The effect of flexor tenotomy on healing and prevention of neuropathic diabetic foot ulcers on the distal end of the toe.

0.15 MB·English

by  van Netten, Jaap J

vanNettenetal.JournalofFootandAnkleResearch2013,6:3
JOURNAL OF FOOT
http://www.jfootankleres.com/content/6/1/3
AND ANKLE RESEARCH
RESEARCH Open Access
The effect of flexor tenotomy on healing and
prevention of neuropathic diabetic foot ulcers on
the distal end of the toe
Jaap J van Netten*, Adriaan Bril and Jeff G van Baal
Abstract
Background: Flexortenotomy is a minimally invasive surgical alternative for thetreatmentof neuropathic diabetic
footulcersonthe distal end of thetoe. The influence of infection onhealing and time to heal after flexor
tenotomy is unknown.Flexor tenotomy can also be used as a prophylactictreatment. The effectiveness as a
prophylactic treatment has not been described before.
Methods: A retrospective study was performed with theinclusion ofall consecutive flexortenotomiesfrom one
hospital between January 2005 and December 2011.
Results: From 38 ulcers, 35 healed (92%), with a mean time to heal of 22 ±26 days. The longest duration for
healing was found for infected ulcersthat were penetrating to bone (35 days; p = .042). Cases of prophylactic flexor
tenotomies (n=9) didnot resultinany ulcer or othercomplications during follow-up.
Conclusions: The results of this study suggestthat flexor tenotomy may be beneficial for neuropathic diabetic foot
ulcers on thedistal end of thetoe, with a high healing percentage and a shortmeantime to heal.Infected ulcers
that penetratedto bone took a significantly longer time to heal. Prospective research, to confirm the results ofthis
retrospective study, should be performed.
Keywords: Flexor tenotomy, Diabetic foot, Diabetic neuropathy,Wound healing
Background However, limited patient information was provided in
Foot ulcersareafrequentlyoccurringandcostlycompli- those studies, leaving relevant questions unanswered [4].
cation of diabetes, with a yearly incidence around 2% For example, the influence on healing and time to heal
[1]. Claw and hammer toe deformities frequently de- of preoperative treatment, ulcer duration before flexor
velop in people with diabetes, leading to increased pres- tenotomy, ulcer location or infection at the moment of
sure on the distal end of the toes [2]. In combination flexor tenotomyareallunknown.
with neuropathy, this may lead to abundant callus and Flexor tenotomy can also be performed for prevention
the development of ulcers. Conservative treatment of of diabetic foot ulcers, when abundant callus is present
these ulcers consists of wound care, sharp debridement on the distal end of claw and hammer toes. It was
and off-loading of the foot by means of shoe adaptations described in one study that in ten cases the flexor tenot-
or casting [3]. A minimally invasive surgical alternative omy was prophylactic [7]. Unfortunately no further
isflexor tenotomy [4-9]. details were provided regarding effectiveness or compli-
Four small retrospective studies have recently been cations during follow-up of this prophylactic surgery [7].
published, describing positive results of flexor tenotomy: The preventative effects of flexor tenotomy are still
healing rates of 98% to 100% [6-9] after flexor tenotomy, unknown.
and mean time to heal ranging from 21 to 56 days [6-9]. Theaimof this study wasto retrospectively investigate
all consecutive flexor tenotomies in people with neuro-
pathic diabetic foot ulcers onthedistal endofthetoe, to
*Correspondence:[email protected]
Departmentofsurgery,HospitalGroupTwente,Almelo,POBox7600, report healing and time to heal, and to investigate the
Almelo,SZ7600,theNetherlands
©2013vanNettenetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
vanNettenetal.JournalofFootandAnkleResearch2013,6:3 Page2of5
http://www.jfootankleres.com/content/6/1/3
influence of preoperative treatment, ulcer duration be- Dataanalysis
fore flexor tenotomy, ulcer location, and infection on Data were analyzed using SPSS for Windows, version
healing and time to heal. The second aim was to de- 17.0 (SPSS Inc., Chicago IL, United States of America).
scribe the outcomes of all consecutive prophylactic Differences between groups were tested using non-
flexor tenotomies in patients with diabetes and claw or parametric tests, because of non-normal distribution of
hammertoe deformities. thedata.
