Background: Literature in the past decade has shown that Achilles tendon-lengthening surgery in addition to total contact casting decreases the rate of plantar ulcer recurrence in the forefoot and midfoot; however, the risk of heel ulceration or recurrent equinus deformity with new forefoot or midfoot wounds is not insignificant. The purpose of this study was to compare the rate of recurrent ulceration between the patient groups who have undergone soft-tissue repair of diabetic forefoot or midfoot wounds either with or without concomitant Achilles tendon-lengthening surgery.
Methods: All diabetic patients with plantar forefoot or midfoot ulceration who underwent soft-tissue reconstruction during two different time periods-from 1983 to 1991 or from 1996 to 2004-were reviewed. Multiple patient-related factors were compared. The "early group" consisted of 179 wounds in 149 patients who underwent wound closure surgery alone. The "later group" included 145 wounds in 138 patients who underwent similar wound closure procedures with the addition of Achilles tendon-lengthening surgery.
Results: Twenty-five percent in the early group and 2 percent of patients in the later group developed recurrent ulceration requiring reoperation, which resulted in 94 percent relative risk reduction (p < 0.001), whereas the risk factors and demographic data were similar in each group. In addition, 12 percent in the early group and 4 percent of the later group developed transfer lesions (p < 0.001).
Conclusion: If one avoids excessive Achilles lengthening, the addition of an Achilles tendon-lengthening procedure can significantly reduce the risk of recurrent diabetic foot ulcerations.
Clinical question/level of evidence: Therapeutic, III.