What are the recommendations for patients undergoing TAL (Tendo Achillis Lengthening) procedures?

Recommendations for Tendo Achillis Lengthening (TAL) Procedures

In patients with diabetes and neuropathic plantar forefoot ulcers that have failed conservative treatment, Achilles tendon lengthening (TAL) in combination with an appropriate offloading device is recommended to promote healing and prevent ulcer recurrence. 1

Indications for TAL

• Primary indication: Neuropathic plantar forefoot ulcers that have failed non-surgical offloading treatment 1
• Specific patient characteristics:
  • Limited ankle dorsiflexion (ankle equinus) 2
  • High forefoot plantar pressures 2
  • Recurrent or non-healing plantar forefoot ulcers despite appropriate conservative care 1

Benefits of TAL

TAL provides several important clinical benefits:

• Increases sustained healing of ulcers once healed (RR 3.41,95% CI 1.42-8.18) 1
• Significantly decreases forefoot plantar pressure (MD 218 kPa lower) 1
• Reduces risk of ulcer recurrence (relative risk reductions of 75% at 7 months and 52% at 2 years) 1
• Decreases amputation risk (RR 0.35) 1
• Provides more permanent offloading solution even when patients are not adherent to offloading devices 1

Potential Risks and Complications

TAL is associated with several important risks that must be considered:

• Increased risk of new rearfoot ulcers (RR 9.56) 1
• Higher fall risk (RR 5.31) 1
• Risk of infection (RR 3.19) 1
• Possible tendon rupture during or after surgery 2
• Temporary reduction in plantar flexor strength (typically recovers by 7 months) 3
• Risk of overcorrection 2

Surgical Techniques

Several surgical approaches can be considered:

1. Traditional triple hemisection: The established approach along the length of the Achilles tendon 2
2. Z-lengthening: Can be performed with a transverse skin incision on the heel crease for better cosmetic results and fewer complications 4
3. Minimally invasive lengthening: Associated with simpler operation, fewer complications, and lower recurrence rates 5

Postoperative Management

Proper rehabilitation is crucial for successful outcomes:

• First 7 days: Reduced loading and protected range of motion to avoid tendon rupture 2
• After initial period: Gradual reintroduction to loading to increase tendon strength 2
• Offloading device: Continue use of appropriate offloading device in combination with TAL 1
• Monitoring: Watch for potential heel ulcers, which occur in approximately 13-15% of patients within 12-24 months 1

Alternative Surgical Options

When TAL is not appropriate, consider:

• Metatarsal head resection: For neuropathic plantar metatarsal head ulcers that fail non-surgical treatment 1
• Joint arthroplasty: For neuropathic hallux ulcers that fail non-surgical treatment 1
• Metatarsal osteotomy: For neuropathic plantar ulcers on metatarsal heads 2-5 that fail non-surgical treatment 1

Decision Algorithm for TAL

1. Initial approach: Start with conservative treatment for 6 months 6

   • Non-removable knee-high offloading devices
   • Calf-muscle stretching exercises
   • Appropriate footwear modifications

2. Evaluate for TAL if conservative treatment fails:

   • Confirm limited ankle dorsiflexion
   • Verify high forefoot pressures
   • Ensure patient has adequate muscle strength (quadriceps and triceps surae strength at least grade IV) 5

3. Contraindications:

   • Uncontrolled infection
   • Severe peripheral arterial disease
   • Muscle strength less than grade III after preoperative rehabilitation 5

4. Proceed with TAL when:

   • Conservative treatment has failed for at least 6 months
   • Patient has appropriate indications
   • Benefits outweigh risks for the specific patient

Expected Outcomes

Following TAL, patients can expect:

• Increased dorsiflexion range of motion (from 0° to approximately 18°) 3
• Reduced forefoot plantar pressure (up to 55% reduction with proper footwear) 3
• Improved walking ability (24% increase in physical performance test scores) 3
• Initial decrease in plantar flexor strength that typically recovers by 7 months 3

TAL represents an effective surgical intervention for patients with diabetes and recalcitrant neuropathic plantar forefoot ulcers, particularly when conservative management has failed and ankle equinus is present.