Methods Results
Studydesign A total of 47 flexor tenotomies were performed on 33
A retrospective cohort study was performed including all patients in the study period. Of these flexor tenotomies,
consecutive flexor tenotomies in patients with diabetes 38 were performed because of an ulcer and 9 were
mellitus, performed in one hospital and by one surgeon prophylactic. Patient, foot and ulcer characteristics are
betweenJanuary2005andDecember2011.Forthisretro- describedinTables1(groupcharacteristics).Forindivid-
spective study, no ethical approval was required. A data- ualcharacteristicsseethe Additionalfile1.
basecontainingallsurgicalproceduresinthestudyperiod
was scanned for the code representing flexor tenotomy,
after which a list was compiled of all patients who had Table1Characteristicsofallpatients
undergoneaflexortenotomy. Patientcharacteristics(n=33)
The medical files of these patients were reviewed for: Gender M: 17
(i) patient characteristics (gender, date of birth, diabetes
F: 16
type, neuropathy assessed with a 10 g Semmes-Weinstein
Age(years) Mean±SD 69±12
monofilament, peripheral arterial disease assessed by pal-
(range) (41–93)
pation of pulses in the lower limb followed by hand-held
Doppler evaluation of the flow signals from both foot ar- Diabetestype Type1: 0
teries and measurement of toe pressure, pre-operative Type2: 33
treatment);(ii)ulcercharacteristics(durationbeforeflexor Neuropathy* Yes: 31
tenotomy,location,presenceofinfectionbasedonclinical
No: 1
assessment, depth divided in three groups as superficial,
Unknown: 1
penetrating to tendon or capsule, penetrating to bone or
PAD Yes: 0
joint,UniversityofTexasWoundClassificationgradeand
stage[10],basedonpresenceofperipheralarterialdisease, No: 33
infectionanddepth,dateofflexortenotomy,dateofulcer Footcharacteristics(n=47)
healing, complications amputation re-ulceration(develop- Pre-operativeTreatment Orthopedicshoe: 14
mentofanewulceronthesamelocation,aftertheprevi-
Castshoe: 3
ousulcerwashealed)andshiftedflexortenotomy(whena
Orthosis: 5
subsequent flexor tenotomy was performed on the same
Felt: 2
footbutonadifferenttoe,thesubsequentflexortenotomy
waslistedasshiftedflexortenotomy)duringfollow-up). None: 23
Location† Digit1: 15
Flexortenotomy Digit2: 16
All flexor tenotomies in the study period were performed
Digit3: 15
by one surgeon, following a standard protocol [7,8].
Digit4: 1
Patientsunderwentoutpatientflexortenotomyunderase-
Ulcercharacteristics(n=38)
lective block using 2% lidocaine without adrenaline. The
flexor digitorum longus is placed under tension (‘bow- Ulcerduration(days) Mean±SD 96±112
stringing’) by positioning the ankle joint in dorsiflexion, (range) (9–525)
while at the same time positioning the affected toe in Ulcerclassification‡ 1A: 14
hyperextension. A stab-wound incision (around 3 mm) is
1B: 6
made atthe middle ofthe proximal phalanx,and the ten-
3B: 18
don is cut. All stab wounds are sutured and a pressure
Note:Valuesaren,orasindicated;SD=standarddeviation;PAD=peripheral
bandageisappliedforthefirstdays.Thefootremainsoff-
arterialdisease,scoredasnowhenfootarterieswerepalpablebythesurgeon;
loaded for 24 hours, after which the patient can weight- *:neuropathywasunknownfor1patient,1patienthadnoneuropathyand
noulcer(prophylacticflexortenotomy);†:nodifferencebetweenleftandright
bear again. The patient is examined at 1-week, and
ismade.‡:ulcerclassification=UniversityofTexasWoundClassification
subsequentlyfollowed-upatregularintervals. system;[10];Castshoe=MAnning-Baal-ALmelocastshoe;[11].
