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Omar IM, Weaver JS, Altbach MI, Herynk BA, McCurdy WE, Kadakia AR, Taljanovic MS. Imaging of osteoarthritis from the ankle through the midfoot. Skeletal Radiol 2023; 52:2239-2257. [PMID: 36737484 PMCID: PMC10400729 DOI: 10.1007/s00256-023-04287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.
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Affiliation(s)
- Imran M Omar
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 800, Chicago, IL, 60611, USA.
| | - Jennifer S Weaver
- Department of Radiology, Medical Center North, Vanderbilt University Medical Center, 1161 21St Ave. South, Nashville, TN, 37232, USA
| | - Maria I Altbach
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
| | - Bradley A Herynk
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 800, Chicago, IL, 60611, USA
| | - Wendy E McCurdy
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
| | - Anish R Kadakia
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 1350, Chicago, IL, 60611, USA
| | - Mihra S Taljanovic
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
- Department of Orthopaedic Surgery, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
- Department of Radiology, University of New Mexico School of Medicine, 2211 Lomas Boulevard NE, Albuquerque, NM, 87106, USA
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Mateen S, Thomas MA, Siddiqui NA. Comparison of Minimally Invasive and Open Approaches for Midfoot Charcot Neuroarthropathy Reconstruction. J Foot Ankle Surg 2023; 62:986-990. [PMID: 37558121 DOI: 10.1053/j.jfas.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/29/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
Charcot neuroarthropathy (CNA) is a progressive disease affecting the bones and joints of the foot that can lead to instability, breakdown, and collapse. Minimally invasive surgery (MIS) techniques are becoming a popular option within musculoskeletal surgery of the foot and ankle and may be an alternative to aggressive dissection seen during corrective surgery. An MIS approach minimizes vascular disruption, provides structural stability at an osteotomy or arthrodesis site, and encourages early mobilization if indicated. This retrospective study compares 17 patients who underwent an open approach for midfoot CNA reconstruction with 17 patients who underwent an MIS approach for midfoot CNA reconstruction. Preoperative and postoperative radiographic parameters were measured: lateral talus-first metatarsal, anteroposterior (AP) talus-first metatarsal, calcaneal pitch, and cuboid height. Difficulties that occurred during treatment were gathered and sorted into postoperative problems (stage I), obstacles (stage II), and complications (stage III). Changes from preoperative to postoperative radiographic lateral talus-first metatarsal and AP talus-first metatarsal angles were statistically significant (p < .001) for both the MIS and open approach. No true postoperative complications (stage III) were observed at last follow-up. The most common difficulty encountered was pin-site infection (stage I; in 23.5% of patients) in the MIS group. In the open group, the most common complications were wound development (stage I; 23.5%) and nonunions (stage II; 23.5%). Our findings suggest that midfoot CNA reconstruction with MIS methods offers similar outcomes to the open approach.
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Affiliation(s)
- Sara Mateen
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Michael A Thomas
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Noman A Siddiqui
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD; Division of Podiatry, Northwest Hospital, Randallstown, MD.
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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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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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Hong CC, Rammelt S. Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes. Foot Ankle Clin 2022; 27:617-637. [PMID: 36096555 DOI: 10.1016/j.fcl.2022.02.001] [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
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.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
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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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Frøkjær J. Surgical treatment of midfoot charcot neuroarthropathy review of literature and our results after superconstruct reconstruction of midfoot charcot neuroarthropathy. J Clin Orthop Trauma 2021; 17:59-64. [PMID: 33680840 PMCID: PMC7919936 DOI: 10.1016/j.jcot.2021.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the midfoot was traditionally treated non-operatively with off-loading in a total contact cast (TCC). After introduction of the super construct concept, promising results were reported, however there is a need for further studies on this concept. Analysis of non-operative versus operative treatment is presented as well as our results from a consecutive series of 20 patients operated with the superconstruct concept. METHODS Twenty patients were operated from July 2017 until June 2020. Mean age was 58 years (50-80), mean weight was 116 kg (68-156), giving a BMI of 31 (26-45). Preoperative patients off-loaded in a TCC until decreased swelling and skin temperature measurement or ulcer had healed, mean 16 weeks immobilization. Surgery was without tourniquet, using a standard medial and lateral incision. Mean follow up is 24 (5-40) months. RESULTS Mean operation time was 227 (150-315) minutes. Medial column fusion was mandatory, in five cases as an isolated procedure, in 12 cases in combination with lateral column fusion and in three cases with a talocalcaneal fusion. Preoperative lateral Meary angle decreased from 23.5 to 9.6°, antero-posterior Meary angle decreased from 16.0 to 4.7°. Eight patients had postoperative incisional wound problems. Four patients had partial implant removal. All healed with a good clinical result. Two patients had an acute Charcot attack in the ankle joint during postoperative mobilization. One had a severe collapse of the talus resulting in a below knee amputation, giving an amputation rate of 5%. Radiographic examination at follow up, showed bone union of all patients. Nineteen patients are ambulated in orthopedic shoes at latest follow up, giving a 95% satisfactory result. CONCLUSION Superconstruct reconstruction of CN midfoot collapse is a safe procedure. There are incisional wound problems, recognition and fast treatment of these complications is important to achieve good results. There is a risk for overloading the ankle, initiating a new acute Charcot attack. Attention must be on this problem. The surgical technique is demanding and should be performed by experienced foot and ankle surgeons in a multidisciplinary team set up.
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