Should one consider primary surgical reconstruction in charcot arthropathy of the feet?

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint

INTRODUCTION

Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge.

METHODS

This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score.

RESULTS

Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002).

CONCLUSION

This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.

Surgical management of the diabetic foot: The current evidence

The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.

Case Report: Supramalleolar osteotomy to preserve joint function and delay the development of Charcot neuroarthropathy of the ankle

Background

Charcot neuroarthropathy (CN) is a severe disease that primarily affects the foot and ankle. Conservative treatment with total contact casts is suitable for early stages, but surgery is necessary for complications such as ulceration, malalignment, infection, or severe pain. The ankle instability caused by excessive axial load may require arthrodesis. However, preserving joint function in young patient can significantly enhance the quality of life.

Case report

A 33-year-old woman underwent open reduction and internal fixation after the right tibia and fibula fractures following a fall while walking. She developed severe pain and deformity in her right ankle after full weightbearing. After further evaluation, she was diagnosed with Charcot neuroarthropathy (CN) of the right ankle. The patient declined arthrodesis and opted for a supramalleolar osteotomy (SMO) instead 18 months after the initial surgery. The SMO procedure involved correcting the hindfoot malalignment through osteotomy and fixation. Although she experienced skin necrosis, the patient eventually achieved satisfactory outcomes with improvements in pain, deformity, and functionality of the ankle. Radiographic measurements showed positive realignment, and the patient reported a significant improvement in her quality of life at the final follow-up.

Conclusions

The SMO procedure could potentially be considered as an option to preserve ankle function and delay the disease development of CN for young patients. The restored foot stability and hindfoot alignment can help improve patients' quality of life.

Surgical Optimization for Charcot Patients

Reconstruction of the Charcot foot and ankle demonstrates significant challenges to the foot and ankle surgeon. At present, there is limited clear consensus on the best approach for preoperative optimization. The primary aim of Charcot reconstructions is to limit the risk of ulceration by providing a stable plantigrade foot allowing ambulation. The focus of this article is the discussion of modifiable risk factors associated with Charcot reconstruction for preoperative optimization.

Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy

Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.

Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes

Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.

Biomechanical Performance of Charcot-Specific Implants

Over the past 2 decades, an increased number of diabetic Charcot neuroarthropathy reconstructions have been performed. Despite advances in implant technology, arthrodesis complication rates remain high. This study examined the biomechanical properties (4-point bending, cantilever bending, and thread pullout resistance) of intramedullary implants designed for midfoot reconstruction. Large implants included A1 (7.4 mm cannulated stainless steel beam), B1 (6.5 mm solid titanium bolt), and C1 (7.0 mm cannulated titanium beam). Smaller implants included A2 (5.4 mm cannulated stainless steel beam) and C2 (5.0 mm solid titanium bolt). Four-point bending testing compared flexural properties of the body of the implants. Cantilever-bending testing was performed with the maximum bending moment being applied off the main thread of the implant to assess the thread portion. Thread pullout strength was tested by fixing the implants to a Sawbone block on a platform, and the distal portion of the implant in a clamp connected to loading actuator. Implant A1 demonstrated higher stiffness, force to failure, and fatigue compared to implants B1 and C1 (p < .05). Pullout strength of implant A1 was higher than implant B1 (p < .05). Thread fatigue strength of implant A1 was higher than implant C1 (p < .05). Implant A2 demonstrated higher stiffness, force to failure, tip fatigue strength, and thread pullout strength compared to implant C2 (p < .05), while implant C2 demonstrated higher body fatigue failure than implant A2 (p < .05). Alteration of beam/bolt parameters influences the biomechanical performance of implants used in Charcot reconstruction. Greater stiffness resists deformation, providing improved stability. Greater static failure load and fatigue limit improves the implant's ability to withstand higher and repetitive loads before failing This study should stimulate further clinical research to determine if these biomechanical properties translate into reduced implant failure rates and improved clinical outcomes in patients with diabetic Charcot neuroarthropathy.

Two Cases of Periprosthetic Fracture After Surgery for Acute Midfoot Charcot

Charcot neuroarthropathy is a rare condition that often results in deformity of the foot and ankle, with a high incidence of ulceration and a high risk of amputation. Traditionally, treatment of the acute stages of Charcot foot has been nonoperative until consolidation. Still, a large number of patients develop deformities, and early operative treatment of unstable Charcot feet has been suggested. To overcome some of the inherent challenges when operating on acute-stage Charcot feet, the superconstruct technique has been proposed. Early surgery for dislocated Charcot foot is sparingly described in the literature. To investigate the utility of the superconstruct technique for acute midfoot Charcot, we planned a prospective cohort study including patients with midfoot manifestation (Brodsky 1) in the active stages of the disease. Patients eligible for the study were treated with open surgery and midfoot arthrodesis using the superconstruct technique. In this report, we present the development of periprosthetic fractures related to early surgery using the superconstruct technique, possibly causing a more proximal Charcot manifestation in 2 patients with >24 months of follow-up. To our knowledge, such complications have been sparsely noted in the literature.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND

Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference.

QUESTIONS/PURPOSES

To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data.

METHODS

A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty.

RESULTS

The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective.

CONCLUSIONS

Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review

OBJECTIVE

A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes.

METHOD

A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded.

RESULTS

A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction.

CONCLUSION

Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.