vanNettenetal.JournalofFootandAnkleResearch2013,6:3 Page3of5
http://www.jfootankleres.com/content/6/1/3
Of the 38 ulcers, 35 healed (92%) with a mean time to Table3Relationbetweentimetohealafterflexor
heal of 22 ± 26 days. No relation was found between tenotomyandulcercharacteristics
healing and ulcer duration before flexor tenotomy, pre- Timetoheal Sign
operative treatment, ulcer location or ulcer classification (days)(n=35)
(Table2),althoughthethreeulcersthatdidnothealwere Ulcerduration* Correlation§ .170 .329§
allinfectedandpenetratedtobone(Table2).Asignificant Pre-operativetreatment Orthopedicshoes: 15±10 .467†
relationwasfoundbetweentimetohealandulcerclassifi-
Cast: 24±17
cation, with the shortest time to heal in superficial ulcers
Orthosis: 21±3
without infection, and the longest time to heal seen
Felt: 10±4
in infected ulcers penetrating to bone (13 vs. 35 days;
p=.042;Table3).Norelationwasfoundbetweentimeto None 28±34
heal and ulcer duration before flexor tenotomy, pre- Ulcerlocation† Digit1: 15±6 .483ζ
operativetreatmentorulcerlocation(Table3). Digit2: 24±17
Mean follow-up time was 23 ± 11 months (range:
Digit3: 27±43
11– 60months). Complicationsof amputation(n=3) and Ulcerclassification‡ 1A: 13±6 .042ζ
re-ulceration (n=7) were only found in infected ulcers
1B: 18±9
penetrating to bone at the moment of flexor tenotomy
(seeAdditionalfile1). Toeamputationwasperformed for 3B: 33±37
allthreecaseswithanulcerthatdidnotheal,after29,68, Note:Valuesaremean±standarddeviation;Cast=MAnning-Baal-ALmelocast
shoe;(11)sign.=significance;*:durationunknownforthreeulcers;†:no
and134days.Reasonforamputationwasspreadingofthe differencebetweenleftandrightismade;‡:ulcerclassification=Universityof
infection. All amputation wounds healed. Re-ulceration TexasWoundClassificationsystem;(10)§:Spearman’sρ;ζ:Kruskal-Wallistest.
occurred on the plantar side of the toe (n=6), and on the
dorsalsideofthetoe(n=1).Thelatterwastheresultfrom Nine flexor tenotomies were prophylactic, performed
dorsiflexion of the metatarsophalangeal joint caused by when abundant callus was present on the distal end of
the extensor digitorum longus muscle, even though there the toe (see Additional file 1). None of these toes devel-
was no active muscle contraction. Treatment after re- oped an ulcer or any other complication during follow-
ulceration consisted of antibiotics and shoe adaptations. up(seeAdditionalfile1).
