even more in group 2 (36 ± 8.1 N). While there was a significant difference between group 1 and group 2, neither were able to meet the untreated control (49 ± 12). Histopathological evaluation in the post-healing period showed that fibrosis, neovascularization, and inflammation increased in both groups.

Conclusion
The overlapping suture technique and epitenon healing have more stability compared to side-to-side suture technique and endotenon healing. Human population trials may or may not exist, our study suggests it should be considered and further investigation needed before actual clinical application.
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NewsBot · Aug 22, 2022

Concomitant Achilles Tendon Lengthening with Transmetatarsal Amputation for the Prevention of Late Forefoot Ulceration
Mark J Bullock et al
J Bone Joint Surg Am. 2022 Aug 18

Background: Late development of forefoot ulcers is a common finding after transmetatarsal amputation (TMA). The primary aim of this study was to examine whether concomitant prophylactic Achilles tendon lengthening (ATL) was associated with a reduction in the incidence of forefoot ulcers postoperatively.

Methods: A retrospective chart review was performed by 2 authors to identify patients who underwent TMA over a period of 5.5 years from January 1, 2015, through July 31, 2020. They identified 110 feet in 107 patients; the 83 patients (85 feet) who had ≥120 days of follow-up were used for the study. Follow-up was performed with telephone calls (80 patients) or during the last office visit (3 patients). Those who were contacted by telephone were asked if they developed an ulcer after healing from the original surgery. Mean follow-up time was 672 ± 258 days for the 30 feet with concomitant Achilles lengthening and 663 ± 434 days for the 55 feet without Achilles lengthening. Demographic data were analyzed for association with late development of forefoot ulceration.

Results: Eighty-five feet were included in the analysis. Late forefoot ulcers developed in 35% of feet that had a TMA alone (n = 55) compared with 3% of feet who received a concomitant ATL (n = 30; p < 0.001); the 2 groups had similar mean follow-up times. Mean time to ulcer development was 587 ± 420 days in the 19 patients without Achilles lengthening. Of the patients who developed late forefoot ulcers, 47% also developed osteomyelitis, and 16% went on to proximal amputation. Patients who developed forefoot ulcers were younger (55 ± 12 versus 63 ± 11 years of age; p = 0.006) than those who did not.

Conclusions: ATL at the time of TMA is associated with a reduction in the risk of later development of forefoot ulcers, especially in younger patients.
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NewsBot · Jan 5, 2023

Changes in physical function and ambulatory
state after Achilles tendon lengthening for
diabetic foot ulcers
Shinsuke Imaoka et al
J. Phys. Ther. Sci. 35: 51–54, 2023

[Purpose] The recurrence rate of diabetic foot ulcers is high and is related to kinematic factors. Achilles tendon lengthening has been shown to reduce the recurrence rate of foot ulcers by increasing the range of motion
in the ankle joint and decreasing the plantar load. However, there are few reports on the effects of Achilles tendon
lengthening in Japanese patients, but the results are yet to be clarified. This study aims to investigate the effects of
Achilles tendon lengthening on physical function and ambulatory state in patients with diabetic foot ulcers. [Participants and Methods] This study initially included 10 patients with diabetic ulcers who had undergone Achilles
tendon lengthening between April 2013 and March 2020. We retrospectively evaluated the factors available from
the medical records. [Results] The dorsiflexion range of motion in the ankle joint increased by 10.5 degrees on average after surgery, while the plantar load decreased by 19.1 percent, while gait speed and stride length remained
unchanged. [Conclusion] Achilles tendon lengthening for diabetic foot ulcers increased the range of motion in the
ankle joint and decreased the plantar load without changing the ambulatory state.
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NewsBot · Jan 24, 2023

Saving the foot: Simple orthopaedic surgical intervention demonstrates improved outcomes and reduced costs
JessicaBlong et al
Foot and Ankle Surgery; 11 January 2023

Background
Forefoot ulceration in diabetes requires significant resources, with high cost and low rates of success. The authors present the results of tendon procedures (percutaneous toe tenotomy and percutaneous tendo-achilles lengthening) under local anaesthetic to adjust mechanics in patients with diabetic neuropathic forefoot ulceration.

