Diabetes Care: Flexor tendonotomy for diabetic foot

Background: Definition of diabetic foot by the International Working Group on Diabetic Foot Diseases: Diabetic foot refers to foot infections, ulcers and/or deep tissue destruction
caused by distal nerve abnormalities of the lower extremities and varying degrees of peripheral vascular pathology in diabetic patients.
The number of diabetic patients is increasing year by year, and diabetic foot, as a serious complication of diabetes, has always been a feared condition
in the hearts of many patients.
Diabetic foot is extremely harmful to the body, ranging from leg ulceration to daily life, severe amputation or even life-threatening, which is an important cause of
death and disability in diabetic patients.
In the US, the medical cost of diabetic foot ulcers and amputations is equal to the sum of the costs of other diabetes complications; In China, the average cost of diabetic foot patients per hospitalization is 2~30,000, and some are even as high as more than 200,000.

Diabetic foot ulcers take an average of 6~14 weeks to cure, and the recurrence rate is high
.
Studies have shown that the recurrence rate of foot ulcers in 1, 3 and 5 years is 44%, 61% and 70%,
respectively.
Signs and symptoms of diabetic foot vary
depending on the course and severity of the disease.
The light ones only have slight pain in the feet and ulcers on the surface of the skin; In moderate cases, deep penetrating ulcers may occur with soft tissue inflammation; In severe cases, soft tissue abscesses, bone tissue lesions, localized gangrene of the toes, heels or forefoot instep are combined with ulcers, and even total foot gangrene
.

Objective: The objective of this study was to evaluate the effect of
needle flexor tendonotomy in the treatment of diabetic hammer toe deformity.

Study design and methods: A multicentre randomized controlled trial was conducted from 1 November 2019 to 31 March 2021 in patients
with diabetes and ulcers or hammer toe-associated ulcers.
Participants are stratified
according to the presence of ulcers or imminent ulcers.
Participants were randomly assigned to tenotomy and standard non-surgical treatment or standard non-surgical treatment
.
The primary outcome is the time it takes for the ulcer to heal and the progression
from an imminent ulcer to an active ulcer.

Results: Of the 224 screened diabetic patients, 95 (59.
0% male) were enrolled
.
The mean follow-up was 291±70 days, 28 cases (29.
5%) had type 1 diabetes, the mean duration of diabetes (25-75% quartile) was 20 (13-26) years, and the mean age was 67.
7±9.
8 years
.
Of the included participants, 16 had ulcers, eight of whom were randomly assigned to the intervention group
.
Of the remaining 79 patients with imminent ulcers, 39 were randomly assigned to the intervention group
.
For participants with ulcers, healing rates favored tenotomy (100 versus 37.
5 percent, P = 0.
026), as did ulcer healing time (P = 0.
04).

For patients with impending ulceration, the tenotomy group had a lower incidence of progression to active ulceration (1 versus 7, P = 0.
028) and a higher number of ulcer-free days (P = 0.
043).

No serious adverse events were recorded
.

Fig.
1 Flowchart RCT (tenotomy) study

Figure 2.
CONTORT plot of tenotomy studies

Conclusions: This randomized study suggests that simple needle flexor tendonotomy is effective and safe in the treatment and prevention of
ulcers associated with diabetic hammer toe.

Andersen JA, Rasmussen A, Engberg S, et al.
Flexor Tendon Tenotomy Treatment of the Diabetic Foot: A Multicenter Randomized Controlled Trial Diabetes Care 2022 Sep 24