Eighttenotomieswerelistedasshifted,meaningtheywere
performedonthesamefootafterthefirstflexortenotomy Discussion
(seeAdditionalfile1). Flexor tenotomy is a minimally invasive surgical proced-
ure for off-loading claw and hammer toe deformities. In
Table2Relationbetweenhealingafterflexortenotomy thisretrospectivestudy,previouslyreportedfindingsthat
andulcercharacteristics diabetic foot ulcers on the distal end of the toe heal
quickly after flexor tenotomy were replicated [6-9]. The
Nothealed Healed p-value
(n=3) (n=35) rate of non-healing ulcers found in the population of
Ulcer Mean±SD 131±175 93±108 .828‡ this study is slightly higher (9%) than seen in recently
duration*(days) (range) (23–333) (9–525) published retrospective studies (0% - 2% [6-9]). All three
ulcers that did not heal were infected and penetrated to
Pre-operative Orthopedicshoe: 1 9 .711§
treatment bone at the moment of flexor tenotomy. Re-ulceration
Cast: 1 2
was a complication found in seven patients, which is
Orthosis: 0 4 slightly higher than previous studies where this was
Felt: 0 2 described [6,8]. As with amputation, re-ulceration oc-
None 1 18 curred only in toes that were infected and penetrating to
Ulcerlocation† Digit1: 2 10 .178§ bone at the moment of flexor tenotomy. With scarce in-
formation on infection available from previous studies,
Digit2: 1 14
options to reliably compare these findings are unfortu-
Digit3: 0 11
nately limited. Infected ulcers penetrating to bone are
Ulcer 1A: 0 14 .259§ not a contra-indication for performing flexor tenotomy,
classification‡
1B: 0 6 as the majority of these ulcers healed and approximately
3B: 3 15 half of them without complications. However, with am-
putation and re-ulceration only found in this group, the
Note:Valuesarenorasindicated;OS=orthopaedicshoes;Castshoe=
MAnning-Baal-ALmelocastshoe;[11];sign.=significance;*:duration timing of the flexor tenotomy should be investigated in
unknownforthreehealedulcers;†:nodifferencebetweenleftandrightis
respect to performing the procedure earlier or later (be-
made;‡:ulcerclassification=UniversityofTexasWoundClassificationsystem;
[10];‡:Mann–WhitneyUtest;§:Fisher’sExacttest. fore an ulcer becomes infected and penetrating to bone
vanNettenetal.JournalofFootandAnkleResearch2013,6:3 Page4of5
http://www.jfootankleres.com/content/6/1/3
is possible, or when an infection is cleared and penetrat- negative outcomes seen in this study cohort should be
ing to bone is no longer possible), or if a different treat- considered further to determine optimal timing for sur-
ment (e.g. off-loading by means of cast or shoe gicalproceduresinthediabetic foot.
adaptations)ispreferred.
A complication that has been described before is shift- Conclusions
ingofthefoot problem [6]. Aftersuccessful flexor tenot- The results of this study suggest that flexor tenotomy
omy, the next toe may develop an ulcer due to the may be beneficial for neuropathic diabetic foot ulcers on
increased pressure under that toe. The change to the the distal end of the toe, with a high healing percentage
structure and therefore function of the diabetic foot has and a short mean timeto heal. Infection and penetrating
implications for a shift in plantar pressures and other to bone should not be considered contra-indications.
forces affecting the foot, sometimes resulting in a new However, these cases may experience delayed healing
ulcer on the next toe. Shifted flexor tenotomy is then times and an increased risk of complications during fol-
one of the first treatment options to consider. With low-up. Prophylactic flexor tenotomy may hold promise
eight shifted flexor tenotomies found in our population, as a measure for prevention of ulceration on the distal
this is not a rare complication. Frequent follow-up visits end of the toe. Prospective research, to confirm the
are essential to timely detect these ulcers, or the abun- results of this retrospective study and to compare flexor
dant callus which is a pre-sign of these ulcers. Acompli- tenotomy with other forms of treatment, should be per-
cation after flexor tenotomy that has not been described formed beforedefinitive conclusions canbedrawn.
before was dorsiflexion of the metatarsophalangeal joint.
This may be caused by the extensor digitorum longus Additional file
muscle, without active muscle contraction, or by the in-
advertent release of the flexor brevis muscle. This was Additionalfile1:Characteristicsofindividualpatients.
found in one patient, one month after the flexor tenot-
omy. There was inadequate space in the toe-box of the Competinginterests
shoe due to the altered toe position, and consequently Theauthorsdeclarethattheyhavenocompetinginterests.
an ulcer developed on the dorsal side of the toe. Fre- Authors’contributions
quent follow-up visits and timely made shoe adaptations JvNparticipatedinthedesignofthestudy,performedstatisticalanalysis,and
can preventulcerationdue tothis complication. draftedthemanuscript.ABparticipatedinthedesignofthestudyand
performedallretrospectivedatacollection.JvBdesignedthestudy.All
Prophylactic flexor tenotomies have only been
authorsmadesubstantialcontributionstoanalysisandinterpretationofthe
described once, yet without describing the effectiveness dataandhavebeeninvolvedindraftingthemanuscript.Allauthorsread
of the prophylactic intervention [7]. In this study, andapprovedthefinalmanuscript.