An Approach to Managing Midfoot Charcot Deformities

We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.

Union of Brodsky type 1/Eichenholtz stage III Charcot neuroarthropathy after forefoot arthrodesis

INTRODUCTION

One of the surgical intervention options for Charcot neuroarthropathy (CN) is arthrodesis. The arthrodesis procedure for the foot and ankle joint have been widely used in previous studies. This study aimed to evaluate the functional and radiological outcomes after arthrodesis procedure for the CN patient with Brodsky type 1/Eichenholtz stage III.

PRESENTATION OF CASE

A 49-years-old diabetic woman presented with alteration of her right foot's shape and a cracking sensation while walking in the last six months. Rocker-bottom deformity and a decreased sensation on the right foot were found, and the initial American Orthopaedic Foot & Ankle Society (AOFAS) score was 45. Subsequently, forefoot arthrodesis of the right foot was performed.

DISCUSSION

Several studies state that arthrodesis procedure is often used for CN management in order to achieve a plantigrade and stable foot. This study presents an improvement of the foot arch, AOFAS score, and union of the talus six months after surgery.

CONCLUSION

The arthrodesis procedure by using screws and Kirschner wire (K-wire) fixation is an effective method in CN management if the patient is compliant. This study showed a good result, anatomically restored the foot arch, and excellent radiological union, but different tools to analyze foot functional status and longer follow up period are needed for a better analysis.

Charcot foot reconstruction outcomes: A systematic review

BACKGROUND

Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications.

METHODS

We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques.

RESULTS

A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation.

CONCLUSIONS

Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.

Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management

Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.

Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for charcot osteoneuropathy of the foot: A case series

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Retrograde IM Nailing is a promising therapy for Charcot osteoneuroarthopathy.

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Assessment using VAS, AOFAS Scale, and SF-36 showed good result.

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No complication were recorded with this procedure using Expert Tibia Nail.

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Overall patients satisfaction for this procedure was 9/10.

Introduction

Charcot osteoneuroarthopathy (CN) is a progressive degenerative arthropathy determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines. The aim of treatment is to maintain the foot on plantigrade position, recover foot deformity, osseous stability, and prevent ulceration. Intramedullary fixation in calcaneotalotibial arthrodesis has been described in promotion of rigid internal fixation with minimal soft tissue violation producing deformity correction, minimal periosteal aggression, vascular damaged and good functional outcome, with less postoperative fusion time and able to achieve fusion of the ankle and the subtalar joint after failed fusion.

Presentation of case

Two patients with charcot foot underwent tibiocalcaneal arthrodesis with retrograde intramedullary technique by Expert Tibial Nail (ETN). The patients are both male 59 years with right ankle deformity 9 months prior to admission and history of trauma and 40 years old with history of Type 2 Diabetes Mellitus. Visual analog scale (VAS), AOFAS and SF score were assessed pre and post operative.

Discussion

A good stability, plantigrade ankle and painless foot on both patients were achieved with a mean score 9 for satisfaction. Pre and 3 months post operative VAS were 4 and 1, AOFAS Scale were 58 and 83, mean of SF-36 were 28.4 and 48.6 for physical condition, 37.3 and 67.2. for mental condition consecutively. No severe postoperative complication were recorded

Conclusion

Tibiotalocalcaneal arthrodesis with retrograde intramedullary technique using ETN system was proven to have a good option for ankle joint salvage with improvement of clinical and functional score. Hence, its application in the charcot joint is promising.

Charcot Neuroarthropathy: From the Laboratory to the Bedside

BACKGROUND

The diabetic Charcot foot syndrome is a serious and potentially limbthreatening lower-extremity complication of diabetes.

INTRODUCTION

The present review provides a concise account of the advances made over the last twentyfive years in understanding the pathogenesis and management of Charcot neuroarthropathy (CN).

METHODS

In this study, the widely known pathogenetic mechanisms underpinning CN are brought into focus, particularly the role of RANKL/RANK/OPG system and advanced glycation end production in the pathogenesis of CN. Furthermore, other potential triggering factors, namely nitric oxide, endothelial dysfunction, macro calcifications and body weight that influence CN have also been discussed.

RESULTS

The wide range of diagnostic tools available to clinicians for accurate staging of this pathology has been examined, particularly radiological and nuclear medicine imaging. Additionally, the difficult differential diagnosis between osteomyelitis and CN is also elucidated.

CONCLUSION

The review concludes with the comprehensive summary of the major promising therapeutic strategies, including conservative treatment involving orthopedic devices, pharmacological approach, and the most common surgical techniques currently employed in the diagnosis and treatment of this acute disease.

The acute Charcot foot in diabetics: Diagnosis and management

Acute Charcot foot is a diagnostic challenge.

The exact pathophysiology is not fully understood.

Acute Charcot foot is often present with a history of trauma or cellulitis which does not respond to antibiotics.

The condition is best managed within a multidisciplinary team.

The mainstay of the treatment is mechanical off-loading and total contact casting.

Surgery is reserved for select cases.

Cite this article: EFORT Open Rev 2018;3:568-573. DOI: 10.1302/2058-5241.3.180003

High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot

Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.

A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.

Functional pedal construct achieved by combined operative treatment in peritalar complex Charcot arthropathy: A prospective study of 38 feet

BACKGROUND

Charcot arthropathy of the peritalar complex carries a high risk of amputation if not properly managed. Our aim is to assess the functional outcome of severe Charcot arthropathy of the peritalar complex following enblock resection of the ulcer, massive debridement and stabilizing all the elements of the peritalar complex.

