This Level I RCT (n=64) asked whether adding percutaneous Achilles tendon lengthening to total-contact casting reduces forefoot ulcer recurrence in diabetic patients with equinus (dorsiflexion ≤5°). Patients were followed for a mean of 2.1 years after initial ulcer healing. Secondary measures included ankle ROM, plantar flexor strength, and peak plantar pressures.
The diabetic foot patient who keeps reulcerating despite custom footwear and total-contact casting often has an untreated root cause: equinus.
This trial established the operative threshold at dorsiflexion ≤5° and proved that correcting it surgically reduces recurrence fourfold at 7 months and roughly halves it at 2 years. When you see a diabetic patient with a Wagner Grade II forefoot ulcer and dorsiflexion capped at 5° or less, the Hoke triple hemisection is the intervention that changes the long-term trajectory.
The critical postoperative trap: hindfoot pressure rises 34% after ATL and does not normalize. Counsel every patient about heel skin surveillance and confirm their footwear offloads the heel from the moment the cast comes off.
Prior to this RCT, ATL for diabetic ulcers rested on small descriptive series (Lin et al., 15 patients; Armstrong et al., 10 patients). This trial gave the intervention the Level I evidence base that now anchors diabetic foot society guidelines.
This Level I RCT (n=64) asked whether adding percutaneous Achilles tendon lengthening to total-contact casting reduces forefoot ulcer recurrence in diabetic patients with equinus (dorsiflexion ≤5°). Patients were followed for a mean of 2.1 years after initial ulcer healing. Secondary measures included ankle ROM, plantar flexor strength, and peak plantar pressures.
The diabetic foot patient who keeps reulcerating despite custom footwear and total-contact casting often has an untreated root cause: equinus.
This trial established the operative threshold at dorsiflexion ≤5° and proved that correcting it surgically reduces recurrence fourfold at 7 months and roughly halves it at 2 years. When you see a diabetic patient with a Wagner Grade II forefoot ulcer and dorsiflexion capped at 5° or less, the Hoke triple hemisection is the intervention that changes the long-term trajectory.
The critical postoperative trap: hindfoot pressure rises 34% after ATL and does not normalize. Counsel every patient about heel skin surveillance and confirm their footwear offloads the heel from the moment the cast comes off.
Prior to this RCT, ATL for diabetic ulcers rested on small descriptive series (Lin et al., 15 patients; Armstrong et al., 10 patients). This trial gave the intervention the Level I evidence base that now anchors diabetic foot society guidelines.