Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening

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.     

Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial

BACKGROUND: Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with and without an Achilles tendon lengthening. Our primary hypothesis was that the Achilles tendon lengthening would lead to a lower rate of ulcer recurrence. Methods: Sixty-four subjects were randomized into two treatment groups, immobilization in a total-contact cast alone or combined with percutaneous Achilles tendon lengthening, with measurements made before and after treatment, at the seven-month follow-up examination, and at the final follow-up evaluation (a mean [and standard deviation] of 2.1 +/- 0.7 years after initial healing). There were thirty-three subjects in the total-contact cast group and thirty-one subjects in the Achilles tendon lengthening group. There were no significant differences in age, body-mass index, or duration of diabetes between the groups. Outcome measures were time to healing of the ulcer, ulcer recurrence rate, range of dorsiflexion of the ankle, peak torque (strength) of the plantar flexor muscles, and peak plantar pressures on the forefoot. RESULTS: Twenty-nine (88%) of thirty-three ulcers in the total-contact cast group and all thirty ulcers (100%) in the Achilles tendon lengthening group healed after a mean duration (and standard deviation) of 41 +/- 28 days and 58 +/- 47 days, respectively (p > 0.05). (One patient in the Achilles tendon lengthening group died before treatment was completed.) In the first seven months of follow-up, sixteen (59%) of the twenty-seven patients in the total-contact cast group who were available for follow-up and four (15%) of the twenty-seven patients in the Achilles tendon lengthening group who were available for follow-up had an ulcer recurrence (p = 0.001). At the time of the two-year follow-up, twenty-one (81%) of the twenty-six patients in the total-contact cast group and ten (38%) of the twenty-six patients in the Achilles tendon lengthening group had ulcer recurrence (p = 0.002). Compared with the group treated with the total-contact cast, the group treated with Achilles tendon lengthening had increased dorsiflexion and it remained increased at seven months (p < 0.001). Plantar flexor peak torque also decreased after Achilles tendon lengthening (p < 0.004), but it returned to baseline after seven months. Peak plantar pressures on the forefoot during barefoot walking were reduced (p < 0.0002) following Achilles tendon lengthening yet returned to baseline values within seven months after treatment. CONCLUSIONS: All ulcers healed in the Achilles tendon lengthening group, and the risk for ulcer recurrence was 75% less at seven months and 52% less at two years than that in the total-contact cast group. Achilles tendon lengthening should be considered an effective strategy to reduce recurrence of neuropathic ulceration of the plantar aspect of the forefoot in patients with diabetes mellitus and limited ankle dorsiflexion (相似文献   

Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot

BACKGROUND: The purpose of this study was to determine the degree to which pressure on the plantar aspect of the forefoot is reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. METHODS: Ten diabetic patients who had a history of neuropathic plantar ulceration of the forefoot were enrolled in a laboratory gait trial. A repeated-measures design and a computer analysis of force-plate data were used to examine dynamic pressures on the forefoot, with the patient walking barefoot, immediately before percutaneous lengthening of the Achilles tendon and at eight weeks afterward. Although the wound in each patient had healed at least one month before the operation, we considered the patients to be at high risk for ulceration because they had had an ulcer previously. RESULTS: The mean peak pressure (and standard deviation) on the plantar aspect of the forefoot decreased significantly from 86+/-9.4 newtons per square centimeter preoperatively to 63+/-13.2 newtons per square centimeter at eight weeks postoperatively (p<0.001). Commensurately, the mean dorsiflexion of the ankle joint increased significantly from 0+/-3.1 degrees preoperatively to 9+/-2.3 degrees at eight weeks post-operatively (p<0.001). CONCLUSIONS: The results of this study suggest that peak pressures on the plantar aspect of the forefoot are significantly reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. We are unaware of any other reports in the medical literature that describe such findings. These data may lend support to studies that have indicated that this procedure should be used as an adjunctive therapeutic or prophylactic measure to reduce the risk of neuropathic ulceration.     