METHODS

We prospectively studied 38 feet in 35 patients with peritalar complex Charcot arthropathy. All Feet underwent intense debridement and fusion using a combination of (Ilizarov) external fixation, and (plate and locked nail) internal fixation. Thirty two feet were graded as Eichenholtz 2, and six feet were graded as Eichenholtz 3. The mean follow up was 35.9months.

RESULTS

The mean AOFAS score was significantly elevated from 25.4±9.1 preoperatively to 67.6±5.7 at the most recent follow-up (p<0.001). Complete bony fusion was achieved in 28 feet. Unsound bony fusion occurred in 8 feet. Two feet required below knee amputation.

CONCLUSION

Peritalar complex Charcot arthropathy is not uncommon variety. Such cases carry high risk of complications and amputation is not excluded. The proper timing of surgery is crucial. Massive debridement and rigid fixation with strict follow up is mandatory to achieve the ultimate goal of obtaining a plantigrade, stable, mechanically sound, painless and infection free pedal construct.

Corneal Subbasal Nerve Plexus Changes in Severe Diabetic Charcot Foot Deformity: A Pilot Study in Search for a DNOAP Biomarker

INTRODUCTION

Diabetic neuroosteoarthropathy (DNOAP) early symptoms are unspecific, mimicking general infectious symptoms and rendering a diagnosis challenging. Consequently, unfavourable outcomes occur frequently, with recurrent foot ulceration, infectious complications, and eventually amputation. Corneal confocal microscopy (CCM) of the subbasal nerve plexus (SNP) is used to detect early peripheral neuropathy in diabetic patients without diabetic retinopathy. This pilot study was designed to determine if specific SNP changes manifest in severe DNOAP in comparison to a healthy control group.

METHODS

This pilot study utilized a matched-pair analysis to investigate SNP changes by in vivo CCM for 26 patients (mean patient age 63.7 years, range 27 to 78) with severe DNOAP defined by condition after the need for reconstructive foot surgery (n = 13) and a healthy control group (n = 13). Corneal nerve fibre length (CNFL), nerve fibre density (CNFD), nerve branch density (CNBD), average weighted corneal nerve fibre thickness (CNFTh), nerve connecting points (CNCP), and average weighted corneal nerve fibre tortuosity (CNFTo) were assessed as well as the general clinical status, diabetic status, and ophthalmologic basic criteria.

RESULTS

In vivo CCM revealed significantly reduced SNP parameters in the DNOAP group for CNFL (p = 0.010), CNFD (p = 0.037), CNBD (p = 0.049), and CNCP (p = 0.012) when compared to the healthy control group. Six patients (46%) of the DNOAP group suffered from diabetic retinopathy and none of the control group.

CONCLUSIONS

This pilot study revealed a rarefication of SNP in all measured parameters in patients with severe DNOAP. We see a potential value of CCM providing a SNP-based biomarker for early stages of DNOAP prior to the development of any foot deformities that needs to be evaluated in further studies. This trial is registered with German Clinical Trials Register (DKRS) DRKS00007537.

5th Congress of WUWHS Abstract book Florence, Italy September 25–29 2016

The abstract book contains the abstracts of keynote lectures, focus sessions, symposia, workshops, AIUC annual meeting, AISLEC annual meeting, EPUAP annual meeting, ETRS special session, sponsor symposia, oral presentations, poster presentations and the subject index.

Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients

Background

Charcot neuropathic arthropathy (CN) is a chronic, progressive, destructive, non-infectious process that most frequently affects the bone architecture of the foot in patients with sensory neuropathy. We evaluated the outcome of protected weightbearing treatment of CN in unilaterally and bilaterally affected patients and secondarily compared outcomes in protected versus unprotected weightbearing treatment.

Methods

Patient records and radiographs from 2002 to 2012 were retrospectively analyzed. Patients with Type 1 or Type 2 diabetes with peripheral neuropathy were included. Exclusion criteria included immunosuppressive or osteoactive medication and the presence of bone tumors. Ninety patients (101 ft), mean age 60.7 ± 10.6 years at first diagnosis of CN, were identified. Protected weightbearing treatment was achieved by total contact cast or custom-made orthosis. Ulcer, infection, CN recurrence, and amputation rates were recorded. Mean follow-up was 48 (range 1–208) months.

Results

Per the Eichenholtz classification, 9 ft were prodromal, 61 in stage 1 (development), 21 in stage 2 (coalescence) and 10 in stage 3 (reconstruction). Duration of protected weightbearing was 20 ± 21 weeks and 22 ± 29 weeks in patients with unilateral and bilateral CN, respectively. In bilaterally affected patients, new ulcers developed in 9/22 (41%) feet. In unilaterally affected patients, new ulcers developed in 5/66 (8%) protected weightbearing feet and 4/13 (31%) unprotected, full weightbearing feet (p = 0.036). The ulceration rate was significantly higher in bilaterally versus unilaterally affected patients with a protected weightbearing regimen (p = 0.004). Soft tissue infection occurred in 1/13 (8%) unprotected weightbearing feet and 1/66 (2%) protected weightbearing feet in unilaterally affected patients, and in 1/22 (4%) protected weightbearing feet of bilaterally affected patients. Recurrence and amputation rates were similar across treatment modalities.

