The Foot and Ankle Online Journal Official Publication of the International Foot & Ankle Foundation facj.com / ISSN 1941-6806 Outcome after early open reduction and Kirschner wire fixation of Lisfranc joint injuties by Irfan Ahmad Latoo (MS)', Reyaz Ahmad Dar (MS)!, Mubashir Magbool Wani (MS)!_, Iftikhar Hussain Wani (MS)!, Mohammad Shafi bhat! ‘The Foot and Ankle Online Journal 7 (1): The study was a consecutive study conducted over a period of four years commencing in 2008 on Lisfianc joint injusies of feet. We studied che outcome of early open reduction and internal fixation of 20 cases of Lisfrane injusies using AOFAS.M score (American Orthopaedic Foot and Ankle Society-Midfoot score). ‘Most patients were in the age group of 18-35 years. In our series the cause of injury was road traffic accidents Jn 50% cases followed by fall from height in 40% of cases. Most of Lisfranc fractunes were of type B (60%) followed by type A. Most common associated injuries were metatarsal Fractare (30% cases). The follow-up was 1-3 years with an average of 2 years. The mean AOFAS-M score was 78.36 with patients losing points to pain and decreased recreational function. Ours wes not a comparative study but we strongly feel that tly ‘open reduction and Kirschner wire fixation of Lisfrane fractuze dislocations within 24 hours of injury considerably improves functional outcome in these cases Key words: Lisfrane fracture, Kirschner wize “his ts an Open Access arc dlstibuted under the toms ofthe Crealve Commons Atibulon License. lt pemits unrestricted use, stb, ae production in any mac, rowed the orginal work is propa etd, Fot and Ankle Online Journal (eager) 2004 All ight eseved fhe Lisfeane joint has been an eponym of tarsometatarsal joint injuties since Jacques Lisfeanc, a field surgeon in Napoleon’s army described an ‘amputation through the joint for gangrenous injuries of the forefoot [1]. Fracture dislocations of the Lisfranc (tazsometatarsal) joints of foot are uncommon but serious injuries with high potential for chronic disability. These injuries can easily be missed in the emergeney department as radiographs may show only subtle incongruity of the joint (2) Address correspondence: Mubeshir Magboo! Wai, asp ee Bane ‘ud Jon Surgery Baral ea 10005, att mushimauteolssnidssions ISSN 1941-6806 do: 10.3821 oj 2014.0701.0001 In the treatment of fracture dislocation of tarsometatarsal joints, early accurate diagnosis, combined with prompt anatomic reduction and stable intetnal fixation provides optimal tesults [3]. Closed reduction and percutaneous Kirschner wite fixation has been advocated by some (4,5), but the trend is towards open reduction and screw/Kisschner wire fixation [6,7] The purpose of this study was to evaluate the functional outcome of patients with Lisfranc joint injuries treated with open reduction and internal fixation with Kirschner wires within 24 hours of injury.‘The Foot and Ankle Onkine Journal 7 (1): 1 Figure 4 X-ray right foot AP view showing C2 injury. Materials and Methods We performed a consecutive study of 20 patients with tarsometatarsal joint injuries at our hospital commencing in 2008 after approval by hospital ethics committee. An informed consent was taken from all the patients. Only those patients were included who presented < 24 hours of injury and were aged between 16 years and 65 years, the patients who were excluded from study were patients with open injuties, patients presenting > 24 hours of injury and polytrauma patients. The injuries were classified by Myerson’s modification of Hardcastle classification 8). Abimad Latoo et al Figure 2 X-ray right foot oblique view of same patient as Figure 1. Surgical Technique A dossal longitudinal incision was made between the first and second metatarsal. ‘The extensor hallucis longus tendon, deep peroneal nerve and dorsalis pedis astery were identified and retracted as a wait. Small irreducible fragments were debrided from the joint. The first tarsometatarsal joint was aligned by reducing the medial border of medial cuneiform to the medial border of the first metatarsal. ‘The planter medial aspect of the joint was directly visualized to ensure that there was no planter gap. ‘The second metatarsal was then reduced to the medial