The Effect of Gastrocnemius Recession and Tendo-Achilles Lengthening on Adult Acquired Flatfoot Deformity Surgery: A Systematic Review

The purpose of this study was to evaluate the available clinical and radiographic evidence for incorporation of a gastrocnemius recession or tendo-Achilles lengthening into the surgical correction of adult acquired flatfoot deformity. A systematic review of the literature was performed using PubMed, Embase, Cochrane, CINAHL, and Google Scholar. Among the relevant articles, the level of evidence and quality was identified using the Methodological Index for Non-Randomized Studies tool. No study explicitly examined whether clinical or radiographic outcomes after adult acquired flatfoot deformity correction are improved when incorporating a gastrocnemius recession or tendo-Achilles lengthening compared with when no such procedure is performed, nor have they directly compared outcomes between 2 procedures. Studies demonstrated an overall improvement in postoperative range of motion and plantar flexion power after gastrocnemius recession, but such findings are hard to separate from the clinical contribution of concomitant corrective procedures to the foot itself. All studies that analyzed anteroposterior talo-calcaneal angle, anteroposterior lateral talo-first metatarsal angle and calcaneal inclination angle revealed improvement of each parameter postoperatively. There were no high-level evidence studies in the literature explicitly quantifying ankle range of motion, plantar flexion power, or radiographic impact of gastrocnemius recession or tendo-Achilles lengthening on adult acquired flatfoot deformity correction. Although gastrocnemius-soleus complex contractures have certainly been demonstrated to coexist with adult acquired flatfoot deformity, support for lengthening procedures is largely based on expert opinion or case series and is difficult to distinguish from the clinical contribution of associated corrective procedures.     

Gastrocnemius Recession as an Alternative to TendoAchillis Lengthening for Relief of Forefoot Pressure in a Patient with Peripheral Neuropathy: A Case Report and Description of a Technical Modification

The gastrocnemius recession is a popular surgical procedure for the treatment of equinus contracture. Lengthening the gastrocnemius tendon has been show to be an effective means of reducing pressure to the plantar forefoot by weakening the triceps surae complex. The more traditional method of weakening the triceps surae is a modification of Hoke's triple hemisection through the tendoAchillis. This technique unfortunately carries a serious risk of the development of a calcaneal gait. The purpose of this case report is to demonstrate that the gastrocnemius recession is an effective and safe alternative to the traditional tendoAchillis lengthening. The authors also describe a minimally invasive technique that uses a pediatric speculum for a self-retrained retractor and portal for instrumentation and visualization.     

Tendo-achilles lengthening and total contact casting for plantar forefoot ulceration in diabetic patients with equinus deformity of the ankle

Total contact casting has been successful in treating neuropathic foot ulcers, but little information is available abouttreating patients with diabetes mellitus for whom total contact casting treatment for forefoot ulceration fails. Equinus deformity of the ankle and limited joint motion in a neuropathic foot can lead to abnormal foot pressures, resulting in failure of total contact casting. This report describes the technique of tendo-Achilles lengthening in conjunction with total contact casting and reports the results achieved in a randomly selected group of diabetic patients with unhealed forefoot ulcerations. Surgical correction with percutaneous tendo-Achilles lengthening and total contact casting can result in rapid healing of the forefoot ulcer and helps prevent ulcer recurrence.     

High recurrence after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity

Both gastrocnemius recession and Achilles tendon lengthening lead to scarring in the calf and have high reported recurrence rates when performed under the age of 8 years. Triceps surae lengthening by external fixation seemed to be a valuable alternative. Twelve calf lengthenings have been performed with an Ilizarov device with a mean correction of 27 degrees. No calcaneal gait was observed, but there was a slow continuous loss of dorsiflexion over the observation period. The Ilizarov technique has a higher recurrence rate than most operative procedures for calf lengthening, but carries virtually no risk in producing calcaneus. The technique cannot be recommended for routine clinical use and may only be an alternative for selected cases.     

The effects of a medializing calcaneal osteotomy with and without superior translation on Achilles tendon elongation and plantar foot pressures

BACKGROUND: The medial calcaneal osteotomy (MCO) is a frequently used corrective procedure for posterior tibial tendon (PTT) insufficiency; however, patients often complain of lateral foot pain postoperatively. Published findings have documented the usefulness of MCO in off-loading the plantar surface of the first and second metatarsal heads but with a concomitant increase in peak pressure over the lateral forefoot and heel. Achilles tendon elongation revealed a trend toward shortening of the ventromedial aspect of the tendon. It was then hypothesized that translating the osteotomized posterior aspect of the calcaneus medially and superiorly would reduce lateral forefoot pressure and decrease the amount of lengthening of the Achilles tendon while continuing to relieve medial forefoot pressure. METHODS: Twenty-eight fresh-frozen cadaver legs were axially loaded on a load-frame device to 100 lbs to assess the effects of a 1-cm MCO in conjunction with either 0.5-cm or 1-cm superior translation on plantar foot pressures and Achilles tendon elongation. RESULTS: The 0.5-cm superior translation resulted in a greater off-loading of the first and second metatarsals than the MCO alone with a trend toward decreased pressures in the lateral forefoot. The 1-cm superior translation continued to unload the first and second metatarsals; however, lateral forefoot and midfoot pressures were increased. Achilles tendon lengthening remained unchanged in the cadaver foot model. CONCLUSIONS: Our findings suggest that the addition of a 0.5-cm superior translation to the traditional 1-cm MCO should allow some degree of off-loading of the medial forefoot without increasing lateral forefoot or heel pressures.     

