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Mateen S, Kwaadu KY. Management of Midfoot Charcot: Minimally Invasive Techniques and Improved Fixation. Clin Podiatr Med Surg 2023; 40:593-611. [PMID: 37716739 DOI: 10.1016/j.cpm.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
The objective of this article is to review the etiology and pathophysiology of Charcot neuroarthropathy as it contributes to the breakdown of the midfoot. The article will also discuss the emerging techniques in minimally invasive surgery and how this is applied to Charcot reconstructive surgery as well as reflect on a newer thought processes to surgical intervention.
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Affiliation(s)
- Sara Mateen
- Foot and Ankle Deformity and Orthoplastics, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
| | - Kwasi Y Kwaadu
- Department of Podiatric Surgery, Temple University School f Podiatric Medicine, 148 North 8th Street, Philadelphia, PA, USA; Podiatric Surgical Residency, Temple University School f Podiatric Medicine, 148 North 8th Street, Philadelphia, PA, USA; Department of Surgery, Temple University School f Podiatric Medicine, 148 North 8th Street, Philadelphia, PA, USA.
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Mateen S, Thomas MA, Jappar A, Wu S, Meyr AJ, Siddiqui NA. Progression to Hindfoot Charcot Neuroarthropathy After Midfoot Charcot Correction in Patients With and Without Subtalar Joint Arthrodesis. J Foot Ankle Surg 2023:S1067-2516(23)00066-2. [PMID: 36965749 DOI: 10.1053/j.jfas.2023.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/27/2023]
Abstract
Charcot neuroarthropathy (CNA) is a disabling and progressive disease that affects the bones and joints of the foot. Successful Charcot reconstruction focuses on restoring anatomic alignment, obtaining multiple joint arthrodesis, selecting stable fixation, preserving foot length, and creating a foot suitable for community ambulation in supportive shoegear. Intramedullary fixation arthrodesis of the medial and lateral columns has been previously reported to produce improvement in midfoot Charcot reconstruction. More recently, a growing trend of stabilization of the subtalar joint (STJ) has been incorporated alongside the medial and lateral column fusion. Our objectives were to retrospectively review patients who underwent midfoot Charcot reconstructive surgery, whether with or without accompanying STJ arthrodesis, and establish which patients progressed to ankle CNA. Of the 72 patients who underwent midfoot Charcot reconstruction, 28 (38.9%) underwent STJ arthrodesis, and 22 converted to ankle CNA (30.6%). Fourteen (63.6%) of 22 ankle CNA cases had not undergone STJ arthrodesis; 8 patients (36.4%) had it. A Fisher exact test was performed to identify the relationship between those without STJ arthrodesis and those progressing to ankle CNA; it revealed statistical significance (P = 0.001). Performing an STJ arthrodesis with midfoot Charcot reconstructive surgery may be beneficial to aiding in hindfoot stability, establishing a plantigrade foot, and providing further insight into the management of midfoot Charcot. LEVEL OF CLINICAL EVIDENCE: III.
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Affiliation(s)
- Sara Mateen
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Ave, Baltimore, MD 21215
| | - Michael A Thomas
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Ave, Baltimore, MD 21215; Veterans Affairs Maryland Health Care System, 10 North Greene St, Baltimore, MD 21201
| | - Asma Jappar
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Ave, Baltimore, MD 21215; Veterans Affairs Maryland Health Care System, 10 North Greene St, Baltimore, MD 21201
| | - Stephanie Wu
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Ave, Baltimore, MD 21215
| | - Andrew J Meyr
- Department of Podiatric Surgery, Temple University School of Podiatric Medicine and Temple University Hospital, 148 North 8(th) St, Philadelphia, PA 19107
| | - Noman A Siddiqui
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Ave, Baltimore, MD 21215; Division of Podiatry, Northwest Hospital, 5401 Old Court Rd, Randallstown, MD 21133.
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Miller R. NEMISIS: Neuropathic Minimally Invasive Surgeries. Charcot Midfoot Reconstruction, Surgical Technique, Pearls and Pitfalls. Foot Ankle Clin 2022; 27:567-581. [PMID: 36096552 DOI: 10.1016/j.fcl.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The last decade has seen a significant development in early surgical intervention for patients with or at risk of ulceration owing to deformity resulting from the sequalae of diabetic foot disease. Midfoot Charcot neuroarthropathy is the most common deformity; its correction is enabled by specialized surgical implants designed to maintain surgical corrections. There has also been an increasing number of orthopedic foot and ankle surgeons, with a specific interest in diabetic foot disease who provide early surgical correction in patients identified as high risk. Minimally invasive surgery using percutaneous incisions completes the triumvirate, facilitating earlier surgical intervention to decrease reulcerations.
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Affiliation(s)
- Roslyn Miller
- NHS Lanarkshire Universities Hospitals, Lanarkshire, Scotland, UK; Glasgow Caledonian University, Glasgow, Scotland, UK; Department of Orthopaedics, Foot and Ankle Service Lead, Hairmyres University Hospital, 218 Eaglesham Road, East Kilbride, Glasgow G75 8RG, UK.
