Percutaneous lengthening of Achilles tendon

A 55-year-old African-American male with poorly controlled type 2 diabetes (HbA]c = 10.6%) of 8 years' duration, and dense peripheral neuropathy was seen regularly in the diabetic foot clinic for treatment of a chronic nonhealing full-thickness ulcer located beneath the 2nd and 3rd metatarsal heads of his left foot. The ulcer did not probe to bone. Treatment consisted of surgical wound debridement, total-contact casting, walking brace and a variety of topical wound healing agents.

Diagnostic studies

• Serial X-rays were negative for osteomyelitis: however, they revealed a long 3rd metatarsal

• MRI was unremarkable

• Non-invasive vascular studies were normal with evidence of strong pedal pulses

• EMED plantar pressure measurements revealed markedly elevated peak plantar pressure, 117N/cm2, located beneath the 2nd to 3rd metatarsal heads, right foot

• Arthrometric evaluation revealed ankle joint dorsiflex-ion was -6° with the knee extended, -2° with the knee flexed on the right ankle.

The proposed treatment for this patient was a percutaneous lengthening of the right Achilles tendon, by triple hemisection, under local anaesthesia. The patient consented to this minimally invasive procedure. Within 3-4 weeks the plantar ulcer was completely healed and has remained healed for the last 3 years. Peak pressure at the site of ulcer was significantly reduced to 42 N/cm2. The surgical technique is described below.

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