border of middle cuneiform. ‘The joints were fixed with Kirschner wires. In some cases a second longitudinal incision was made centered over the fourth metatarsal and the thitd metatarsocuneiform joint was reduced. ‘The fourth and fifth metatarsals usually reduced once the above three reductions were achieved and were held with one or two transasticular K-wires from the base of Sth metatarsal to the cuboid. Copyright © 2014 The Foot and Ankle Online Journal‘The Foot and Ankle Online Journal 7 (I): 1 Figure 3 X-ray foot AP View of same patient 8 weeks after fation. Results Most patients (70%, n=14) were in age group of 18- 35 years with a mean 33.2 years. Males (80%, n=16) outnumbered females (20% n=4). Both right and left foot were equally involved. Cause of injury were road traffic accidents in 50% cases (n=10), fall from height in 40% (n=8) and other causes in 10% (n=2).. Metatarsal fracture was the most common associated injury (30%, n=6). The injuries were classified by Myerson's modification of Hardcastle classification [8]. The majority of injuries (60%, n=12) were type B followed by type A (20%, n=4). All the operations ‘were done within 24 hours of injury Ahmad Latoo etl. Figure 4 X-ray foot AP view of same patient 1.5 years after fixation, Following surgery a posterior splint was applied and left in place for 10-14 days. During this period alternate wound dressings were done. Stitches wete removed at around 14 days and short leg cast was ziven at the time of removal of stitches. K-wires wete removed at 8 weeks. Full weight bearing was allowed at 10-12 weeks. Anatomical reduction was obtained in 19 patients (95%). ‘There was one case of loss of reduction in our study. ‘There were two cases of superficial wound infection in our seties both of them responded to antibiotics. Primary closure of skin was done in 90% cases (0=18) while in two patients delayed primary closure was done. There was no case of compartment syndrome of foot in our series. Good to fair results ‘were seen in 90% cases (n=18). (Copytight © 2014 The Foot and Ankle Online Journal‘The Foot and Ankle Online Jourral 7 (I): 1 Figure 5 X-ray foot Lateral view of the same patient after 1.5 years of fixation, ‘The mean AOFAS-M score in our study was 78.36 ‘with most patients losing points to pain and decreased recreational function. Eighty percent of patients were able to return to their original ‘occupation, including 10 household or office workers and six laborers. Discussion Lisfrane injuries reeult from high-energy injuries. In our study, motor vehicular accidents were the most common cause of injury, a finding consistent with the already available literature. Anatomic reduction and internal fixation has become standard principle governing treatment of tarsometatarsal fracture dislocations. Most authors agree stable anatomic seduction leads to optimal results [9]. The advantage of open zeduction is that it allows direct visualization of the fracture dislocation for debridement of comminuted fracture fragments and osteochondral defects. ‘There is controversy about which method of fixation is best, There ate proponents of kwite fixation [10,11], while others rely on screw fixation [9,12]. In our study the age group ranged from 16-65 years with mean of 33.2 years. In Goossens et al study [13], age groups ranged from 10-52 years with mean of 34 while as reported in Pereira et al [14], age group ranged from 17-50 years Abmad Latoo etl with mean of 31.53. ‘The mean age group in our study was close to the study of Goossens et al [13] ‘Males outnumbered females in our study with ratio of 4:1 while as in Hesp et al [15], the male to female ratio was 2.31. The reason for higher male to female ratio in our study may be due to the fact that most of females in ous setup are houschold sedentary workers Both right and left feet were equally involved in our study. ‘The mode of injury was road traffic accidents (RTA) in majority of patients (50%) followed by fall from height which was consistent with Hardcastle et al [8}, 40.3% RTA and Kuo etal. [16], with RTA 42%, In our study most of the Lisftanc injuries (60%) were type Hardcastle type B followed by type A (20%). In Enriquez et al [17] series type B injuries were most common