Conclusions

Bilateral CN results in significantly more ulcers than unilateral CN and leads to slightly higher soft tissue infections. Protected weightbearing in an orthopedic device can reduce the risk for complications in acute CN of the foot and ankle.

Staged Reconstruction for Acute Charcot's Subtalar Joint DislocationA Case Report

Charcot's neuroarthropathy can have devastating consequences if left untreated or misdiagnosed. With progression of the disease from the acute to the chronic phase, substantial deformity and instability may result, leading to ulceration and a nonfunctional limb. The purpose of this case report is to present a staged reconstruction for active Charcot's neuroarthropathy involving the subtalar joint with complete dislocation that resulted in limb salvage and maintenance of limb function at 1-year follow-up. Although for many patients the mainstay of treatment for early Charcot's neuroarthropathy is conservative care with off-loading, early surgical correction that includes external fixation followed by definitive arthrodesis for select patients may be warranted.

Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction

Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group.

Internal Versus External Fixation of Charcot Midfoot Deformity Realignment

Internal and external fixation techniques have been described for realignment and arthrodesis of Charcot midfoot deformity. There currently is no consensus on the optimal method of surgical reconstruction. This systematic review compared the clinical results of surgical realignment with internal and external fixation, specifically in regard to return to functional ambulation, ulcer occurrence, nonunion, extremity amputation, unplanned further surgery, deep infection, wound healing problems, peri- or intraoperative fractures, and total cases with any complication. A search of multiple databases for all relevant articles published from January 1, 1990, to March 22, 2014, was performed. A logistic regression model evaluated each of the outcomes and its association with the type of fixation method. The odds of returning to functional ambulation were 25% higher for internal fixation (odds ratio [OR], 1.259). Internal fixation had a 42% reduced rate of ulcer occurrence (OR, 0.578). External fixation was 8 times more likely to develop radiographic nonunion than internal fixation (OR, 8.2). Internal fixation resulted in a 1.5-fold increase in extremity amputation (OR, 1.488), a 2-fold increase in deep infection (OR, 2.068), a 3.4-fold increase in wound healing complications (OR, 3.405), and a 1.5-fold increase in the total number of cases experiencing any complication (OR, 1.525). This was associated with a 20% increase in the need for unplanned further surgery with internal fixation (OR, 1.221). Although internal fixation may decrease the risk of nonunion and increase return to functional ambulation, it had a higher rate of overall complications than external fixation for realignment and arthrodesis of Charcot midfoot deformity. [Orthopedics. 2016; 39(4):e595-e601.].

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Tibiotalocalcaneal arthrodesis with a triple-bend intramedullary nail (A3)-2-year follow-up in 60 patients

BACKGROUND

The aim of the study was to analyze the clinical aspects including 2-year follow-up of tibiotalocalcaneal arthrodesis (TTCA) with a triple-bend retrograde intramedullary nail (A3, Stryker, Airview Boulevard, MN, USA).

METHODS

All patients with TTCA with A3 between October 18, 2011 and April 29, 2013 were included. Visual Analogue Scale Foot and Anklenkle (VAS FA), indications for surgery, details of surgery, radiographic measurements, and complications were analyzed.

RESULTS

A total of 66 patients were included. The mean VAS FA was 29.6. Most common indications were arthrosis (n=43; 65%) and deformity (n=36; 55%). The accuracy of correction and implant position was 9.4 (maximum 10) on average. Infection rate was 3% (n=2). Sixty (91%) patients completed follow-up: VAS FA 59.9, fusion rate 100%, high accuracy of correction and implant position.

CONCLUSIONS

TTCA with the A3 implant system showed accurate correction and implant position. Two-year follow-up in 60 patients (91%) showed good clinical outcome scores and 100% fusion rate.

Lower Extremity Amputation and Mortality Rates in the Reconstructed Diabetic Charcot Foot and Ankle With External Fixation: Data Analysis of 116 Patients

The aim of this study was to determine the lower extremity amputation and mortality rates of a group of patients who underwent reconstructive surgery using circular external fixation for treatment of diabetic Charcot neuroarthropathy (CN) of the foot and/or ankle. Existing studies regarding lower extremity amputation or mortality rates for diabetic CN of the foot and/or ankle have been performed on mostly conservatively treated patients. The objective of the statistical analysis in this studied population was to understand the difference in overall amputation and mortality rates between the 2 main groups: one with foot and/or ankle ulceration (group 1), and the other without ulceration or osteomyelitis (group 2, control group). Within group 1, 2 subgroups were established: one with osteomyelitis (group 1A) and the other without osteomyelitis (group 1B). Initially, a retrospective analysis of 150 consecutive surgically reconstructed diabetic foot and ankle cases using circular external fixation from January 2005 through December 2012 was conducted. Those which were not supported with the diagnosis of diabetic CN were excluded and the 2 other charts without proper follow-up duration (6 months) for analysis were removed, resulting in the final sample size of N = 116. There were a total of n = 7 (6.0%) below the knee amputations (group 1A = 1, group 1B = 4, and group 2 = 2) with a total of n = 5 mortalities (4.3%) (group 1A = 2, group 1B = 2, and group 2 = 1). The total amount of time for a lower extremity amputation event (n = 7) since the time of surgical reconstruction was 729.43 ± 519.73 days (range 230-1777 days) while for a mortality event (n = 5), it was 1302.00 ± 765.48 days (range 633-2499 days).