Methods
Retrospective review of electronic patient record of 19 patients (22 feet) undergoing local anaesthetic tendon procedures between April 2019 and April 2021 with a 12 month follow up period. Size of ulcer, rate of ulcer healing, complication rates and ulcer recurrence were recorded and compared to a population of conservatively-managed patients (14 patients, 15 feet) treated prior to the introduction of tendon procedures. All clinical information obtained from electronic patient records.

Results
All patients undergoing tendon procedures achieved complete ulcer healing at a mean time of 3.3 weeks for toe tip ulcers (after toe tenotomy) and 4.5 weeks for metatarsal head ulcers (after Achilles lengthening). There were no admissions for diabetic foot sepsis, reduced recurrence, reduced amputation rates and no mortality.

Of the conservatively managed cohort, only 3 of the 15 achieved ulcer resolution without recurrence within the 12 month study period.

The cohort managed conservatively had an average cost of £ 9902 per patient, per annum. The intervention cost was £ 1211 per patient, saving an average of £ 8691 per patient, per annum with ulcer resolution (88 % reduction in costs).

Conclusion
Significant patient benefit, reduction in resource use and cost saving was seen with this simple intervention, which merits full evaluation in a clinical trial.
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NewsBot · Mar 30, 2023

Quantifying the effects of achilles tendon lengthening surgery: An intraoperative approach
Elena Brendecke et al
Front Physiol. 2023 Mar 6

Achilles tendon lengthening (ATL) is frequently used in the treatment of foot deformities. However, there is currently no objective method to determine the optimal muscle length during surgery. We developed an intraoperative approach to evaluate the passive and active forces of the triceps surae muscle group before and after ATL and aimed to test the following hypotheses: 1) the ankle passive range of motion (ROM) increases, 2) passive muscle forces decrease post-ATL, and 3) forces measured from patients with non-neurological and neurological conditions demonstrate different characteristics. Passive forces at various ankle joint positions were measured in ten patients (11.3 ± 3.0 years old) pre- and post-ATL using a force transducer attached to the Achilles tendon. In six patients, active isometric forces were measured by stimulating the triceps surae supramaximally. Passive forces decreased by 94.3% (p < 0.0001), and ROM increased by 89.4% (p < 0.0001) post-ATL. The pre-ATL passive forces were 70.8% ± 15.1% lower in patients with idiopathic foot deformities than in patients with neurological conditions (p < 0.001). The peak active force of 209.8 ± 114.3 N was achieved at an ankle angle of 38.3° ± 16.0°, where the passive force was 6.3 ± 6.7 N. The inter-individual variability was substantial in both groups. In conclusion, the hypotheses posed were supported. The present findings suggest that muscle passive and active force production as well as the inter-individual variability should be considered when planning further treatment.
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NewsBot · Nov 13, 2023

A 2-Stage Approach in Managing Diabetic Forefoot Ulcers
Madhu Tiruveedhula et al
Foot Ankle Int. 2023 Nov 8

Background: Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer.

Methods: A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations.

Results: Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion.

Conclusion: TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months.
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NewsBot · Feb 21, 2024

Complications of Percutaneous Tendo-Achilles Lengthening for Treatment and Prevention of Diabetic Foot Ulcers: A Systematic Review
Alec J Dierksheide et al
J Foot Ankle Surg. 2024 Feb 1

Percutaneous Achilles tendon lengthening is an effective surgical procedure to treat and prevent forefoot and midfoot ulcerations in patients with diabetes. Patients with diabetes are prone to plantar ulcerations due to a combination of factors, such as peripheral neuropathy, decreased tendon elasticity, peripheral vascular disease, and hyperglycemia. Complications such as re-ulceration and transfer lesion to the heel, associated with a calcaneal gait secondary to over-lengthening, are possible with percutaneous Achilles tendon lengthening. Although percutaneous Achilles tendon lengthening is well accepted, the overall incidence of complication has not been well described. A systematic review of the reported data was performed to determine the incidence of complication for percutaneous tendo-Achilles lengthening when used for the treatment and prevention of diabetic plantar ulcerations. Nine studies involving 490 percutaneous lengthening procedures met the inclusion criteria. The overall complication rate was 27.8% (8% with transfer heel ulcerations). Given the high rate of complications associated with a percutaneous Achilles tendon lengthening, careful patient selection and consideration of these risks should be considered prior to proceeding with this procedure. Additional prospective comparative analyses with standardization of surgical technique, degrees of lengthening achieved, and post-operative weightbearing and immobilization modalities are needed to decrease incidence of complication and achieve higher healing rates.
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