Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial.
Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial.
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DOI：
10.2106/00004623-200404000-00033
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发表时间：
2003-08
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影响因子：
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通讯作者：
Michael J. Mueller;D. Sinacore;M. Hastings;M. Strube;J. Johnson
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文献类型：
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作者：
Michael J. Mueller;D. Sinacore;M. Hastings;M. Strube;J. Johnson
背景有限的脚踝背屈已被牵涉到糖尿病中前脚底溃疡的促成因素。这项研究的目的是比较糖尿病患者的结局和用有或没有跟腱延长的总触觉治疗的神经性足底溃疡。我们的主要假设是跟腱延长会导致溃疡复发率较低。方法六十四名受试者被随机分为两个治疗组，单独固定在完全接触或与经皮跟腱肌腱延长一起固定，并在治疗前后进行测量，在七个月的随访检查中进行测量，并在最终随访评估（最初愈合后的平均[标准偏差]为2.1 +/- 0.7年）。总体接触式铸造组中有33名受试者，在跟腱延长组中有31名受试者。两组之间的年龄，身体质量指数或糖尿病持续时间没有显着差异。结果指标是愈合溃疡，溃疡复发率，脚踝背反射范围，足底屈肌肌肉的峰值扭矩（强度）以及前脚上足底压力的时间。结果总触觉组中的33次溃疡的结果为29（88％），而在平均持续时间（和标准偏差）为41 +/- 28后，阿喀琉斯肌腱延长组中的所有30张溃疡（100％）愈合。天和58 +/- 47天（p> 0.05）。 （阿喀琉斯肌腱延长组的一名患者在治疗完成前死亡。可用于随访的阿喀琉斯肌腱延长组的27例患者中有4例（15％）患有溃疡复发（p = 0.001）。在两年的随访时，总触觉铸造组的二十六名患者中有21例（81％）和阿喀琉斯肌腱延长组的26名患者中有十名（38％）有溃疡复发（p = 0.002）。与用总触觉铸件处理的组相比，用阿喀琉斯肌腱延长治疗的组具有背屈，并且在七个月时仍然增加了（p <0.001）。阿喀琉斯肌腱延长后，足底屈肌峰值扭矩也降低（p <0.004），但七个月后恢复为基线。在赤脚行走过程中，前脚上的足底压力降低（p <0.0002）（p <0.0002），在治疗后七个月内延长了肌腱延长，但返回到基线值。结论所有溃疡在阿喀琉斯肌腱延长组中愈合，溃疡复发的风险在七个月时少75％，在两年后比总体接触式铸造组少52％。致命肌腱延长应被认为是减少糖尿病患者底足和有限的踝背屈（</= 5度）的前脚底部神经性溃疡复发的有效策略。
BACKGROUND Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with and without an Achilles tendon lengthening. Our primary hypothesis was that the Achilles tendon lengthening would lead to a lower rate of ulcer recurrence. METHODS Sixty-four subjects were randomized into two treatment groups, immobilization in a total-contact cast alone or combined with percutaneous Achilles tendon lengthening, with measurements made before and after treatment, at the seven-month follow-up examination, and at the final follow-up evaluation (a mean [and standard deviation] of 2.1 +/- 0.7 years after initial healing). There were thirty-three subjects in the total-contact cast group and thirty-one subjects in the Achilles tendon lengthening group. There were no significant differences in age, body-mass index, or duration of diabetes between the groups. Outcome measures were time to healing of the ulcer, ulcer recurrence rate, range of dorsiflexion of the ankle, peak torque (strength) of the plantar flexor muscles, and peak plantar pressures on the forefoot. RESULTS Twenty-nine (88%) of thirty-three ulcers in the total-contact cast group and all thirty ulcers (100%) in the Achilles tendon lengthening group healed after a mean duration (and standard deviation) of 41 +/- 28 days and 58 +/- 47 days, respectively (p > 0.05). (One patient in the Achilles tendon lengthening group died before treatment was completed.) In the first seven months of follow-up, sixteen (59%) of the twenty-seven patients in the total-contact cast group who were available for follow-up and four (15%) of the twenty-seven patients in the Achilles tendon lengthening group who were available for follow-up had an ulcer recurrence (p = 0.001). At the time of the two-year follow-up, twenty-one (81%) of the twenty-six patients in the total-contact cast group and ten (38%) of the twenty-six patients in the Achilles tendon lengthening group had ulcer recurrence (p = 0.002). Compared with the group treated with the total-contact cast, the group treated with Achilles tendon lengthening had increased dorsiflexion and it remained increased at seven months (p < 0.001). Plantar flexor peak torque also decreased after Achilles tendon lengthening (p < 0.004), but it returned to baseline after seven months. Peak plantar pressures on the forefoot during barefoot walking were reduced (p < 0.0002) following Achilles tendon lengthening yet returned to baseline values within seven months after treatment. CONCLUSIONS All ulcers healed in the Achilles tendon lengthening group, and the risk for ulcer recurrence was 75% less at seven months and 52% less at two years than that in the total-contact cast group. Achilles tendon lengthening should be considered an effective strategy to reduce recurrence of neuropathic ulceration of the plantar aspect of the forefoot in patients with diabetes mellitus and limited ankle dorsiflexion (</=5 degrees ).