Mid-term walking ability after Charcot foot reconstruction using the Ilizarov ring fixator

Histopathological assessment of a two-stage reconstructive procedure of the infected Charcot foot

INTRODUCTION

Charcot neuropathic osteoarthropathy (CN) can be complicated by osteomyelitis (OM). Surgery is a standard procedure to treat OM including debridement and interposition of antibiotic-loaded cement (ABLC) spacer. The course of CN and OM was investigated on a histopathological level.

MATERIALS AND METHODS

Diabetic patients (n = 15) suffering from CN and midfoot OM underwent surgical debridement and interposition of ABLC was interposed. 6 weeks later, ABLC was removed and bone samples were taken again. Histopathological Charcot Score (HCS), Histopathological Osteomyelitis Evaluation Score (HOES) and microbiological assessment were used to evaluate osteomyelitic and neuroosteoarthropathic activity at both time points.

RESULTS

Interposition of ABLC leads to microbiological/histopathological eradication of OM in 73%/87% of patients. CN activity-measured by HCS-could be reduced from moderate to low activity by ABLC spacer and correlated with HOES.

CONCLUSIONS

CN activity could be reduced by surgery. It can be suggested that neuroosteoarthropathic activity measured by HCS is triggered by OM.

Arthrodesis in the Deformed Charcot Foot

Charcot neuroarthropathy (CN) is a systemic disease that causes fractures, dislocations, and deformities involving the foot and ankle, resulting in substantial risk of ulceration, infection, and function loss. Early recognition and prevention of collapsing foot and ankle are still the best options for the management of patients with diabetic CN. For a successful arthrodesis procedure, the principles of adequate joint preparation, deformity correction, and soft tissue protection and care are essentials, associated with robust fixation (internal and/or external), use of different biological graft options in segmental losses, and prolonged off-loading.

Nonoperative Treatment of Charcot Neuro-osteoarthropathy

Conservative treatment of Charcot neuro-osteoarthropathy (CN) aims to retain a stable, plantigrade, and ulcer-free foot, or to prevent progression of an already existing deformity. CN is treated with offloading in a total contact cast as long as CN activity is present. Transition to inactive CN is monitored by the resolution of clinical activity signs and by resolution of bony edema in MRI. Fitting of orthopedic depth insoles, orthopedic shoes, or ankle-foot orthosis should follow immediately after offloading has ended to prevent CN reactivation or ulcer development.

Rapid Spontaneous Total Fusion of Neuropathic Arthropathy of the Wrist After Limited Intercarpal Arthrodesis: A Case Report and Brief Literature Review

Background

Previous reports on the treatment of neuropathic arthropathy of the wrist were generally conservative, with few case reports of treatment with osteoarticular surgery.

Case Presentation

A 25-year-old right-handed male complained of unpainful swelling of the dorsal aspect of his right wrist for 3 years. He was at that time diagnosed with synovitis and radiocarpal arthritis. The patient underwent a partial Four-Corner Arthrodesis and Synoviectomy to preserve motor function. Over the next 2 months, his right wrist also developed painful redness, with progressive swelling and stiffness. Rheumatoid arthritis, tuberculosis arthritis, and infectious diseases were ruled out in this case. Magnetic resonance imaging (MRI) indicated that he had Chiari II syringomyelia so the patient was eventually diagnosed with destructive neuropathic arthropathy (syringomyelia). After 2 months of conservative treatment, the patient’s right wrist spontaneously and completely fused and the pain disappeared.

Conclusion

Neuropathic arthropathy of the wrist is a rare but clinically significant disease due to its effect on the function of the active limb. Surgeons should rule out a diagnosis of it when treating patients with wrist swelling and osteoarticular abnormalities, otherwise, limited intercarpal arthrodesis should not be taken as a treatment option. Inappropriate partial surgery is likely to lead to rapid total fusion of neuropathic arthropathy of the wrist.

Long-term follow-up of conservative treatment of Charcot feet

BACKGROUND

Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN.

METHODS

A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development.

RESULTS

Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations.

CONCLUSIONS

With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking.

LEVEL OF EVIDENCE

III, long-term retrospective cohort study.

Tibiocalcaneal arthrodesis using the Ilizarov fixator in compromised hosts: an analysis of 19 patients

INTRODUCTION

Salvage of joint destruction of the tibiotalar and subtalar joint with necrosis or infection of the talus in compromised hosts is a challenging problem. In these cases, tibiocalcaneal arthrodesis using the Ilizarov external fixator represents a possible alternative to amputation. This retrospective study presents the results and complications of this salvage procedure.