Salvage of the neuropathic foot by using bone resection and tendon balancing: A retrospective review of 10 patients

Medical records were retrospectively reviewed for 10 patients (mean age, 48.7 years) who had a chronic, recurrent neuropathic forefoot ulceration or osteomyelitis in the presence of an abnormal metatarsal parabola. Two patients had multiple lesser metatarsal osteomyelitis, 3 patients had chronic ulceration in the presence of an abnormal metatarsal parabola, and 5 patients had previous lesser ray resection or metatarsal head resection. None of the patients had signs of skin breakdown under the first metatarsal. All of the patients were treated with a combination gastrocnemius recession, peroneus longus to peroneus brevis tendon transfer, and resection of the second through fifth metatarsal heads to decrease plantar forefoot pressure and preserve the first ray without increasing the risk of ulceration under the first metatarsal head. All patients achieved a healed plantigrade foot without ulcer recurrence, transfer callus development, or contralateral foot breakdown at a mean follow-up of 14.2 months. Postsurgical complications consisted of dehiscence of various incision sites on 3 individual patients and one local reaction to antibiotic-impregnated beads. This preliminary study suggests that this combination of reconstructive procedures may provide an alternative method of foot salvage to panmetatarsal resection and transmetatarsal amputation.     

Gastrocnemius fascia release under local anaesthesia as a treatment for neuropathic foot ulcers in diabetic patients: a short series

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 anaesthesia 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. Post-operative follow-up was 12 months.

Results: Seven patients were included in the study. An improvement in dorsiflexion of 10.4° (mean) was recorded post-operatively (p?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.     

Neuropathic plantar forefoot ulcers treated with tendon lengthenings

BACKGROUND: Foot ulcers are a common cause of infection and amputation in patients with neuropathy. This retrospective study evaluated the healing and recurrence rates after treating neuropathic ulcers plantar to the metatarsal heads with tendon lengthenings in the leg. MATERIALS AND METHODS: Between 1995 and 2003, 20 ulcers plantar to the metatarsal heads in 17 patients were treated with tendon lengthenings. All patients had gastroc-soleus recession (Vulpius procedure). Patients with first metatarsal head ulcers also had Z-type lengthenings of the peroneus longus. Patients with fifth metatarsal head ulcers also had intramuscular lengthening of the tibialis posterior. Patients with second, third, and fourth metatarsal head ulcers had only a gastroc-soleus recession. RESULTS: All patients had neuropathy; 15 patients with 17 ulcers had diabetes mellitus. All incisions healed primarily without infection. Nineteen of 20 ulcers healed. One patient with one ulcer was lost to followup after the ulcer healed. Average followup for the remaining 19 ulcers was 45 months. Average duration of the 19 ulcers before surgery was 17 months. Three of 19 ulcers recurred and had repeat tendon lengthening and healed again. None of the patients whose ulcers healed had to be admitted for foot infection or amputation. The one patient whose ulcer did not heal developed progressive dry gangrene which required trans-femoral amputation six months after tendon lengthening. CONCLUSION: Tendon lengthenings in the leg seem to be effective in healing and preventing recurrence of neuropathic ulcers plantar to the metatarsal head with a low complication rate.     

Preserving plantar flexion strength after surgical treatment for contracture of the triceps surae: A computer simulation study

