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* Active Staff Podiatrist, Davis Hospital and Medical
Center, Layton, Utah. McKay-Dee Hospital Ogden, Utah. Logan Regional
Hospital, Logan, Utah. Private Practice Mailing Address: 1660 West
Antelope Drive # 110 Layton, Utah 84041. Web Site: www.DrBrianRichman.com
Author's note: This is the first article in a series of three on
diabetic foot care. TAL in
Diabetic Neuropathic Osteoarthropathy - Charcot Foot, Surgical Approach
to Diabetic Foot
Ulcers, and Diabetic Puncture Wounds. New and exciting break through
events are happening in the surgical treatment of the diabetic foot. I
believe that these three articles will have some value that will help
prevent many diabetic foot problems.
The views and opinions expressed in these journal articles are the sole
responsibility of the
author and should not be considered standard of care.
Abstract
The achilles tendon has a strong plantarflexory force that contributes
to the breakdown of active charcot foot. By performing a achilles tendon
lengthening or weakening procedure it helps eliminate the destructive
forces in the charcot process. When you decrease the destructive forces
in active charcot disease, you eliminate the further collapsing and
breakdown of the foot and ankle. You also prevent rocker bottom
deformity, ulceration, infection, and amputation.
Within the last couple of years, the author has had eight diabetic
patients with active charcot foot with midfoot bone and joint
destruction. All eight patients had a achilles tendon lenghtening/weakening
procedure which stopped the collapsing and further destructive forces
from occurring in their foot.
Introduction
For many years, doctors have been aware of the seriousness of the
complications associated with diabetic neuropathic osteoarthropathy or
charcot foot. Ulceration, infection, foot deformities, delayed healing,
amputation, rocker bottom deformity and chronic wounds are all potential
problems in the diabetic foot, but especially dangerous in charcot
disease. Avoiding complications and preventing this disease from
progressing has been a long term goal of many physicians.
Charcot foot has been described in three phases - development,
coalescence, and reconstruction. Acute or atrophic (destructive) phase
is the most dangerous and destroys normal foot and ankle anatomy. The
acute phase of neuroarthropathy is often precipitated by minor trauma
and is characterized by swelling, local heat, erythema, laxity of
ligaments, joint effusion, and bone resorption. (1) Weight bearing of
the affected foot can cause increased bone destruction, subluxations,
and ulceration with a rocker bottom foot deformity. Chronic or
hypertrophic (coalescence and reconstruction) phase is where the body
tries to repair the damage done from the destructive phase. Usually the
damage is done by the time the charcot foot enters the chronic or
hypertrophic phase.
The achilles tendon is the strongest and thickest of all the tendons in
the body. (2) It forms the common insertion of the gastrocnemius and
soleus muscles or the triceps surae muscles and originates about 6
inches (15 cm) above the calcaneous. (3) The tendo calcaneus or achilles
tendon is a major plantarflexory force through the midfoot and hind
foot. The soleus and gastrocnemius are powerful plantar flexors of the
ankle joint. (4)
A Case Report
A 57 IDDM male who works as a baker complains of a painful Right foot x
3 weeks. States that he works on concrete 8 to 10 hours per day. States
his family practitioner thought he had Cellulitis and has been on
antibiotics x 2 weeks. Denies any fever. States that his foot still
hurts to walk.
Past Medical History - IDDM x 20 years, HTN, CAD, Hypothyroid,
Asthma, Arthritis, Low Back Pain, Peripherial Neuropathy, Allergies,
Hayfever.
Past surgical history - Heart Bypass, L shoulder surgery,
gallbladder removal.
Medications - Prozac, Insulin, Levothyroxin. Allergies - NKDA.
On exam - the patient has swelling and pain Right midfoot and
ankle area. Slight erythema R foot noted. Pain upon palpation R midfoot
Lis Franc's area. No red streaking up foot or leg. Slight tightness R
achilles tendon on knee extension. X-rays show bone destruction Right
Lis Franc's area ( See Figures 1-3 ).
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1 |
Figure
2 |
Figure
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Assessment - IDDM. Charcot Foot. Patient would benefit from an
achilles tendon lengthening procedure to reduce the destructive charcot
forces. Patient needs to find a job that does not require so much
walking, standing, working on concrete.
A Right percutaneous achilles tendon lengthening procedure was performed
using two small incisions. The Patient had a weight bearing fiberglass
cast applied. He was given crutches and a bone stimulator to help reduce
the destructive forces from charcot foot.
The surgical Goal of the percutaneous achilles tendon lengthening
procedure includes Limb Salvage, preserving function, and to reduce the
destructive forces on the Midfoot and ankle. Patient can not be non
weight bearing. The patient needs to change employment to reduce
standing, lifting, walking forces. ( patients with charcot foot needs to
slowed down as much as possible.) If I suspect that a patient has
charcot foot I will perform the achilles tendon lengthening procedure as
soon as I can, this helps reduce the strong plantarflexory force from
the achilles tendon. Allowing the patient to be non weight bearing
without performing the percutaneous achilles tendon lengthening
procedure will still cause charcot destruction, because you still have a
strong plantarflexory force present on the midfoot and ankle.
Summary
The author presents a new procedural technique of weakening the achilles
tendon for helping eliminate destructive plantarflexory forces in
diabetic neuropathic osteoarthropathy. Performing an Achilles Tendon
Lengthening procedure and/or an achilles tendon release procedure helps
prevent further destruction of the active charcot disease process and
reduces the risk of more severe complications like ulceration,
infection, and amputation. Patients are still able to ambulate without
serious side effects associated with active charcot foot.
Acknowledgment: Marva Myler Jensen, MEd, for her
contributions to this manuscript.
References:
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Frykberg R: The
High Risk Foot in Diabetes Mellitus, Churchill Livingstone,
London, 1991,
pp 300.
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Williams PL,
Warwick R: Gray's anatomy, ed 36. Philadelphia, W.B.
Saunders, 1980, pp 405, 604-606, 729-735, 1111-1115.
-
Hollinshead WH: Anatomy
for Surgeons: The Back and Limbs, ed 3. New York, Harper &
Row, 1982, vol 3, pp 720-725, 758-759, 773-778, 783-790, 792-794.
-
Draves D: Anatomy
of the Lower Extremity, Williams and Wilkins, Baltimore, MD,
1986, pp
264.
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