LEVELS OF EVIDENCE

Prognostic, Level III: Retrospective study.

Surgical Management of Charcot Deformity for the Foot and Ankle-Radiologic Outcome After Internal/External Fixation

Charcot neuropathy (CN) is a severe joint disease that makes surgical planning very challenging, because it is combined with ankle instability, serious deformities, and recurrent ulceration. The aim of the present study was to examine the rate of bone fusion after external or internal fixation in patients with CN. We retrospectively examined 58 patients with CN who had undergone reconstruction of the ankle either with tibiotalocalcaneal or tibiocalcaneal arthrodesis. The mean age was 59.1 (range 26 to 81) years at surgery. Of the 58 patients, 38 were treated using intramedullary nail arthrodesis and 19 using an external fixator (1 patient received neither). At a mean follow-up period of 31.3 (range 12 to 57) months, limb salvage and bone fusion had been achieved in 94.83%. The mean time to bone fusion was 12 (range 6 to 18) months. Three patients (5.2%) required a more proximal amputation. All but these 3 patients gained independent mobilization in custom feet orthoses or off the shelf orthoses. Of the 58 patients in the present cohort, 56 (96.6%) would undergo surgery again. In conclusion, internal and external fixation both lead to promising results in the treatment of CN. Internal fixation should be preferred when no indications of ulcer or infection are present.

Charcot Neuroarthropathy in Patients With Diabetes: An Updated Systematic Review of Surgical Management

Charcot neuroarthropathy (CN) of the foot and ankle is a demanding clinical dilemma, and surgical management can be very complicated. Historically, the evidence guiding surgical management of CN has been small retrospective case series and expert opinions. The purpose of the present report was to provide a systematic review of studies published from 2009 to 2014 and to review the indications for surgery. A Medline search was performed, and a systematic review of studies discussing the surgical management of CN was undertaken. Thirty reports fit the inclusion criteria for our study, including 860 patients who had undergone a surgical procedure for the treatment of CN. The surgical procedures included amputation, arthrodesis, debridement of ulcers, drainage of infections, and exostectomy. The midfoot was addressed in 26.9% of cases, the hindfoot in 41.6%, and the ankle in 38.4%. Of the 30 studies, 24 were retrospective case series (level 4), 4 were controlled retrospective studies (level 3), and 2 were level II studies. The overall amputation rate was 8.9%. The quality of the published data on the surgical management of CN has improved during the past several years. Evidence concerning the timing of treatment and the use of different fixation methods remains inconclusive.

[Surgical treatment of the Charcot foot : long-term results and systematic review]

BACKGROUND

Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.

OBJECTIVES

The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.

MATERIALS AND METHODS

In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.

RESULTS

After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.

CONCLUSION

Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.

Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction - Results from a multi-centre study

BACKGROUND

Charcot osteo-neuroarthropathy (CN) of the foot can induce severe instability and deformity. Results of a consecutive clinical multi-centre study with Midfoot Fusion Bolt (MFB, Synthes GmbH, Oberdorf, Switzerland) are reported.

METHODS

All patients (aged 18 years and older) treated between 2009 and 2013 with surgical reconstruction of the midfoot with MFB for CN were included. Demographics, pre-surgical health status, details of foot pathology, details of surgery, postoperative treatment, treatment failure, and adverse events were registered. The following radiographic angles were measured on pre-op, post-op and last follow-up radiographs: talo-1st metatarsal (TMT) angle dorsoplantar and lateral view, and calcaneo-5th metatarsal angle.

RESULTS

Forty-seven patients (48 feet) were included in three centres. In 38 patients (80.1%) diabetes was diagnosed. Wound healing problems occurred in 21% of patients and recurrent ulceration in 13%. Revision surgery for loss of correction was performed in three cases (6%). Union rate at final follow-up was 98%. Major amputation for deep infection was performed in two patients (4%), minor amputation at the foot level in three cases (6%). Failure was more frequent when only one MFB (instead of 2 or 3) was used and no Gastrocnemius lengthening was performed. Radiographic alignment significantly improved pre- versus postoperatively and preoperatively versus follow-up.

CONCLUSIONS

Realignment and fixation with MFB in severe CN result in adequate correction with minimal loss of correction in the observed clinical course. The non-union rate was lower than previously reported. Stable fixation with MFB is a valuable treatment option for CN with minimal loss of correction and high union rates. The use of a minimum of two bolts is recommended to avoid recurrent deformity. Clinical Trials.gov: NCT01770639.

Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score

Background

All diabetic neuroosteoarthropathy (Charcot arthropathy) treatment concepts are focused on a long-term infection-free, ulcer-free, and plantigrade sufficiently stable foot in order to avoid amputation. Reconstructive arthrodesis techniques for severe deformities are associated with high postoperative complication rates. This study reports a detailed complication analysis and provides a strategy that may help detect patients at risk for a complicated postoperative course.

Methods

The study comprised 43 feet in 37 patients with severe non-plantigrade or unstable Charcot deformity, Eichenholtz stages II/III (Sanders and Frykberg types II-V), who underwent reconstructive arthrodesis of the mid- and/or hindfoot. Patients were retrospectively enrolled 4.5 years postoperatively (range 1.8–11.2 years). All patients showed at least two out of five positive Pinzur high-risk criteria (immuno-compromising illnesses, large bone deformity, longstanding ulcer overlying infected bone, regional osteopenia, obesity). Follow-up included a detailed clinical analysis and radiologic assessment with emphasis on complication analysis and evaluation in accordance to the PEDIS classification system.