Contractures of the triceps surae commonly are treated by surgical lengthening of the gastrocnemius aponeurosis or the Achilles tendon. Although these procedures generally relieve contractures, patients sometimes are left with dramatically decreased plantar flexion strength (i.e., decreased capacity to generate plantar flexion moment). The purpose of this study was to examine the trade-off between restoring range of motion and maintaining plantar flexion strength after surgical treatment for contracture of the triceps surae. A computer model representing the normal moment-generating characteristics of the triceps surae was altered to represent two conditions: isolated contracture of the gastrocnemius and contracture of both the gastrocnemius and the soleus. The effects of lengthening the gastrocnemius aponeurosis and the Achilles tendon were simulated for each condition. The simulations showed that nearly normal moment-generating characteristics could be restored when isolated gastrocnemius contracture was treated with lengthening of the gastrocnemius aponeurosis. However, when isolated gastrocnemius contracture was treated with lengthening of the Achilles tendon, the moment-generating capacity of the plantar flexors decreased greatly. This suggests that lengthening of the Achilles tendon should be avoided in persons with isolated gastrocnemius contracture. Our simulations also suggest that neither lengthening of the gastrocnemius aponeurosis nor lengthening of the Achilles tendon by itself is an effective treatment for combined contracture of the gastrocnemius and soleus. Lengthening the gastrocnemius aponeurosis did not decrease the excessive passive moment developed by the contracted soleus. Lengthening the Achilles tendon restored the normal passive range of motion but substantially decreased the active force-generating capacity of the muscles. Our simulations indicate that independent lengthening of the contracted gastrocnemius and soleus, rather than lengthening of their common tendon, accounts for differences in the architecture of these muscles and may be a more effective means to restore range of motion and maintain plantar flexion strength when combined contracture of the gastrocnemius and soleus is present.     

Effects of medializing calcaneal osteotomy on Achilles tendon lengthening and plantar foot pressures

Posterior tibial tendon insufficiency, or adult acquired flatfoot deformity, involves collapse of the longitudinal arch of the foot with ensuing changes in the bony architecture of the foot as well. While it is generally accepted that a medializing calcaneal osteotomy (MCO) is a very useful treatment for restoring the fallen arch, questions regarding the effects of this procedure upon plantar foot pressures and Achilles tendon length changes need to be answered. This study focuses on changes in plantar foot pressures and Achilles tendon length as the result of performing a MCO. Fourteen fresh-frozen cadaver legs were used to test the effects of MCO on Achilles tendon length changes 2 cm proximal to the Achilles tendon insertion on the calcaneus. Differential variable reluctance transducers were anchored in ventromedial, dorsomedial, dorsolateral, and ventrolateral positions of the Achilles tendon at the aforementioned level. The effects of the MCO on plantar foot pressures were assessed simultaneously using the Tekscan HR Mat. Axial loading (100 lbs) of each specimen was performed in neutral and dorsiflexion (15 degrees). Data were gathered for Achilles tendon length changes and plantar foot pressures for three trials in both the neutral and dorsiflexed positions. A medializing calcaneal osteotomy (1 cm medial translation) was then performed and testing was repeated in the fashion outlined heretofore. Analysis of the data revealed that there was no significant increase in Achilles tendon length as a result of the MCO. The data also showed that average pressure over the first and second metatarsal regions of the forefoot decreased significantly after MCO. At the same time there was a significant increase in average pressure over the medial and lateral aspect of the heel. These findings suggest that the Achilles tendon aids in inversion of the forefoot without undergoing a significant increase in length change of Achilles tendon fibers in any of the regions tested.     

The effect of triceps surae contracture force on plantar foot pressure distribution

BACKGROUND: Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure. METHODS: Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions. RESULTS: The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p相似文献   

Dynamic loading of the plantar aponeurosis in walking

BACKGROUND: The plantar aponeurosis is known to be a major contributor to arch support, but its role in transferring Achilles tendon loads to the forefoot remains poorly understood. The goal of this study was to increase our understanding of the function of the plantar aponeurosis during gait. We specifically examined the plantar aponeurosis force pattern and its relationship to Achilles tendon forces during simulations of the stance phase of gait in a cadaver model. METHODS: Walking simulations were performed with seven cadaver feet. The movements of the foot and the ground reaction forces during the stance phase were reproduced by prescribing the kinematics of the proximal part of the tibia and applying forces to the tendons of extrinsic foot muscles. A fiberoptic cable was passed through the plantar aponeurosis perpendicular to its loading axis, and raw fiberoptic transducer output, tendon forces applied by the experimental setup, and ground reaction forces were simultaneously recorded during each simulation. A post-experiment calibration related fiberoptic output to plantar aponeurosis force, and linear regression analysis was used to characterize the relationship between Achilles tendon force and plantar aponeurosis tension. RESULTS: Plantar aponeurosis forces gradually increased during stance and peaked in late stance. Maximum tension averaged 96% +/- 36% of body weight. There was a good correlation between plantar aponeurosis tension and Achilles tendon force (r = 0.76). CONCLUSIONS: The plantar aponeurosis transmits large forces between the hindfoot and forefoot during the stance phase of gait. The varying pattern of plantar aponeurosis force and its relationship to Achilles tendon force demonstrates the importance of analyzing the function of the plantar aponeurosis throughout the stance phase of the gait cycle rather than in a static standing position. Clinical Relevance: The plantar aponeurosis plays an important role in transmitting Achilles tendon forces to the forefoot in the latter part of the stance phase of walking. Surgical procedures that require the release of this structure may disturb this mechanism and thus compromise efficient propulsion.     