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Waibel FWA, Böni T. Nonoperative Treatment of Charcot Neuro-osteoarthropathy. Foot Ankle Clin 2022; 27:595-616. [PMID: 36096554 DOI: 10.1016/j.fcl.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Felix W A Waibel
- Division of Technical and Neuroorthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland.
| | - Thomas Böni
- Division of Technical and Neuroorthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland
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Martínez-Ayora A, Cuervas-Mons M, Fajardo-Ruiz A, Rodríguez-López T, Vaquero J, Sanz-Ferrando L. Ultrasound-guided distal minimally invasive metatarsal osteotomies (US-DMMO): A cadaveric study about its safety and accuracy. Foot Ankle Surg 2022; 28:445-449. [PMID: 34465522 DOI: 10.1016/j.fas.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/28/2021] [Accepted: 08/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Distal minimally invasive metatarsal osteotomies have become increasingly popular. This technique requires fluoroscopic control, but recently, an ultrasound-guided procedure has been described. The aim of this anatomical study was to assess the quality safety of ultrasound-guided minimally invasive metatarsal osteotomies. METHODS Ultrasound-guided distal minimally invasive metatarsal osteotomies were performed in 9 cadaveric pieces. The location of the osteotomy, its angulation, and the adjacent anatomical structures injuries was evaluated RESULTS: Thirty-six osteotomies were performed. The osteotomy was metaphyseal in 97.2% of the cases, the average angulation was 47.67° (±4.49, 40-59°) and the average distance to the articular cartilage was 3.22 mm (±1.27, 1-7 mm). One osteotomy (2.8%) was intraarticular and there was one joint capsule lesion (2.8%). The failure, the extreme point distance and angulation values, and the joint capsule injury correspond to a fifth metatarsal. CONCLUSIONS The ultrasound-guided technique is safe and allows a correct location and angulation of the osteotomies.
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Affiliation(s)
- Alvaro Martínez-Ayora
- Department of Orthopaedics and Trauma Surgery, Torrejón University Hospital, C/Mateo Inurria. 28850, Torrejón de Ardoz, Madrid, Spain.
| | - Manuel Cuervas-Mons
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañon' University Hospital, C/Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Ana Fajardo-Ruiz
- Department of Orthopaedics and Trauma Surgery, Torrejón University Hospital, C/Mateo Inurria. 28850, Torrejón de Ardoz, Madrid, Spain
| | - Tamara Rodríguez-López
- Department of Orthopaedics and Trauma Surgery, Torrejón University Hospital, C/Mateo Inurria. 28850, Torrejón de Ardoz, Madrid, Spain
| | - Javier Vaquero
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañon' University Hospital, C/Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Luis Sanz-Ferrando
- Department of Orthopaedics and Trauma Surgery, Torrejón University Hospital, C/Mateo Inurria. 28850, Torrejón de Ardoz, Madrid, Spain
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Dos Santos-Vaquinhas A, Parra G, Martínez P, Sobrón B, Cuervas-Mons M. Beaming in the Charcot foot: A case series with 12-month minimum follow-up. Foot (Edinb) 2021; 47:101814. [PMID: 33946005 DOI: 10.1016/j.foot.2021.101814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/27/2021] [Accepted: 04/12/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Charcot neuropathic arthropathy is a progressive degeneration of the weightbearing joints of the foot induced by denervation and disturbance of sensorial perception. This entity clinically behaves as a destructive fast-progressive arthropathy, resulting in loss of independent walking and often requiring amputation of the leg. This study analyzes our experience with midfoot realignment arthrodesis and stabilization by intramedullary beaming in patients with Charcot diabetic foot as a limb-sparing procedure. METHODS Patients with Charcot foot treated in our Foot and Ankle unit between January 2018 and December 2019 were analyzed. In all of the patients beaming technique was performed: open reduction and stabilization by a midfoot medial fusion beam and a lateral fusion bolt. Demographical, clinical and radiological pre and post-surgery data were assessed. The primary outcome measure was defined as an autonomous ambulation through an ulcer-free plantigrade foot. A minimum follow-up of 12 months was performed. RESULTS A total of 5 patients were treated. Median age 64 years, mean follow-up 25 months (12-31). An ulcer-free plantigrade foot was obtained in 80% of the patients. Complications were observed in 80% of patients: 1 deep infection, 2 hardware failure, 3 Charcot foot progression. Rate of reoperation 40%, including 1 amputation. Significant improvement in all radiographic angles was observed. CONCLUSION Beaming the medial and lateral columns of the foot in patients with Charcot foot enabled the restoration of a functional plantigrade foot and an ulcer-free autonomous ambulation, despite a relatively high complication rate. LEVEL OF EVIDENCE IV, prospective case series.
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Affiliation(s)
- A Dos Santos-Vaquinhas
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Madrid, Spain
| | - G Parra
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Madrid, Spain
| | - P Martínez
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Madrid, Spain
| | - B Sobrón
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Madrid, Spain
| | - M Cuervas-Mons
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Madrid, Spain.
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Abstract
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.
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Affiliation(s)
- Ashtin Doorgakant
- Foot and Ankle Unit, Northern General Hospital, Foot and Ankle Offices, Selby Wing, Herries Road, Sheffield S5 7AU, UK.
| | - Mark B Davies
- Northern General Hospital, Foot and Ankle Unit, Herries Road, Sheffield, S5 7AU, UK
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