Gavin Ripp, DPM, then shared his expertise on in-office releases and flaps to improve ulcer healing. Beginning with Achilles tendon lengthening, he cited indication for equinus contracture and forefoot ulcers or preulcerative forefoot calluses. Researchers compared the impact of Achilles tendon lengthening for neuropathic plantar ulcers to treatment with total contact casting, and found 75% less recurrence at 7 months and 52% less at 2 years.¹ Dr. Ripp added that this procedure can take place in an office environment with an 18-gauge needle making the 3 small incisions, and allowing for protected weight-bearing.

Flexor hallucis longus tendon release has applications for hallux malleus, distal or plantar hallux ulcers, and preulcerative lesions of the hallux. Dr. Ripp shared that he does these in the office when the deformity is at least semireducible (reducible is best), with a 61- or 62-blade. He related that an 18-gauge needle will also work, but that he finds this requires more passes. He uses a Band-Aid and adhesive bandage to splint, changing daily for the next 2 weeks. Dr. Ripp said he allows patients to walk that same day.

He added that flexor tenotomy has utility for distal toe ulcers, flexible hammertoes, preulcerative distal toe lesions, or as an adjunct or a plantar metatarsal head ulcer. He prefers to use a 62-blade, but noted that an 18-gauge needle also works nicely. He stressed that surgeons should be aware of the potentiality for transfer ulcers, as shown in the literature², as the flexor slips go to toes 2-5. In his experience, he advocates releasing all of the toes to aid in decreasing risk of recurrence.

An extensor digitorum longus or MTPJ capsulotomy may be a reasonable choice when the patients has a contracted MTPJ and a dorsal digital ulcer or preulcerative lesion of the IPJ, or as an adjunct for a plantar metatarsal head ulcer. Dr. Ripp said he uses a 64- or 67-blade for these procedures, but that an 18-gauge needle can also work.

In his observation, multitendon releases are actually more common, however, often with splintage and dressing, allowing for prompt weight-bearing.

Plantar fasciotomy, specifically selective plantar fascia release, may have application for medial pinch callus/ulcer or plantar hallux callus/ulcer.³ The goal, he shared, is to improve range of motion of the hallux.

Dr. Ripp then reviewed several flap and plastic techniques that surgeons can employ in an office environment, including V-Y skin plasty, Z-plasty, unilobe, bilobe, O-Z, and Schrudde flaps.

Overall, he urged the audience to keep perfusion and coagulation factors in mind when deciding if an in-office procedure is indicated, as well. It also makes sense to look at the economics of the procedure, and in what environment this is most advantageous for all parties.

References

1.     Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003;85(8):1436-45.
2.     Smith SE, Miller J. The safety and effectiveness of the percutaneous flexor tenotomy in healing neuropathic apical toe ulcers in the outpatient setting. Foot Ankle Spec. 2020;13(2):123-131.
3.     Kim JY, Hwang S, Lee Y. Selective plantar fascia release for nonhealing diabetic plantar ulcerations. J Bone Joint Surg Am. 2012;94(14):1297-302.