Lisfrane injuries (60%). While as in Pereira et al seties [14], type B Lisfranc joint injuries constituted 80.94 percent of Lisfrane fracture dislocations. Metatarsal fracture were the most common associated injury in our study in 30% cases. In Goossens et al, series [13] metatarsal injuries were also the most common associated injuries (40%). ‘The mean duration of hospital stay in our series was three days. K-wire were removed at mean of 8 weeks in our study while as in Kuo et al (16] K-wites were removed at 6-8 weeks. There was no case of compartment syndrome in our study and primary closure was done in 90% cases. While two cases delayed primary closure was done. Complication in our study inchided loss of reduction in one case and two cases of superficial wound infection. Both cases ‘occurred within one week of surgery and responded well to antibioties and daily dressings. In Kuo et al series [16], there was no case of postoperative wound infection and one patient in their series required fasciotomy with split-thickness skin graft. There was ‘one case of loss of reduction in our series. ‘The percentage of loss of reduction with K-wires was less in our series as we immobilized the foot for longer duration in short leg cast (mean 8 weeks), Molded arch support was given to patients after three months, which was discarded at 6 months in 70% cases while as 30% cases felt its need up to one year. In our study good to fair results were seen in 90% cases as per scale used by Pereira etal [U4], with mean Copyright ® 2014 The Foot and Ankle Online Journal‘The Foot and Ankle Online Journal 7 (I 1 AOFAS scote 78.23. Our mean AOFAS score was higher than Kuo et al [16], while as in Pereira et al [14] it was 77.36. Like this study most of our patients lost points to pain and decreased recreational function. We believe that early open reduction and K-wire fixation considerably improves the functional outcome in these injuries. There is an added advantage that no second surgery for removal of hardware is required. ‘The disadvantage is that this method needs longer period of immobilization in cast. The limitation of our study is that there was no control group so that we could compare our results. References |. Cain PR, Seligson D. Listrane’s facture-dislocation with intercuneiform dislocation: presentation of two cases an a plan for treatment. Foot Ankle. 1981;2 (3): 156-60. - [Pubmed 2, Norfiay JF, Geline RA, Steinberg RI et-al. Subtities of Lisfrane ffacture-dislecations, AJR Am J Rosntgenol, 1981;137 (6): 1151-6. - [Pubmed 3, Kuo RS, Tejwani NC, Digiovanni CW et-al. Outcome after ‘open reduction and internal fixation of Lisfrane joint injuries, J Bone Joint Surg. Am. 2000;82-A (11): 1609-18, - [Pubmed 4. Amiz CT, Veith RG, Hansen ST. Fractures and fracture- Aislocations of the tarsometatarsal joint. J Bone Joint Surg ‘Am, 1988;70 (2): 173-81. - [Pubmed] 5. Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop Relat Res. 1998;(353): 125-33. [Pubmed] 6. Curtis MI, Myerson M, Szura B. Tarsometatarsal joint injures in the athlete. Am J Sports Med. 21 (4): 497-502. - ‘(Pubmeslh Ahmad Latoo eta. 7. Myerson M. The diagnosis and treatment of injures to the Lisfranc joint complex. Orthop Clin North Am. 1989:20 (4): 655-64. - [Pubmed] 8. Myerson MS, Fisher RT, Burgess AR et.al. Fracture dislocations oft tarsometatarsal joints: end results correlated ‘with pathology and treatment, Foot Ankle. 1986;6 (5): 225-42 = [Pubmed 9. Rosenberg GA, Patterson BM. Tarsometatarsal (Lisftanc's) facture-dislocation. Am J Orthop. 1995;Suppl : 7-16. ~ Pubmed 10, Pérez blanco R, Rodriguez merchén C, Canosa sevillano R eval. Tarsometatarsal fractures and dislocations. J Orthop ‘Trauma. 1988:2 (3): 188-94. - [Pubmed} U1, Tan YH, Chin TW, Mitra AK etal, Tarsometatarsel (Listranc’'s) injuries-results of open reduction and internal fixation. Ann Aced Med Singap. 1995;24 (6): 8169. - Pubmed) 12, Jeffreys TE, Listrenc’s fracture-dislocation: a clinical and experimental study of tarso-metatarsal dislocations. and fcture-disiocations. J Bone Joint Surg Br. 1963;45 : $46.51. + [Pubened) 13, Goossens M, De stoop N. Listianc'sfracture-dislocations: etiology, radiology, and results of treatment. A review of 20 ‘cases, Clin Orthop Relat Res. 1983;(176): 154-62. - [Pubmed] 14, Pereira Cal, Espinosa EG, Miranda I, Pereira MB, Canto SGT. Evaluation of the surgical treatment of Lisfane joint fracture-distocation. Acta ortop bras. 2008;16(2) — [Webpage] 15. Hesp WL, Van der werken C, Goris RJ. Listrane dislocations: fractures and/or dislocations through the tarso- metatarsal joints Injury. 