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.