Results

Significantly lower overall complication rates, as well as re-operation, reulceration and amputation counts were found for patients with a cumulative PEDIS count below 7. For PEDIS single criteria, significantly lower overall complication rates were found for patients without signs of occlusive peripheral artery disease, an ulcer extent <0.9 cm², ulcer depth including erosion and inflammation of the skin and subcutaneous tissues only. Soft-tissue complications affected 49 % of patients, hardware breakage 33 %, hardware loosening 19 %, non-union 18 % and amputation 21 %. Radiographs revealed a correct reconstruction and restoration of all foot axes postoperatively with partial recollapse at the lateral foot column; however, fixation strength for the medial column was maintained.

Conclusions

Internal corrective arthrodesis for patients within the deformed stages of Charcot deformity can provide adequate reconstruction, as assessed by intraoperative radiographic measures, that exhibit superior long-term stability for the medial column. Despite a high risk patient population, a favourable outcome in terms of overall complication, re-ulceration, and amputation rates for patients/feet with a cumulative PEDIS count below 7 was found. The cut-off value of 7 may aid clinical decision-making during preoperative planning for Charcot deformity.

[Corrective arthrodesis of midfoot Charcot neuroosteoarthropathy with internal fixation]

OBJECTIVE

The goal of treatment is a plantigrade, stable, ulcer-free foot which can be addressed with diabetes-adapted insoles and/or DNOAP shoes.

INDICATIONS

Charcot foot of the midfoot with/without infection-free ulcers.

CONTRAINDICATIONS

Inacceptable anesthesiological risk in polymorbidity. Severe anesthesiological risks in multimorbid patients; symptomatic peripheral arterial occlusive disease not suitable for reconstruction; infections PEDIS/IWGDF grade 3 or 4, nonreconstructable osseous defects.

SURGICAL TECHNIQUE

Corrective arthrodesis with segmental resection or bone grafting of the midfoot to achieve a plantigrade foot position. Plantar plate application or intramedullary (e.g., midfoot fusion bolt) and extramedullary (preferably: angular stable locking plates) implant combinations to create the highest possible degree of primary stability of the medial and/or lateral foot columns (superconstruct). In case of higher degrees of instability, the hindfoot should also be included into the arthrodesis.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing (20 kg) with forearm crutches for 3-5 months postoperatively in special orthosis or total contact cast. Therapeutic shoes with diabetes-adapted insoles with full weight-bearing.

RESULTS

Using any of these stabilization variants, a plantigrade, stable, and long-lasting ulcer-free foot may be obtained that is suitable for custom-made footwear. The outcome does not depend on definite osseous healing of the arthrodesis and allows for the patient to have a self-determined lifestyle. The consecutive rate of amputation is low.

COMPLICATIONS

High rate of surgical complications (e.g., infection, implant failure, non-union, loss of correction, reulceration), in particular, in cases of inadequate indication or insufficient primary stability.

[Management of midfoot instability in Charcot foot with the ring fixator : Use of a hybrid technique with internal and external stabilization]

OBJECTIVE

Combination of external and internal fixation for improvement of stabilization in midfoot arthrodesis.

INDICATIONS

Charcot foot of the midfoot with/without (infection-free) ulceration.

CONTRAINDICATIONS

Severe anesthesiological risks in multimorbid patients; untreated symptomatic peripheral arterial occlusive disease; severe soft tissue infection and defect with the necessity of amputation.

SURGICAL TECHNIQUE

Performing subtractive resection arthrodesis of the midfoot with locking plates and screws combined with an external ring fixator of the foot and lower leg.

POSTOPERATIVE MANAGEMENT

Postoperative partial weight bearing with sole contact and walking frame for 3 months. Then removal of external fixator, CT scan and based on the result, staged increasing of stress load with short-leg cast over a period of 4-6 weeks. Podomechanotherapy with full weight bearing.

RESULTS

With this surgical procedure, sufficient stabilization with fully load bearing, plantigrade foot with podomechanotherapy with the help of a combined internal and external fixation is possible. Complications (pin-tract infection or dislocation) exist, but they can be controlled. High healing rate of ulceration was achieved by bony position correction and stabilization.

[Treatment of hindfoot instability in Charcot foot using a hybrid technique of internal and external fixation]

OBJECTIVE

The main problem of patients with Charcot foot is their inability to off-load. Therefore the risk of internal fixation failure is increased, especially in hindfoot instability (Sanders type IV) with osteonecrosis of the talus. Combination of internal and additional external fixation guarantees the reconstruction and improves surgical outcome. The main objective of this surgery is to obtain a resilient, plantigrade foot that is shoeable in custom-made orthopedic shoes.

INDICATIONS

Charcot foot with instable collapse of the hindfoot with or without fragment dislocation, with or without (noninfected) ulceration not shoeable in custom-made orthopedic shoes.

CONTRAINDICATIONS

Very poor general condition, non-reconstructible peripheral vascular disease, deep infection and defects in the region of surgery which makes amputation nescessary, and poor patient compliance.