1984;15 (4): 261-6. - [Pubmed] 16. Kuo RS, Tejwani NC, Digiovanni CW etal. Outcome after open reduction and intemal fixation of Listranc joint injuries. J Bone Joint Surg Am. 2000;82-A (11): 1609-18. - Pubmed 7. Enriquez CJA, Lopez VA, Garcia HA, Gonzilez TA, Ventura MA, Soto RV. Lisirane’s fracture dislocation. Epidemiological study and results at the General Hospital in Mexico. Acta Orcop Mex 2005; 19 (si). ~ [Webpane] Copysight © 2014 The Foot and Ankle Online Journalausnican onruoragole Article FOOT B ANKLE SOCIETY. Foor Ai nr ats Vel 35) 30-0 Othe Auber 213 ‘gee conjouraieonanay (BOE entrar var aosso4 blageetbcon Percutaneous Tenotomy for the Treatment of Diabetic Toe Ulcers Eran Tamir, MD'*?, Mordechai Vigler, MD™, Erez Avisar, MD", and Aharon S. Finestone, MD, MHA'?? Abstract Background: Foot ulcers have been implicated as @ causative factor in diabetic foot amputations. The purpose of this ‘study was to evaluate treating foot ulcers in patients with diabetes by percutaneous cenotomy. Methods: We retrospectively reviewed the computerized medical fles of 83 patiencs treated for foot ulcers by Percutaneous tenotomies. Results were analyzed on the basis of indication and per patient. Results: The 83 patients had 160 tenotomies for 4 indications: 103 tip-of-toe ulcers (treated by flexor digitorum longus ‘tenotomy), 26 cock-upldorsal ulcers (extensor digitorum longus tenotomy), 2 kissing ulcers (extensor cigicorum longus and/or flexor digitorum longus tenotomies), and 10 plantar metatarsal ulcers (extensor digitorum longus with or without flexor digitorum longus tenotomy). Healing at 4 weeks was 98%, 96%, 81%, and 0% respectively. The complication rate was very low, with the exception of “transfer lesions,” where an adjacent toe became involved and needed subsequent enotomy in 8% of tp-of-coe ulcers. ‘Conclusions: Percutaneous tenotomy was an effective and safe method for treating toe ulcers in neuropathic patients ‘was not effective in treating plantar metatarsal ulcers. Level of Evidence: Level IV, case series. Keywords: neuropathic ulcers, ofieading, tenotomy ‘The annual incidence of ulcer development in pationts ‘with diabetes is about 2%." In a 2-year follow-up of 1666 patients with diabetes in San Antonio, Lavery etal found 120.6% rate of amputations.® Sun et al recently reported a 20% rate of major lower extremity amputations among 789 patients admitted to the Diabetic Foot Care Center at ‘Chang Gung Memorial Hospital, Taiwan,"” aod Nather et al reported « 27% major amputation rate in 202 pationts treated by a multidisciplinary team for diabetic Foot prob- lems." Inthe presence of sensory neuropathy end lack of protective sensation, an ulcer con develop in a toe with normal anatomy as result of an aeute injury or tightfit- ting shoes. More often, however, ulcers develop in a toe with sn anatomic abnormality causing increased pressure ina specific region, The most common site of uleers in patients with diabetes isthe toes,* and the most common deformity in patients with diabetic neuropathy is a claw toe.” present in 3% of patients with diabetes.” This deformity is usually attributed to motor neuropathy affecting the intrinsic foot muscles (interossei and tu bricals), although this concept has been chellenged? The uwnopposed action ofthe extensor digitorum longus (EDL) and the flexor digitorum longus (FDL) results in ahyper= extension deformity of the metalarsophalangeal joint and flexion contracture of the distal and/or proximal interpha- langeal (PIP) joints (Figure 1b).