Review Question - QID 218909

Flexor tenotomies have been shown to improve healing rates in diabetic toe ulcerations via passively correcting toe deformities thereby offloading the ulceration site.

Superficial ulcerations over the tip (apical) of the toe are often secondary to flexion deformities that increase pressure points experienced with normal shoe wear and ambulation. In the diabetic population, these altered pressures initially result in callous formation, ulceration, and then infection. Wound care, antibiotics (if an infection is present), and wide-toe or offloading shoe wear is the mainstay of treatment. Flexor tenotomies have been increasingly utilized as an adjuvant modality that serves to passively correct hammer or claw toe deformities and thereby offload apical toe ulcerations. The risk of complications in flexor tenotomy is low (<15%), and the procedure can be performed in the office. Further, it may be performed with percutaneous needle techniques, minimizing the risk of surgical site infection. Some advocate its use as a prophylactic procedure as well if callous formation is present without ulceration.

Bonanno and colleagues performed a systematic review of the outcomes of flexor tenotomies for the treatment of diabetes-related toe ulcerations. They found that overall healing rates were exceedingly high (>95%) with a low risk for complications. They also reported that patients who underwent prophylactic flexor tendon tenotomy effectively remained ulceration free at the final follow-up. They concluded that flexor tenotomy to address toe deformity is safe, effective, and can be used as a preventative measure in cases with heavy callous formation.

Sanz-Corbalan and colleagues performed a cross-sectional study evaluating dynamic toe deformities and how they related to the patient’s history of toe ulcerations. The authors discussed that toe deformities in patients with diabetes are usually attributed to motor neuropathy with dysfunction of the intrinsic muscles; these patients may not be appreciated by a static deformity, but rather a dynamic one. The majority of patients showed flexor stabilization deformity (toes curled during heel lift phase of gait) which correlated with a history of apical toe ulcerations. The authors concluded that an evaluation of dynamic deformities during gait should be included as a presurgical assessment to achieve successful surgical rates.

Figure A shows apical ulceration of the patient’s second toe. The prior third toe amputation can be appreciated as well.

Incorrect Answers:
Answer 2: Figure B shows a diabetic foot ulceration overlying the plantar aspect of the metatarsal head. This is at least partially attributable to an equinus deformity. These patients’ physical examinations should include a Silfverskiöld test to determine if they would benefit from a gastrocnemius recession or Achilles tendon lengthening.
Answer 3: Figure C shows ulceration adjacent to the medial malleolus consistent with venous insufficiency ulceration. This is seldom an area of diabetic foot ulceration and is more often secondary to chronic venous stasis.
Answer 4: Figure D shows dry gangrene of the fourth toe secondary to arterial insufficiency. Peripheral vascular disease is unfortunately common in the diabetic population. This patient would benefit from toe disarticulation.
Answer 5: Figure E shows a heel pressure ulceration. This is most commonly seen in bed-bound elderly patients. Wound care is the mainstay of treatment with emphasis on persistent hindfoot offloading/padding boots. If underlying osteomyelitis develops within the calcaneus, partial calcanectomy and Achilles tendon lengthening may be beneficial.