Georgetown University Hospital Department of Plastic Surgery

How to Fix Altered Biomechanics

after Diabetic Surgery

Paul J Kim, DPM, MS, FACFAS

Associate ProfessorGeorgetown University School of Medicine

Director of ResearchDivision of Wound Healing & Hyperbaric Medicine

Department of Plastic Surgery

MedStar Georgetown University Hospital

The Diabetic Foot Update

San Antonio, TX

December 4-6, 2015

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Research & Consulting

Georgetown University Hospital Department of Plastic Surgery

• Nothing to disclose relevant to the lecture

• I am totally biased

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Georgetown University Hospital Center for Wound Healing

LIMB FUNCTION PRESERVATION

LIMB SALVAGE

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Procedures

• Exostectomy

• Osteotomies- angular

correction

• Arthrodesis

• Functional amputation

Georgetown University Hospital Department of Plastic Surgery

Skeletal Reconstruction

• Tendon lengthening

• Tendon transfer

• Tendon release

Tendon Rebalancing

Sagittal Force Correction

&

Shear Force Correction

Sagittal Force Correction

&

Shear Force CorrectionWate

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Goals of Tendon Procedures

• Weakening of muscle group(s) to reduce

the deforming force

• Not to increase length or range of motion

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General Principles of Tendon Rebalancing

1. Reducible Deformity

2. Reducible Deformity

3. Reducible Deformity

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Tendon Rebalancing

• Spastic conditions

• Guess at appropriate

tension

• Technically complicated

• Moderately predictable

• Retraining of new position

• Nonweightbearing

Georgetown University Hospital Department of Plastic Surgery

Tendon Transfers

• Nonspastic conditions

• Nonexact

• Technically simple

• Moderately predictable

• No retraining needed

• Immediate weightbearing

Tendon Lengthening

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Commonly Performed Procedures

• Sagittal Plane– Achilles Tendon Lengthening

– Gastrocnemius Recession

– Digital Flexor Tenotomies

– Jones Tenosuspension

– Hibbs Tenosuspension

• Transverse/Frontal Plane

– Tibialis Anterior Tendon Lengthening?

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Sagittal Force Correction

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Digital Flexor Tenotomies

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Jones Tenosuspension

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Posterior Muscle Group Weakening

Georgetown University Hospital Department of Plastic Surgery

Soleus Muscle Belly

Gastroc AponeurosisWate

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Practical Assessment for Equinus

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Achilles Tendon Lengthening

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Evidence For Sagittal Force

Tendon Rebalancing• Lin et al. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic

patients: the effect of tendo-Achilles lengthening and total contact cast. Orthop. 1996;19(5): 465-75.

• Armstrong et al. Lengthening of the Achilles tendon in diabetic patients who are at high risk ofr ulceration of th foot. JBJS. 1999;81(4):533-8.

• Mueller et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers: a randomized clinical trial. JBJS. 2003;85(8):1436-45.

• Kim et al. FHL transfer in diabetics for treatment of nonhealing plantar heel ulcers. Foot Ankle Int. 2010; 31(6):480-5.

• Dayer et al. Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: a prospective cohort study. JBJS. 2009;91(4):487-93.

• Tamir et al. Percutaneous tenotomy for the treatment of diabetic toe ulcers. Foot Ankle Int. 2014;35(1):38-43.

• Roukis et al. Percutaneous flexor tenotomy for treatment of neuropathic toe ulceration secondary to toe contracture in persons with diabetes: a systematic review. JFAS. 2009;684-9.

• Armstrong et al. Is prophylactic diabetic foot surgery dangerous? JFAS. 1996;35(6);585-9.

Georgetown University Hospital Department of Plastic Surgery

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Shear Force Correction

Georgetown University Hospital Center for Wound Healing

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Tibialis Anterior Tendon Lengthening

Georgetown University Hospital Department of Plastic Surgery

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Evidence For Shear Force

Tendon Rebalancing

• None

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Other Biomechanical Data

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Hallux Limitus

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Partial Calcanectomy

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Conclusions

• Must be a reducible deformity for tendon

surgery to work

• Address the sagittal and/or shear forces

• Surgical offloading may be temporary,

may need to be repeated

Georgetown University Hospital Center for Wound Healing

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