* Claw toe deformity ofthe toes can lead to uleoration of the toe in 4 distinet regions Tip ofto2 ulcers: The most common type, tip-of te ulcers result from pathologic dynamic forces generated by the EDL, which presses the tp ofthe toe toward the ground during the stance phase. These ulcers are often resistant {o offloading with shoes and foot orthoses, and they may persist for montis or even years and can lead 19 infection and amputation Figure 2). Dorsal ioe ulcers: Dorsal toe ulcers include uleers over ‘the interphalangeal joints of cock-up big toes, ulcers 'Dopartmant of Orthopedic Sugery, Assaf HaRaeh Medial Cener, ere, sel *Sstar Seno of Mii, Tal fy Univer, al ‘etacral Heath Serves, rel ‘Departmenc of Orthopaedic Surgery Rabin Medial Cee, HaStaron Hosp Petah Ta raat Corresponding Author: ‘Aaron 5. Fnestone, MD, MHA, Deparment of Orthopnede Surgery. ‘Ase HoRofch Medal Canter, Zvi rel mat aef@terneclTemir et @ Figure |. Mechanism of dp-oftoe ulcer formation and treatment (2) The normal toa. Note how the Incerossl (and lumbricals, noc delineated) poss below the center of the Mead of| ‘the metatarsal (marked with across inserting into the extensor hood. They act a flexors ofthe metatarsophalangel jolt and ‘extensors ofthe proximal and eistal interphalangeal joins. * {) In che absence ofthe Mexing momene of te interosse. the extensor digitorum longus forces the metatarsophalangeal joint into extention. n the absence of the extending moment ‘ofthe invecossel and lumbricalsehraugh the exensor sheath, ‘the flexor cigtorum longus frees the proximal and dlsal interphalangeal joints into Nexto, (c) The flexor tanotamy with the Beaver krifeseaightons the te, reliving pressure from the Ler ies, ‘over the PIP joint and, less common, ulcers over the distal iesphalangeal (DIP) joint. These ulcers are ‘caused by rubbing against the toe box secondary to hyperextension of the metatarsophalangeal. joint, resulting from overactivity of the long extensor (extensor hallueis longus [EHL] / EDL), The close proximity ofthe PIP joint capsule to the skin increases the risk of septic arthritis and osteomyelitis. In cor ‘nast 0 tip-oftee uleers, these ulcers respond well to ‘conservative treatment with a healing shoe or @ shoe ‘with bigh toe box, but recurrence is commnon owing to lack of compliance, Kissing ulcers: Kissing ulcers develop from pressure of | ‘ne toe against the other inside the shoe, They most Frequently develop between the fourth and fifth toes. 39 ‘The medial aspect of the DIP joint ofa fifth claw toe compresses the lteral aspect ofthe fourth toe, causing ‘uleeration ofthe fourth toe. The parallel lesion in non- diabetic patents isa com between the fourth and fifth toos that ean be extremely painful and is sometime called a soft cor, an interdigtal clavus, ora tyloma mole." As in the ease of dorsal PIP joint ulcers, the close proximity ofthe joint capsule tothe kissing ulcer increases the risk of septic arthritis and osteomyelitis, Plantar metatarsal ulcers: Plantar metatarsal ulcers develop from pressure under the metatarsal heads (Gimilarto metatarslgia in nondiabetics). We hypoth- sized tha tis lesion might also be caused by overac- tivity of both the long extensor and the long flexor in the absence of the correcting forces of the intrinsic muscles. ‘Tenotomies can reduce or eliminate the force causing the pressure responsible for ulcer formation and have recently been shown to cure tip-ofoe ulcers by van Netten et a.” ‘They are most effective when the deformity is completely ‘flexible and less effective ifitis rigid. Tenotomy ofthe FDL, ‘corrects the clawing and eliminate the pressure over te tip of the toc. As a result, rapid healing should take place. ‘Texotomy of the EDL partially corrects the clewing by reducing the extension of the metatersophslangeal joint. This lowers the level of the dorsum of the PIP joint and reduces the friction against the toe box. Tenotomy of the EDL, the EDL, o both can reduce the pressure between 2 toes in eases of a kissing uleer by changing the position of| the toes and lowering the overall tension. The purpose of this study was to report on performing percutaneous flexor and/or extensor tenotomies for treating neuropathic ulcers Methods, We retrospectively reviewed the medical files of patients with diabetes having a percutaneous tenotomy at the Maltiisciplinary Clinic forthe Treatment of Complications of Diabetic Feet of the Maccabi Health Care Services in Tel Aviv between September 2007 and May 2011 ‘There were 83 patients (45 men), with mean and median age of 65 years (range, 48-89). The cause of the neuropathy