Saving the foot: Simple orthopaedic surgical intervention demonstrates improved outcomes and reduced costs

BackgroundForefoot 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.MethodsRetrospective 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.ResultsAll 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).ConclusionSignificant patient benefit, reduction in resource use and cost saving was seen with this simple intervention, which merits full evaluation in a clinical trial.Level of EvidenceLevel-IV     

The cavovarus foot deformity. Etiology and management

The cavovarus foot is a complex deformity of the forefoot and hindfoot, frequently of neuropathologic etiology. A progressive spinal or peripheral neuromuscular disorder must be excluded by a thorough clinical evaluation. With the failure of nonoperative modalities, surgical options depend on patient age, etiology of the deformity, and the constellation and flexibility of the defects observed. If the hindfoot varus is flexible, correction of the cavus and forefoot pronation through extensive plantar release and metatarsal osteotomies is reliable. The underlying muscle imbalance must be addressed through tendon transfers to prevent further progression. In the young child, a rigid hindfoot varus will often be corrected by a radical plantar-medial release, but the more mature foot may require midtarsal osteotomy and calcaneal osteotomy or triple arthrodesis. The surgery is usually staged to provide correction of deformity and stabilization of the hindfoot prior to tendo Achilles lengthening or tendon transfer. Arthrodesis of a previously well-corrected foot is common due to progression of the neurologic deficit or failure to achieve muscular balance. The claw toe deformity also must be corrected by tendon transfer, osteotomy, and arthrodesis for reasons of both comfort and function.     

Biomechanical consequences of adding plantar fascia release to metatarsal osteotomies: Changes in forefoot plantar pressures

Destruction of the normal metatarsal arch by a long metatarsal is often a cause for metatarsalgia. When surgery is warranted, distal oblique, or proximal dorsiflexion osteotomies of the long metatarsal bones are commonly used. The plantar fascia has anatomical connection to all metatarsal heads. There is controversial scientific evidence on the effect of plantar fascia release on forefoot biomechanics. In this cadaveric biomechanical study, we hypothesized that plantar fascia release would augment the plantar metatarsal pressure decreasing effects of two common second metatarsal osteotomy techniques. Six matched pairs of foot and ankle specimens were mounted on a pressure mat loading platform. Two randomly assigned surgery groups, which had received either distal oblique, or proximal dorsiflexion osteotomy of the second metatarsal, were evaluated before and after plantar fasciectomy. Specimens were loaded up to a ground reaction force of 400 N at varying Achilles tendon forces. Average pressures, peak pressures, and contact areas were analyzed. Supporting our hypothesis, average pressures under the second metatarsal during 600 N Achilles load were decreased by plantar fascia release following proximal osteotomy (p < 0.05). However contrary to our hypothesis, peak pressures under the second metatarsal were significantly increased by plantar fascia release following modified distal osteotomy, under multiple Achilles loading conditions (p < 0.05). Plantar fasciotomy should not be added to distal metatarsal osteotomy in the treatment of metatarsalgia. If proximal dorsiflexion osteotomy would be preferred, plantar fasciotomy should be approached cautiously not to disturb the forefoot biomechanics. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:800–804, 2017.

     

Simplified approach to idiopathic toe-walking.

Controversy exists as to the treatment of idiopathic toe-walking (ITW). Since 1993, the authors have managed children with ITW using an outpatient percutaneous lengthening of the Achilles tendon, followed by placement of below-knee walking casts for 4 weeks. The authors reviewed 15 children who were treated for ITW with percutaneous Achilles tendon lengthening between 1993 and 1999. Ten of the 15 patients could be contacted for a follow-up survey. None of the parents stated that their child's toe-walking had recurred. There were no painful scars. All of the children were able to keep up with other children and did not notice any calf weakness. Two children had occasional Achilles tendinitis, which was relieved with antiinflammatory medications. All parents were satisfied with their child's outcome. The authors believe that percutaneous tendo-Achilles lengthening in ITW greatly simplifies the management of ITW.