SURGICAL TECHNIQUE

Excision of the distal fibula and removal of the destroyed talus body using a lateral approach. Medial approach to remove the medial malleolus. Tibiocalcaneal fusion using screws for internal fixation. Fusion of the talus head to the anterior tibia. Ilizarov external fixateur to stabilize the internal fixation.

POSTOPERATIVE MANAGEMENT

Off-loading for 3 months, then CT scan to verify bony fusion and according to the findings stepwise weight-bearing in a cast or walker over 4-6 weeks. Then custom-made orthopedic shoes with a high shaft and insoles for neuropathic patients and full weight-bearing.

RESULTS

In a retrospective cohort study, 14 of 16 patients could be fitted in custom-made shoes after undergoing tibiocalcaneal fusion. During follow-up, 2 patients required below-knee amputation, 3 patients had stress fractures of the tibia, one related to a pin track infection. All patients had a bony fusion of calcaneus and tibia; 10 of 16 patients had fusion of midfoot/talus head and the distal tibia. The 10 patients who had an ulcer before surgery could be healed. In 1 patient, a heel ulcer developed due to talipes calcaneus.

A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

Surgical management of Charcot neuroarthropathy

BACKGROUND

Charcot neuroarthropathy is one of the more devastating complications of diabetes. It is a progressive, destructive condition that is characterized by acute fracture, dislocation, and joint destruction in weight-bearing neuropathic foot. In its acute phase, it is often misdiagnosed and can lead to several deformities such as ulcerations and amputation. Early diagnosis and management is, therefore, imperative to avoid rapid progression.

OBJECTIVES

Review current literature on the diagnosis and management of diabetic patients with Charcot neuroarthropathy.

STUDY DESIGN

Narrative review.

METHODS

Particular attention is directed to the role of surgical management in achieving long term osseous stability and alignment so that appropriate footwear and bracing are possible.

CONCLUSION

Charcot neuroarthropathy is a serious and potentially limb-threatening lower extremity late complication of diabetes. Correct timing, adequate fixation and a long post-operative weightbearing period are key to optimizing reconstructive surgery.

CLINICAL RELEVANCE

Primary care providers who treat diabetic patients should be cognizant of the possible complication among patients with diabetic neuropathy of which includes Charcot neuroarthropathy. In this paper, discussion is provided on a rational approach to functional limb salvage with various surgical techniques when non-operative management fails.

Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates

INTRODUCTION

Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates.

MATERIALS/METHODS

21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis.

RESULTS

A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially.

CONCLUSION

Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.

[Hindfoot fusion for Charcot osteoarthropathy with a curved retrograde nail]

BACKGROUND

Charcot osteoarthropathy of the hindfoot with considerable dislocation and instability represents a therapeutic dilemma. The treatment goal is a plantigrade, stable foot that is free of infection and ulceration with the ability to ambulate in special footwear.

MATERIALS AND METHODS

Over a period of 6 years, we performed 23 hindfoot fusions in 21 patients with manifest Charcot arthropathy with the help of a curved retrograde nail (HAN). All patients suffered from insulin-dependent diabetes mellitus with polyneuropathy; 12 patients had additional peripheral vasculopathy. An average of 3.5 previous surgeries had been performed prior to hindfoot fusion.

RESULTS

Complete tibiotalocalcaneal fusion was obtained in 16 of 21 patients (76 %). Of these 21 patients, 18 (86 %) were followed clinically and radiologically for an average of 2 years. Overall, 16 patients (89 %) reported a substantial subjective improvement compared to the preoperative state. Hardware failure occurred in 7 cases (30 %) that could be brought to consolidation with exchange of the locking bolts or the complete nail. In 5 cases (22 %), a postoperative hematoma had to be removed and in 8 cases (35 %) wound edge necrosis was treated with local wound care. In 2 cases (9 %), a secondary or reactivated osteitis occurred that finally required below knee amputation.

CONCLUSION

Tibiotalocalcaneal fusion with a curved retrograde intramedullary nail (HAN) is an effective treatment option in highly unstable and deforming Charcot osteoarthropathy of the hindfoot. It is an alternative to external or other internal fixation methods and helps to avoid below knee amputation in more than 90 % of cases.

Use of a definitive cement spacer for simultaneous bony and soft tissue reconstruction of mid- and hindfoot diabetic neuroarthropathy:a case report

The prevalence of diabetes mellitus has been increasing, and ≤25.8 million people, or 8.3% of the US population, have diabetes. Diabetic Charcot arthropathy and foot ulcers are serious complications of diabetes mellitus. They have been associated with greater risks of lower extremity amputation and mortality. Studies have shown that the amputation risk relative to patients with Charcot arthropathy alone is 7 times greater for patients with a foot ulcer, and 12 times greater for patients with Charcot arthropathy and a foot ulcer. Surgical reconstruction of Charcot arthropathy of the foot is often difficult, because of bone loss, deformities, vasculopathy, and the presence of active infection with or without soft tissue loss. It will be even more challenging if >1 region of the foot has been affected, such as the mid- and hindfoot. In such situations, an amputation would usually be the surgical option. We present a case of limb-threatening Charcot deformity with instability complicated by osteomyelitis, bone loss, and a large soft tissue defect. We used a limb salvage strategy with hindfoot fusion combined with an antibiotic-impregnated cement spacer for reconstruction of the midfoot, which was performed simultaneously with a local adipofascial flap for soft tissue coverage, resulting in a plantigrade, painless, and functional foot.