was diabetes mellitus for 77 patients. This subgroup had diabetes mellitus for a mean of 17 years (median, 15. interquartile range, 12-20), and its mean AIC was 83% (cnedian, 7.7%; interquartile range, 7.0%-9.3%). A total of| 160 procedures were conducted over the 44-month period. ‘Overall, 58% of the patients had 1 procedure, 24% had 2, and the remaining 18% had between 3 and 8. The median age of the ulcers was 33 weeks (interquartile range, 3-52), and the median follow-up was 22 months (minimum, 5 ‘months; interquartile range, 16-29),0 Foot & Ankle International 35(1) oh Pa Figure 2. A tip-ottoe ulcer (8) Ater minimal debridement before the tenotomy. Note the clawing responsible for the uler.() Immedately after pereucneovs exor tenotomy, Note the stab wound from the procedure and the fact that the toe is now salght {€) One week postoperatively. Note how the ulcer has dried up and become smi. () Two weeks postoperatively, Note how the Ulcer is almast recovered Patients with foot ulcers were evaluated for the most ‘appropriate management, and when the foot and ankle ‘surgeon thought appropriate, they were referred for a per- ‘cutaneous tenotomy. When pedal pulses were not palpa- ble, 2 noninvasive limb investigation was performed. Anikle brachial index below 0.5 or flat pulse volume recording at the ankle level was considered a contraindi- cation for the procedure, and suitable patients were referred for a vascular consultation. Another contraindi- cation was soft tissue infection presenting as cellulitis of the toe or foot. Osteomyelitis of the distal phalonx dem- onstrated by physical examinetion or radiograph was not 1 contraindication for the procedure in the absence of associated cellulitis. Uleers were graded preoperatively according to the University of Texas system, which takes {nto account the size and depth of the ulcer as well as the presence or absence of infection and ischemia.* ‘There were 4 indications for surgery: 1, tip-of toe ver ofa flexible or semiflexibie claw toe (treated by FDL, / flexor tallucis longus. [PHL] tenotomy); 2, dorsal ulcers of flexible or sa by EDL/EHL tenotony); 3, Kissing uleers (Wetted by EDL and/or FDL tenoto- mies); and 4. plantar metatarsal head ulcers (treted by EDL + FDL tenotomies) xible toe (treated Al tenotomies were performed at the outpatient clinic by the frst author using standard technique. Patients were examined within | week of the procedure to ensure satisfactory wound healing; they were then fol- lowed at regular intervals. A successful response for theTamir et oh Table 1. Healing Rate by Indieations and Patients, No. (8), By Indication By Patient Ingestion ‘Operated Healed Operated Healed Tpottwe cer 10301 (98) S—«53(96) Dorsallcockup «26 25(86) 1615 (84) leer Kissing ulcer 2 7@H 18H) Planear meratarsal 10 ° 9 6 eer Allprocecure) te? 143 (89) 8* 68 (81) patents Nor athe rember freatins (9 umber of pants (N= 83, ‘Nace at he of the colar ie rece han 83 bacaue vera patiant had mare han I typeof nde. 16) greater ha eh ort tenotomy was defined as a healing response at L week after the procedure and wound closure by 4 weeks, Recurrence ‘was assessed by reviewing the electronic medical files. Statistical Analysis We tested the success rate of tenotomy in the 4 clinical indi- cations. In addition, we tested the overall success across all indications, We analyzed the data twice. Firsl, we treated cach procedure as a different case, ignoring covariance fom multiple procedures on the same patient. Second, we conducted the analysis atthe individual patient level, con- trolling for any effects that may have occurred due to raul- tiple procedures (multiple procedures on the same patient tended to have the same outcome). In this second analysis, patients with a failure of any procedure were considered failures. The success rete of each indication was 2 tested against a success rate of 50%, Results Healing rates are presented in Table |, by indication and by patient. The first 3 indications (tip of toe, dorsal, kiss- ing ulcers) were all significantly improved (P < .01), Plantar metatarsal ulcers did not heal, and this too was statistically less than the predetermined 50%. The overall success rate for all indications (89%) was also signi cantly greater than 50%, On analysis by patient, the first 3 indications were also statistically better than 50%, and the fourta, worse, Tip-of Toe Ulcer We operated on 103 toes with tip uleers by performing a Jong flexor enotomy in $5 patients (FHL, n= 16; FDL-2,n = 31; FDL-3, n= 37; FDL-4, n= 16; FDL-S, n= 3) with considerable success (98%, Figure 2), Texas uleer grade 4 as GO in 25 cases, GI in 78, and G2/3 in 5. AIL ulcers healed except 2 hallux ulcers: 1 due to hallux rigidus and insufficient offloading and 1 to moderate arterial insusti- cicney. Thore were 14 minor complications in 11 patients ulcer developed in an adjacent toe (transfer lesion) during the first B weeks following the pro= cedure, In3 cases, a plantar skin rupture occurred from pas- sive extension ofthe toe, | had a minor infection, and 1 had pain, No serious complication occurred, such a infection or vascular compromise of a toe, No recurrences were recorded. The mean duration that the tip-of-toe ulcer had ‘been present befare scheduling surgery in 39 ulcers was 33 weeks (median, 4 interquaztile range, 3-52; range, 1-156). DorsalfCock-Up Ulcers ‘There were 26 dorsal ulcers in 16 patients (FHL, n= 4; EDL-2, n= 6; EDL-3, n= 7; EDL-4, n= 4; EDL-S, n: EDL. not specified, n = 3). Texas ulcer grade was GO in 6 ‘eases, Gi in 19, and G3 in |, All uleers but 2 hed healed after 4 weeks. There were no complications. One ulcer recurred. Kissing Ulcers ‘There were 21 kissing ulcers in 19 patients (between D4 and DS, n= 18; D3-D4, n= 2; D2-D3, n= 1). All ulcers ‘were on the medial toe of the 2 toes involved and on the lateral aspect of the PIP joint. Texas ulcer grade was GO in 4 cases, GI in 11, G2 in |, and G3 in 5. They were caused by pressure from the DIP joint area of the mare Iteral toc and were treated by tenotomy of the lateral toe (EDL cases, a= 15; FDLeases, n= 6) One grade | ulcer developed osteomyelitis, and 2 grade 3 ulcers failed to heal in 4 weeks. There were no complica- tions. One uleer recurred. Plantar Metatarsal Head Ulcer We treated 10 ulcers plantar to the metatarsal head with tenotomies (9 patients), In 5 cases, we performed tenotomy ofthe EHL for ulcers under the head of the first metatarsal, and in 5, we performed tenotomies of both the EDL and the FDL (for 2 ulcers under the third metatarsal heads and 1 under each of 2, 4, and 5). None of these ulcers healed, and there were to complications. Discussion ‘Ulcers have been implicated as a causative factor in up to 84% of diabetic foot amputations.* Their prompt effec- tive treatment is likely to reduce the development of osteo ryeliis and subsequent amputation. A recent systemic review on interventions for preventing diabetic uleers2 mentioned only 2 surgical interventions for preventing relapse of ulcers (debridement and Achilles tendon length ening), and these were not conclusively effective Classically, claw toes that need surgery are treated by excision or realignment of the metatarsal heads.** The fewr published reports on tenotomies have up to 100% ulcer healing rate,"*"* as did Laborde in a retrospective study of 18 patients with 28 ulcers." The latter study reported 3 hal- lux ulcers recurring within 36 months. In a retrospective study of 48 patients with $8 flexor tenotomies, Kearney et al reported a 98% healing rate, with 5% suffering a post- operative infection and 12% experiencing a recurrence in 28 months of follow-up. Two patients with preexisting ‘osteomyelitis underwent a foe amputation.” In contrast to EDL tenotomies that have been reported, tothe best of our knowledge, there are no publications on extensor tenoto~ mies for neuropathic toes ulcers. ur results of using percutaneous tenotomy for uloers demonstrate that this procedure was highly effective for ‘treatment of ulcers in 3 ofthe 4 anatomic locations (tip of toes, dorsum of hammer toes, and kissing wleers) but notin ‘the fourth category (uleers under the metatarsal heads), The procedure ean be performed safely in the outpatient clinic. ‘No serious complication occurred in 160 procedures, and this can be atuibuted to the minimally invasive technique. A great advantage is that there is no need to utilize an operat- ing theater, with all the overhead costs for both the surgeon and the patient. For insensate patients, with an ulcer that bothers their attendants and family more than themselves, 8 procedure that involves an operation can be deterring, This procedure is no more intimidating to them than a pedicure Tip-of-toe ulcers in a claw toe are clearly the most fre- quently encountered ulcers in patients with diabetes anc neuropathic feet. FDL tenotomy straightens a flexible claw toe spontaneously and effectively offtoads the tip of the toe, In the absence of ischemia or infection, a healing pro- ‘ess is induced and is apparent within 1 week of the proce- dure (Figure 2c). As severed flexor tendons never heal, these uloers do not recur. Because the toe tip cannot be effectively off-loaded with conservative methods, we are of| the opinion that tenotomy is likely to become the gold stan- ard treatment for tip-oftoe ulcers. ‘Uleers atthe dorsal aspect of the PIP joint are caused by rubbing against the toe box. Shoes with a high toe box effectively off-load these ulcers, but some patients are not compliant with long-term use of such shoes, EDL tenot- ‘omy lowers the level of the PIP joint and reduces its fricx tion against the toc box. When contemplating EDL tenotomy for cock-up ulcers, there are 2 considerations that make this indication different trom tip-of-toe ulcers ‘Severed extensor tendons sometimes heal spontaneously, ‘which may cause recurrence of the ulcer. While this is an ‘easy and safe procedure that ean be performed in the Foot & Ankle International 35(1) outpatient clinic, offloading with shoes with a high toe box is an effective method of treatment. The clinic rust discus the options carefully with the patient. toe box shoes can be beyond the means of some patients, and even if not, the patent's compliance may not neces- sarily be trusted. Kissing toes ulcers are the result of pressure between 2 toes, The most common location isthe lateral aspect ofthe PIP joint of the fourth toe, which is compressed agains the medial aspect ofthe DIP joint of the fh toe. Clawing of the fith toe is usually the cause for a kising lesion Tenotomy ofthe flexor or extensor tendoa of the fit toe changes the postion of the fifth toe relative tothe fourth and offloads the ulcer There is no way to offload these ulers, so as the suocess rate of tenotomy is around 80%, {his has to be decided with the patent. In comparison to the previous types of ulcer, these tend to be diagnosed more in the more sensate patients, who are therefore sometimes more eager to have surgery than other diabetic neuropathic patients Al 10tenotomies ofthe EUL for plantar frst metatrsal head ulcers filed (fe, EDL + FDL tenotomies for plantar metatarsal head ulcers). We concladed that even though the clawing ofthe foot appears to comtToue to the pressure and ulcers under the metatarsal beads, the musee imbalance is probably net a major causative factor, and we have stopped doing tis procedure. ‘The main Grawbacks of this study are its retrospective method and the numberof patients in some ofthe catego- ries It also does not discuss the efficacy of tenotomies in nondiabetic paints. Tenotorcies are effective in testing painful tp-oF te calluses resulting from clawing and pain- ful soft coms between the toes that become so painful such tat they need surgery. In conclusion, percutaneous FDL and/or EDL tenoto- ries were safe and offestve for offloading tip-f-tee ulcers, cock-up ulcers, and kissing uloars. AS these toe deformities have been Clearly shown tobe ask Factor for consequent ulcer development in patients with diabetes, percutaneous tenotomy offers an effetive therapeutic and preventive management for these patents. Patents sufer- ing from diabetes mellitus with complications should be tweated in a multdisciplnary clinic with a elinizian capable of both diagnosing uleers amenable to tenotomy and per- forming the procedure Declaration of Conflicting Interests ‘The authors) declared no potential confess of imerest with respect to the researc, authorship, andlor publication of this atl. Funding “The authors) received 0 financial support for the research, _cthorshi, andor publication of his artel,Tamir et oh References 1 ‘Aad Y, Fonseca V, Peters A, Vinik A. 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