Four-stage regimen for operative treatment of diabetic foot ulcer with deformity - a results of 300 patients

Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis

Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.

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

•

Retrograde IM Nailing is a promising therapy for Charcot osteoneuroarthopathy.

•

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

•

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

•

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.

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.

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.

Arthrorisis with calcaneostop screw in children corrects Talo-1st Metatarsal-Index (TMT-Index)

BACKGROUND

Arthrorisis (other terms: Arthrorhisis or Arthroreisis) with calcaneostop screw is one option for the treatment of flatfoot (Pes abductoplanovalgus) in children. The aim of the study was to analyze the amount of correction (for example Talo-1st Metatarsal-Index (TMT-Index)) and clinical outcome including pedographic assessment.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients that were treated with arthrorisis with calcaneostop screw from September 1st 2006 to August 31st, 2009 were included. One foot was operated at a time, and the contralateral foot was operated 3 months later if indicated. Postoperatively, 15 kg partial weight-bearing was performed for 6 weeks. The screws were removed after 2-year-followup. Assessment was performed before surgery, at two-year-followup, and at 2.5-year-followup. The assessment staging of posterior tibialis insufficiency, radiographs with full weight bearing (TMT-Index), pedography, and Visual-Analogue-Scale Foot and Ankle (VAS FA).

RESULTS

18 patients/31 feet were included in the study (age, 10.6 [8-12], 45% male). No complications were observed. In comparison with the preoperative parameters, the parameters posterior tibialis insufficiency stage, percentage of increased pedographic midfoot contact area and force were decreased, and TMT dorsoplantar/lateral/Index and VAS FA scores were increased at both followups (each p<.05). The parameters did not differ between followups (each p ≥.4).

CONCLUSIONS

All relevant parameters (stage of posterior tibialis insufficiency, TMT dorsoplantar/lateral/Index, pedographic midfoot contact area and force, VAS FA) improved after arthrorisis with calcaneostop screw (before and after screw removal) in pes abductoplanovalgus in children. Since the complication rate is very low, this method allows safe and predictable correction.

Lengthening osteotomy of the calcaneus and flexor digitorum longus tendon transfer in flexible flatfoot deformity improves talo-1st metatarsal-Index, clinical outcome and pedographic parameter

Lengthening osteotomy of the calcaneus (LO) and flexor digitorum longus tendon (FDL) transfer to the navicular is one option for the treatment of flexible flatfoot deformity (FD). The aim of the study was to analyse the amount of correction and clinical outcome including pedographic assessment. In a prospective consecutive non-controlled clinical followup study, all patients with FD that were treated with LO and FDL from September 1st 2006 to August 31st, 2009 were included. Assessment was performed before surgery and at 2-year-followup including clinical examination (with staging of posterior tibialis insufficiency) weight bearing radiographs (Talo-1st metatarsal angles (TMT)), pedography (increased midfoot contact area and force) and Visual Analogue Scale Foot and Ankle (VAS FA). 112 feet in 102 patients were analysed (age, 57.6 (13-82), 42% male). In 12 feet (9%) wound healing delay without further surgical measures was registered. All patients achieved full weight bearing during the 7th postoperative week. Until followup, revision surgery was done in 3 patients (fusion calcaneocuboid joint (n=2), correction triple arthrodesis (n=1)). 101 feet (90%) completed 2-year-followup. TMT dorsoplantar/lateral/Index and VAS FA scores were increased, and posterior tibialis insufficiency stage, pedographic midfoot contact area and force percentage were decreased (each p<.05). All relevant parameters (stage of posterior tibialis insufficiency, TMT angles and Index, pedographic midfoot contact area and force percentage, VAS FA) were improved 2 years after LO and FDL transfer to the navicular in FD. The complication rate was low. This method allows safe and predictable correction.