The management of Charcot midfoot deformities in diabetic patients

Charcot foot neuropathic osteoarthropathy is a disorder affecting the soft tissues, joints, and bones of the foot and ankle. The disease is triggered in a susceptible individual through a process of uncontrolled inflammation leading to osteolysis, progressive fractures and articular malpositioning due to joint subluxations and dislocations. The progression of the chronic deformity with a collapsed plantar arch leads to plantar ulcerations because of increased pressure on the plantar osseous prominences and decreased plantar sensation. Subsequent deep soft tissue infection and osteomyelitis may result in amputation. The Charcot foot in diabetes represents an important diagnostic and therapeutic challenge in clinical practice. Conservative treatment remains the standard of the care for most patients with neuropathic disorder. Offloading the foot and immobilization based on individual merit are essential and are the most important recommendations in the active acute stage of the Charcot foot. Surgical realignment with stabilization is recommended in severe progressive neuropathic deformities consisting of a collapsed plantar arch with a rocker-bottom foot deformity.

Intramedullary medial column support with the Midfoot Fusion Bolt (MFB) is not sufficient for osseous healing of arthrodesis in neuroosteoarthropathic feet

INTRODUCTION

To address midfoot instability of Charcot disease a promising intramedullary implant has recently been developed to allow for an arthrodesis of the bones of the medial foot column in an anatomic position. We report on a group of patients with Charcot arthropathy and instability at the midfoot where the Midfoot Fusion Bolt had been employed as an implant for the reconstruction of the collapsed medial foot column.

MATERIAL AND METHODS

A total of 7 patients (median age 56.3 years, range 47-68) were enrolled with severe Charcot deformation at Eichenholtz stages I-II (Sanders and Frykberg types II and III). The medial column was stabilised primarily with an intramedullary rod (Midfoot Fusion Bolt) in stand-alone technique in order to reconstruct the osseous foot geometry. The bolt was inserted in a retrograde mode via the head of MTI and forwarded into the talus. Follow-up time averaged 27 months (range 9-30).

RESULTS

Intraoperative plantigrade reconstruction and restoration of the anatomic foot axes of the medial column was achieved in all cases with the need for revision surgery in 6 out of 7 patients due to soft tissue problems (2 impaired wound healing, 1 postoperative haematoma, 3 early infection). Implant-associated problems were seen in one case intra-operatively with fracture of the first metatarsal shaft and two cases with implant loosening of the MFB and need for implant removal during long time follow-up. Two patients underwent lower leg amputation due to a progressive deep soft tissue infection. One patient healed uneventfully without need for revision surgery. Except for one case recurrent ulcerations were not observed, so far.

CONCLUSION

Medial column support in midfoot instability of Charcot arthropathy with a single intramedullary rod does not provide enough stability to achieve osseous fusion. MFB loosening was associated with deep infection in a majority of our cases. To prevent early loosening of the intramedullary rod and to increase rotational stability, additional implants as angular stable plates are needed at the medial column and eventually an additional stabilisation of the lateral foot column where manifest instability exists at the time of primary surgical intervention.

Charcot neuroarthropathy of the foot and ankle

Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.

Orthopaedic surgery and the diabetic Charcot foot

Many surgical and nonsurgical options exist with the aim of improving quality of life and preventing amputation in patients with CN. A multidisciplinary approach is necessary to achieve the best outcomes in this high-risk group. Modern advanced diagnostic and imaging techniques have improved knowledge regarding the biomechanics, biology, and pathophysiology of CN. Despite these advances, surgical management has lagged behind and is based largely on retrospective case series and expert opinion. Although the surgeons of today are better equipped to manage CN, the optimal timing and specific method of surgical treatment have yet to be defined. Multicenter, prospective studies may be the best way to study this relatively uncommon problem.

Charcot neuroarthropathy of the foot and ankle: a review

Charcot neuroarthropathy is a limb-threatening, destructive process that occurs in patients with neuropathy associated with medical diseases such as diabetes mellitus. Clinicians' treating diabetic patients should be vigilant in recognizing the early signs of acute Charcot neuroarthropathy, such as pain, warmth, edema, or pathologic fracture in a neuropathic foot. Early detection and prompt treatment can prevent joint and bone destruction, which, if untreated, can lead to morbidity and high-level amputation. A high degree of suspicion is necessary. Once the early signs have been detected, prompt immobilization and offloading are important. Treatment should be determined on an individual basis, and it must be determined whether a patient can be treated conservatively or will require surgical intervention when entering the chronic phase. If diagnosed early, medical and conservative measures only will be required. Surgery is indicated for patients with severe or unstable deformities that, if untreated, will result in major amputations. A team approach that includes a foot and ankle surgeon, a diabetologist, a physiotherapist, a medical social councilor, and, most importantly, the patient and immediate family members is vital for successful management of this serious condition.

Conservative and surgical treatment of the chronic Charcot foot and ankle

Charcot neuroarthropathy (CN) is a severe joint disease in the foot and ankle that can result in fracture, permanent deformity, and limb loss. It is a serious and potentially limb-threatening lower-extremity late complication of diabetes mellitus. The aim of this manuscript was to evaluate modern concepts of chronic CN through a review of the available literature and to integrate a perspective of management from the authors’ extensive experience.