Study on effective treatment for neuropathic plantar forefoot ulcers

Peggy Reilly
Outreach Programs Manager
preilly@aofas dot org

Rosemont, IL - June 20, 2008.  Diabetic foot ulcers are a frequent and expensive problem with over 500,000 diabetic foot ulcers being treated annually in the United States. The estimated treatment cost in a hospital for treatment of one foot ulcer over a 2-year period is $28,000. Over 80,000 amputations are done per year in diabetics with 85% having foot ulcers. If foot ulcers could be eliminated, most of these amputations could be prevented.

Promising treatment news appeared in recent articles in Foot & Ankle International, the official journal of the American Orthopaedic Foot & Ankle Society. These studies, published in the November 2007 and the April 2008 issues were conducted by AOFAS member James Monroe Laborde, MD, orthopaedic foot and ankle surgeon in New Orleans with teaching appointments at both Tulane University and Louisiana State University medical schools.

According to the studies, 20.8 million people in 2005 were estimated to have diabetes mellitus in the United States with foot ulcers developing in approximately 15% of this population during their lifetime. The danger lies in the potential of these foot ulcers eventually leading to the amputation of the affected foot.

These studies evaluated both the healing and recurrence results after tendon lengthening. The studies followed 28 toe ulcers and 20 ulcers plantar to the metatarsal heads.

The purpose of tendon lengthening is to decrease stress on the area of the ulceration, thereby promoting healing. Patients in the studies had ulcers prior to the surgery for a time period ranging from one month to seven years. Most of these people with chronic ulcers had previously been treated unsuccessfully with decreased weight bearing, debridement and shoe modifications.

Dr. Laborde explains, "Tendons lengthened varied depending on the location of the ulcer. Tendons lengthened included Achilles, peroneus longus, posterior tibial, and toe flexors. Patients were allowed to walk full weight bearing in a boot immediately after surgery."

He goes on to say, "Tendon lengthening decreased pressure on areas of ulceration. Nineteen of 20 metatarsal ulcers healed. Three of these ulcers recurred but healed again after repeat tendon lengthening. All of the 28 toe ulcers healed. Three of the toe ulcers recurred but the two that had repeat tendon surgery healed once again."

Dr. Laborde also feels that prophylactic calf stretching might help prevent calluses and that tendon lengthening can also be done to prevent calluses from progressing to ulceration.

Dr. Laborde explains, "By offering an effective treatment for neuropathic forefoot ulceration plus a low complication and recurrence rate, these procedures are an exciting treatment for forefoot ulcers in the diabetic patient. By healing most forefoot ulcers, they should lower the progression of ulceration to infection and ultimately amputation."

Dr. Laborde is planning additional studies to determine the benefit of tendon lengthening on midfoot ulcers, other forefoot wounds, Charcot arthritis, arch collapse, and foot and ankle pain in diabetic patients.

Dr. Laborde is a member of the American Orthopaedic Foot & Ankle Society. Members of the American Orthopaedic Foot & Ankle Society are orthopaedic surgeons (MD or DO) who have extensive training in the diagnosis, non-surgical care and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves with a special interest in the foot and ankle.

The Society promotes quality, ethical and cost-effective patient care through education, research and training of orthopaedic surgeons and other health care providers. The AOFAS creates public awareness for the prevention and treatment of foot and ankle disorders. It provides leadership and serves as a resource for government, industry and the national and international health care community. This year the AOFAS 24th Annual Summer Meeting will be held in Denver, CO June 25-28.

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