prophylactic flexor tenotomy was successful in the pre-
Received:17October2012Accepted:21January2013
vention of ulcer development during long-term follow- Published:24January2013
up.Thissuggeststhatflexortenotomymayholdpromise
References
as a measure for prevention and might be considered, if
1. BoultonAJ,VileikyteL,Ragnarson-TennvallG,ApelqvistJ:Theglobal
possible, in an early stage of treatment, before an ulcer burdenofdiabeticfootdisease.Lancet2005,366:719–24.
candevelop.Itshouldbenotedthatoursamplewaslim- 2. BakkerK,ApelqvistJ,SchaperNC,InternationalWorkingGrouponDiabetic
FootEditorialBoard:Practicalguidelinesonthemanagementand
ited to nine people only, so more research is needed be-
preventionofthediabeticfoot2011.DiabetesMetabResRev2012,
forewe can drawdefinitive conclusions. 28(1Suppl):225–31.
The retrospective nature of this study presents an im- 3. BusSA,ValkGD,vanDeursenRW,ArmstrongDG,CaravaggiC,HlavacekP,
BakkerK,CavanaghPR:Specificguidelinesonfootwearandoffloading.
portant limitation. Although prospective studies are pre- DiabetesMetabResRev2008,24(1Suppl):192–3.
ferred [4], this retrospective design was chosen to 4. RoukisTS,SchadeVL:Percutaneousflexortenotomyfortreatmentof
investigate the relation between ulcer duration, pre- neuropathictoeulcerationsecondarytotoecontractureinpersonswith
diabetes:Asystematicreview.JFootAnkleSurg2009,48:684–9.
operative treatment, ulcer location, or infection on heal-
5. LaveryLA:Effectivenessandsafetyofelectivesurgicalproceduresto
ing and time to heal after flexor tenotomy. The findings, improvewoundhealingandreducere-ulcerationindiabeticpatients
especially concerning the influence of infection and withfootulcers.DiabetesMetabResRev2012,28(1Suppl):60–3.
6. LabordeJM:Neuropathictoeulcerstreatedwithtoeflexortenotomies.
penetrating to bone at the moment of flexor tenotomy, FootAnkleInt2007,28:1160–4.
are relevant and useful additions when setting up pro- 7. TamirE,McLarenAM,GadgilA,DanielsTR:Outpatientpercutaneousflexor
spective trials. The effect of flexor tenotomy should be tenotomiesformanagementofdiabeticclawtoedeformitieswith
ulcers:Apreliminaryreport.CanJSurg2008,51:41–4.
compared with conservative non-surgical treatment
8. SchepersT,BerendsenHA,OeiIH,KoningJ:Functionaloutcomeand
options such as off-loading by means of casting or shoe patientsatisfactionafterflexortenotomyforplantarulcersofthetoes.
adaptations, and also compared with open surgical pro- JFootAnkleSurg2010,49:119–22.
9. KearneyTP,HuntNA,LaveryLA:Safetyandeffectivenessofflexor
cedures such as resection arthroplasty and toe amputa-
tenotomiestohealtoeulcersinpersonswithdiabetes.DiabetesResClin
tion in future research. The influence of infection on Pract2010,89:224–6.
vanNettenetal.JournalofFootandAnkleResearch2013,6:3 Page5of5
http://www.jfootankleres.com/content/6/1/3
10. ArmstrongDG,LaveryLA,HarklessLB:Validationofadiabeticwound
classificationsystem.thecontributionofdepth,infection,andischemia
toriskofamputation.DiabetesCare1998,21:855–9.
11. HissinkRJ,ManningHA,vanBaalJG:TheMABALshoe,analternative
methodincontactcastingforthetreatmentofneuropathicdiabetic
footulcers.FootAnkleInt2000,21:320–3.
doi:10.1186/1757-1146-6-3
Citethisarticleas:vanNettenetal.:Theeffectofflexortenotomyon
healingandpreventionofneuropathicdiabeticfootulcersonthedistal
endofthetoe.JournalofFootandAnkleResearch20136:3.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit