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Rosemberg DL, Sposeto RB, Godoy-Santos AL. Arthrodesis in the Deformed Charcot Foot. Foot Ankle Clin 2022; 27:835-846. [PMID: 36368800 DOI: 10.1016/j.fcl.2022.08.005] [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] [Indexed: 11/09/2022]
Abstract
Charcot neuroarthropathy (CN) is a systemic disease that causes fractures, dislocations, and deformities involving the foot and ankle, resulting in substantial risk of ulceration, infection, and function loss. Early recognition and prevention of collapsing foot and ankle are still the best options for the management of patients with diabetic CN. For a successful arthrodesis procedure, the principles of adequate joint preparation, deformity correction, and soft tissue protection and care are essentials, associated with robust fixation (internal and/or external), use of different biological graft options in segmental losses, and prolonged off-loading.
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Affiliation(s)
- Dov Lagus Rosemberg
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Dr. Ovídio Pires de Campos, 333 - Cerqueira César, São Paulo, São Paulo 05403-010, Brazil; Hospital Israelita Albert Einstein, São Paulo, Av. Albert Einstein, 627/701 - Morumbi, São Paulo - SP, 05652-900, Brazil; International Scholar at the Midwest Orthopedics at Rush (MOR), 1620 W. Harrison St., Chicago, IL, 6012, USA; RUSH-IBTS International Fellowship Program, 1620 W. Harrison St., Chicago, IL, 6012, USA.
| | - Rafael Barban Sposeto
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Dr. Ovídio Pires de Campos, 333 - Cerqueira César, São Paulo, São Paulo 05403-010, Brazil
| | - Alexandre Leme Godoy-Santos
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Dr. Ovídio Pires de Campos, 333 - Cerqueira César, São Paulo, São Paulo 05403-010, Brazil; Hospital Israelita Albert Einstein, São Paulo, Av. Albert Einstein, 627/701 - Morumbi, São Paulo - SP, 05652-900, Brazil
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Bajuri MY, Ong SL, Das S, Mohamed IN. Charcot Neuroarthropathy: Current Surgical Management and Update. A Systematic Review. Front Surg 2022; 9:820826. [PMID: 35345422 PMCID: PMC8957099 DOI: 10.3389/fsurg.2022.820826] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCharcot neuroarthropathy of the ankle and the hindfoot is a complex clinical entity with a high risk of amputation. Charcot neuroarthropathy limb reconstruction has been proposed as a limb-salvaging procedure. However, there was a lack of information on the various available reconstruction methods, including the outcomes and complications. The present study aimed to evaluate the current literature and update on the trends regarding the surgical management of Charcot neuroarthropathy of the ankle and the hindfoot.MethodsAll data published from January 2010 to January 2020 that investigated the methods of fixation and their respective outcomes for the surgical reconstruction in Charcot neuroarthropathy were analyzed. The union rate, amputation rates, and complications associated with these techniques were taken for statistical analysis.ResultsA total of 16 studies fit the inclusion criteria of this study, with four Level-III studies and 12 Level-IV studies were included. Ten studies utilized internal fixation only; five used a combination of internal fixation and circular external fixator, whereby there are three comparative studies between internal and external fixations, and two studies applied combined technique of internal and external fixations (hybrid fixation). One study describes the usage of circular external fixation only.ConclusionsThe use of retrograde intramedullary nail as a treatment of choice in the reconstruction of Charcot neuroarthropathy ankle is recommended before an ulcer occurrence. Hydroxyapatite (HA)- coated screws are recommended for the locking mechanism to prevent migration in Charcot neuroarthropathy due to poor bony quality. Hybrid fixation is recommended for reconstruction in a condition of ulceration and more complex deformity as it provides a higher rate of limb salvage with less soft tissue irritation.
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Affiliation(s)
- Mohd Yazid Bajuri
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
- *Correspondence: Mohd Yazid Bajuri
| | - Shir Lee Ong
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Srijit Das
- Department of Human Clinical Anatomy, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Isa Naina Mohamed
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Ahluwalia R, Maffulli N, Lázaro-Martínez JL, Kirketerp-Møller K, Reichert I. Diabetic foot off loading and ulcer remission: Exploring surgical off-loading. Surgeon 2021; 19:e526-e535. [PMID: 33642205 DOI: 10.1016/j.surge.2021.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/26/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration. METHODS We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations. RESULTS Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements. CONCLUSIONS AND IMPLICATIONS Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.
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Affiliation(s)
- Raju Ahluwalia
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England, E1 4DG, UK.
| | - José L Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Del Hospital, Clínico San Carlos (IdISSC), 28040, Madrid, Spain.
| | - Klaus Kirketerp-Møller
- Copenhagen Wound Healing Center, Department of Dermatology and Wounds, Bispebjerg Hospital, Copenhagen, Denmark; Steno Diabetes Center Copenhagen, Denmark.
| | - Ines Reichert
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
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Sun Y, Gao Y, Chen J, Sun H, Cai YT, Ge L, Li YN, Zhang J, Tian JH. Evidence mapping of recommendations on diagnosis and therapeutic strategies for diabetes foot: an international review of 22 guidelines. Metabolism 2019; 100:153956. [PMID: 31394109 DOI: 10.1016/j.metabol.2019.153956] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/18/2019] [Accepted: 08/01/2019] [Indexed: 12/14/2022]
Abstract
To systematically review clinical practice guidelines (CPGs) on diabetes foot and assess the consistency of recommendations, quality of CPGs and to present an evidence-map for explicating research trends and gaps. We performed a literature search on PubMed, Embase, and Web of Science, guideline databases and websites of diabetes society to include the diabetic CPGs. The basic information, recommendations for the diabetic foot, methodological quality and reporting quality of diabetic CPGs were exacted by the Excel. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE II instrument and RIGHT checklist. R3.5.1 software was used to create all bubble plots. A total of 22 diabetic CPGs were included, eight CPGs were from different professional diabetes societies. Recommendations on diabetic foot complications involve Diabetic foot ulcer (DFU), Charcot neuropathy (CN) and Osteomyelitis (OM). Eight DFU diagnostic systems presented in 22 CPGs. According to the recommendations of diabetic CPGs, the treatment of DFU can be summarized in four major items; six recommendations on CN diagnosis and six recommendations on treatment of CN were consistent among studies. However, there were inconsistencies in three OM diagnosis recommendations and four OM treatment recommendations. Some recommendations in CPGs were not very specific and clear, and hence they were not reliable for OM diagnosis and treatment. Once these inconsistencies are resolved, validated, accurate and effective diagnosis and treatment of diabetes foot will lead to reduced costs and adverse complications. The results of this review add to our knowledge and promote the development of trustworthy CPGs on diabetes.
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Affiliation(s)
- Yue Sun
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Ji Chen
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Hao Sun
- School of Information Engineering, Zhengzhou University, Henan Province, China
| | - Yi-Tong Cai
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Long Ge
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China; School of Public Health, Lanzhou University, Lanzhou City, Gansu Province, China
| | - Ya-Nan Li
- Binzhou Maternal and Child Health Care Hospital, Binzhou City, Shandong Province, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Jin-Hui Tian
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China.
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