Journal of Bone & Joint Surgery - American Volume:
Letters to The Editor
James W. Pritchett, M.D.; Pacific Medical Center 1101 Madison Medical Tower, Suite 400 Seattle, Washington 98104
David G. Armstrong, D.P.M.; Southern Arizona VA Health Care System Tucson, Arizona 85723 E-mail address: email@example.com
To The Editor:
Lengthening of the Achilles Tendon in Diabetic Patients Who Are at High Risk for Ulceration of the Foot (81-A: 535-538, April 1999), by Armstrong et al., presents new information on how to reduce peak pressures on the plantar aspect of the forefoot in diabetics. They suggest that Achilles tendon lengthening may reduce the risk of ulceration. We have used Achilles tenotomy to reduce the symptoms of claudication in selected diabetic patients with peripheral vascular disease. We offer Achilles tenotomy to patients who are not candidates for or who have had failed revascularization procedures.
Of thirty-one patients treated with Achilles tenotomy, twenty-six were able to walk at least twice as far before disabling pain occurred. No patients were worse. Fourteen patients had a current forefoot ulcer or a history of an ulcer. In ten patients, the ulcer healed and did not recur.
Most of our patients complained of some difficulty with balance for the first three months after surgery, but this resolved. We now use anticoagulants for several days in our tenotomy patients as deep venous thrombosis occurred in a third of untreated patients. No infections occurred in the percutaneous incisions, but the cosmetic deformity was readily visible after surgery. While patients are able to walk farther, they do walk more slowly.
Do the authors have any information about balance and gait pattern in diabetic patients treated by Achilles lengthening? Also, is there a possibility that the circulation to skin and subcutaneous tissues of the forefoot improves after Achilles lengthening? Is there any suggestion that the other neuropathic changes to the foot are improved by Achilles tendon lengthening?
James W. Pritchett, M.D.
Pacific Medical Center 1101 Madison Medical Tower, Suite 400 Seattle, Washington 98104
D. G. Armstrong replies:
Dr. Pritchett's suggestion that a similar procedure (tenotomy of the Achilles tendon) might mitigate claudication symptoms in some patients is both a surprising and a compelling one. While we have no ability to confirm or refute the observations of Dr. Pritchett, we believe that what one might consider a decompression tenotomy is worthy of study, and we urge him or other interested parties to pursue it.
In response to his query regarding gait alterations in these subjects, we do (currently anecdotally) see a small reduction in stride length in the months following an Achilles tendon lengthening. As the majority of the patients on whom this procedure is performed (for these indications) are profoundly neuropathic with relatively good outflow, we have not seen any appreciable change in their overall degree of sensory loss or cutaneous blood flow postoperatively. Quite frankly, however, we have not been looking for such changes and therefore cannot discuss them with any degree of authority.
David G. Armstrong, D.P.M.
Southern Arizona VA Health Care System Tucson, Arizona 85723 E-mail address: firstname.lastname@example.org