Georgetown University Hospital Department of Plastic Surgery How to Fix Altered Biomechanics after Diabetic Surgery Paul J Kim, DPM, MS, FACFAS Associate Professor Georgetown University School of Medicine Director of Research Division of Wound Healing & Hyperbaric Medicine Department of Plastic Surgery MedStar Georgetown University Hospital The Diabetic Foot Update San Antonio, TX December 4-6, 2015 Watermark
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How to Fix Altered Biomechanics after Diabetic Surgery · How to Fix Altered Biomechanics after Diabetic Surgery Paul J Kim, DPM, MS, FACFAS Associate Professor ... General Principles
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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
Georgetown University Hospital Center for Wound Healing
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General Principles of Tendon Rebalancing
1. Reducible Deformity
2. Reducible Deformity
3. Reducible Deformity
Georgetown University Hospital Department of Plastic Surgery
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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?
Georgetown University Hospital Department of Plastic Surgery
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Sagittal Force Correction
Georgetown University Hospital Center for Wound Healing
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Digital Flexor Tenotomies
Georgetown University Hospital Department of Plastic Surgery
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Jones Tenosuspension
Georgetown University Hospital Department of Plastic Surgery
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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
Georgetown University Hospital Department of Plastic Surgery
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Achilles Tendon Lengthening
Georgetown University Hospital Department of Plastic Surgery
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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
Georgetown University Hospital Department of Plastic Surgery
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Other Biomechanical Data
Georgetown University Hospital Center for Wound Healing
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Hallux Limitus
Georgetown University Hospital Department of Plastic Surgery
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Partial Calcanectomy
Georgetown University Hospital Department of Plastic Surgery
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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