September 2009: Letter

In his excellent review of surgical treatment of the diabetic foot (Surgical management of the diabetic foot, WOUNDS, March 2008), Dr. Caputo correctly points out that decreasing pressure in the ulcer area is crucial to healing the foot ulcers. However, there is important information on successful tendon lengthening treatments including results on follow-up not mentioned in the article. I also have referenced some information published after this article. Lin et al¹ reported a study (Level-III) in which ulcers that did not heal with use of a total contact cast were treated with Achilles tendon lengthening; 93% healed and did not recur. More importantly, in a randomized controlled study (Level I), Mueller et al² found that the healing rate after Achilles tendon lengthening combined with treatment in a total contact cast was higher than that associated with treatment with a total contact cast alone. Especially dramatic was the difference in the recurrence rate, which was 81% at 2 years after ulcer healing in patients treated with a total contact cast alone, compared with 38% in those treated with a total contact cast and Achilles tendon lengthening.

Additional studies (Level IV) with longer follow-up demonstrated that treating forefoot ulcers with tendon lengthening without the use of a total contact cast results in a higher rate of healing, a lower complication rate, and a much lower recurrence rate as compared with the results of treatment with a total contact cast alone.^3–6

In my opinion, this literature indicates the superiority of tendon lengthening over other methods of decreasing pressure for the treatment of diabetic foot ulcers. Dayer and Assal⁷ agree that tendon lengthening should now be considered the gold standard treatment for diabetic forefoot ulcers.

J. Monroe Laborde, MD, MS
Director, Diabetic Foot Clinic
LSU Health Sciences Center, New Orleans, LA
Email: monroe@laborde.net