MATERIALS AND METHODS

Between 2005 and 2015, 19 patients were treated with tibiocalcaneal arthrodesis using the Ilizarov external fixator. Ten patients received tibiocalcaneal arthrodesis due to an acute or chronic infection with joint destruction. The other nine patients presented posttraumatic necrosis of the talus or Charcot arthropathy. In addition to demographic data, the time spent in the fixator, the major and minor complications and the endpoint of the consolidation were evaluated retrospectively. Furthermore, clinical outcomes were measured using the modified American Orthopedic Foot and Ankle Society (AOFAS) score.

RESULTS

The average time spent in the fixator was 22 (range 14-34) weeks. The average follow-up in 17 patients was 116 (range 4-542) weeks. Two patients were lost to follow-up. Complete osseous consolidation was achieved in 14 out of 19 patients. One patient presented partial consolidation, and in four patients, pseudarthrosis could be detected. The mean modified AOFAS score at the final follow-up was 53 out of 86 possible points.

CONCLUSION

Tibiocalcaneal arthrodesis using the Ilizarov fixator is a possible salvage procedure even in compromised hosts. However, the healing rates are below the rates reported in the literature for tibiotalar arthrodesis in comparable clinical situations.

Staged Percutaneous Treatment of a Complete Lisfranc Dislocation Secondary to Charcot Arthropathy: A Case Report

CASE

A 36-year-old woman with diabetic neuropathy presented with complete dorsal dislocation of the midfoot secondary to Charcot arthropathy. She was treated in a staged fashion with a Taylor spatial butt frame to distract and reduce the midfoot followed by percutaneous preparation of the tarsometatarsal (TMT) joints and fixator-assisted fusion. The arthrodesis healed successfully with maintenance of function at the 30-month follow-up.

CONCLUSION

Staged treatment with a Taylor spatial frame can be used successfully to treat complete TMT dislocations in the setting of Charcot arthropathy. Complications are not uncommon and must be addressed appropriately.

Treatment Failures in Diabetic Foot Osteomyelitis Associated with Concomitant Charcot Arthropathy: The Role of Underlying Arteriopathy

OBJECTIVE

Therapy for diabetic foot osteomyelitis (DFO) with Charcot neuroosteoarthropathy is challenging. In patients with diabetic Charcot osteomyelitis (DCO), both the anatomic deformity and infection must be addressed. This study assessed the outcomes of DCO therapy and variables associated with treatment failure and compared them with outcomes of DFO cases.

METHODS

A single-center, retrospective, case-control study was performed to compare 93 DCO episodes with 530 DFO episodes, using Kaplan-Meier survival curves and multivariate Cox regression analyses.

RESULTS

Clinical failure occurred in 21.5% of DCO compared with 22.3% in DFO episodes (p=0.89) and was associated with peripheral arterial disease (PAD) stages 3 or 4 (HR 6.1; CI 2.0-18.1) and chronic treatment with immunosuppressives (HR 7.4; CI 2.0-27.1). Major amputations were significantly more frequent in DCO (28% versus 13.6%; p<0.01) and associated with PAD stages 3 and 4 (HR 8.0; CI 2.2-29.4), smoking (HR 5.4; CI 1.2-24.6), alcohol abuse (HR 3.5; CI 1.1-10.6), and renal dialysis (HR 4.9; CI 1.3-18.9).

CONCLUSIONS

Clinical treatment failures did not differ between DCO and DFO. However, patients with DCO underwent major amputation twice as often as those with DFO. Unlike widespread belief, treatment failure in DCO patients may, similar to DFO, be associated with a striking epidemiological link to severe PAD.

Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis

An established treatment strategy in surgical site infection after hindfoot and ankle surgery is a two-stage procedure with debridement and placement of a cement spacer, followed by antibiotic treatment and secondary arthrodesis. However, there is little evidence to favor this treatment over a one-stage procedure with debridement, followed by primary arthrodesis with an Ilizarov external fixator and antibiotic treatment. We compared the infection control and clinical and radiological outcome of a two-stage and a one-stage procedure. In this study, 7 patients with a two-stage revision and 11 patients with a one-stage revision between 2005 and 2015 were included. The primary outcome was infection control (absence of the Musculoskeletal Infection Society PJI criteria) 2 years after the ankle or hindfoot arthrodesis. Secondary outcome measures were the AOFAS hindfoot score and radiological consolidation rate. Infection control was 85% (6 out of 7 patients) in the two-stage group and 81% (9 out of 11 patients) in the one-stage group (p = 1.0). One patient (14%) of the two-stage and two patients (18%) in the one-stage group needed below-knee amputation. In the two-stage group, the mean postoperative AOFAS score was 74.8 (SD: ±11.3) versus 71.7 (SD: ±17.8) in the one-stage group. Radiological consolidation could be achieved in 71% in the spacer group (n = 5) and in 72% in the Ilizarov external fixator group (n = 9). Infection control, AOFAS score, and radiologic consolidation of hindfoot and ankle arthrodesis were comparable in both groups of patients with complicated postsurgical hindfoot or ankle infections.

Long-term outcome of persons with diabetic and non-diabetic neuro-osteoarthropathy after foot correction using external fixation

AIM

Diabetic neuro-osteoarthropathy (Charcot foot) is a serious form of diabetic foot syndrome, often leading to severe deformity of the foot and subsequently to ulcers and osteomyelitis. The aim of this retrospective study was to determine the success rate and long-term outcomes for a Charcot foot operation using external fixation in 115 individuals who underwent surgery between July 2008 and December 2012.

METHODS

Some 115 consecutive persons, 78 (68%) men and 37 (32%) women, were enrolled in this study. The eligibility criterion for this retrospective study was reconstructive foot surgery using a Hoffmann II external fixator in diabetic and non-diabetic neuro-osteoarthropathy. The main examination parameters in the follow-up were walking ability, amputation and mortality. Average follow-up was 5.7 (± 3.2) years.

RESULTS

Ninety-seven per cent of people were able to walk after the operation with bespoke shoes or an orthosis. At follow-up, 77% were able to walk and 51% were fully mobile even outside the home. Subsequent amputations were performed in 29 individuals (26%), with 17 (15%) minor and 12 (11%) major amputations. Forty-seven individuals died before follow-up, the majority (53%) from cardiovascular events. Average survival time post surgery was 4.5 (± 2.9) years.

CONCLUSION

Reconstruction surgery using external fixation is a very useful method for maintaining walking ability in the case of conservatively non-treatable diabetic and non-diabetic neuro-osteoarthropathy. Individuals with severe Charcot foot disease had a low rate of major amputations. Osteomyelitis was the main reason for major amputations.

Midterm Fate of the Contralateral Foot in Charcot Arthropathy

BACKGROUND

The contralateral foot in Charcot arthropathy or neuroarthropathy (CN) is subject to increased plantar pressure. To date, the clinical consequences of this pressure elevation are yet to be determined. The aim of this study was to evaluate ulcer and amputation rates of the contralateral foot in CN.

METHODS

We abstracted the medical records of 130 consecutive subjects with unilateral CN. Rates of contralateral CN development and recurrence, contralateral ulcer development, and contralateral amputations were recorded. Statistical analysis was performed to identify possible risk factors for contralateral CN and ulcer development, and contralateral amputation. Mean follow-up was 6.2 (SD 4) years.

RESULTS

After a mean of 2.5 years, 19.2% patients developed contralateral CN. Female gender was associated with contralateral CN development (odds ratio 3.13, 95% confidence interval 1.27, 7.7). Overall, 46.2% patients developed a contralateral ulcer. Among the patients who developed contralateral CN, 60% developed an ulcer. Sanders type 2 at the index foot (midfoot CN) was significantly associated with contralateral ulcer development. Ulcer-free survival (UFS) differed significantly between patients with diabetes type 1 (median UFS 5131 days) and patients with diabetes type 2 (median UFS 2158 days). A total of 25 amputations had to be performed in 22 (16.9%) patients. Three of those 22 patients (2.3%) needed major amputation.

CONCLUSION

Almost 20% of patients developed contralateral CN. Nearly half of people with CN developed a contralateral foot ulceration. Patients with type 2 diabetes had significantly shorter UFS than patients with diabetes type 1. Every sixth patient needed an amputation, with the majority being minor amputations. The contralateral foot should be monitored closely and included in the treatment in patients with CN.

LEVEL OF EVIDENCE

Level IV, retrospective study.