Orthopaedic surgery and the diabetic Charcot foot

Availability and service provision of multidisciplinary diabetes foot units in Australia: a cross-sectional survey

BACKGROUND

With growing global prevalence of diabetes mellitus, diabetes-related foot disease (DFD) is contributing significantly to disease burden. As more healthcare resources are being dedicated to the management of DFD, service design and delivery is being scrutinised. Through a national survey, this study aimed to investigate the current characteristics of services which treat patients with DFD in Australia.

METHODS

An online survey was distributed to all 195 Australian members of the Australian and New Zealand Society for Vascular Surgery investigating aspects of DFD management in each member's institution.

RESULTS

From the survey, 52 responses were received (26.7%). A multidisciplinary diabetes foot unit (MDFU) was available in more than half of respondent's institutions, most of which were tertiary hospitals. The common components of MDFU were identified as podiatrists, endocrinologists, vascular surgeons and infectious disease physicians. Many respondents identified vascular surgery as being the primary admitting specialty for DFD patients that require hospitalisation (33/52, 63.5%). This finding was consistent even in centres with MDFU clinics. Less than one third of MDFUs had independent admission rights.

CONCLUSIONS

The present study suggests that many tertiary centres in Australia provide their diabetic foot service in a multidisciplinary environment however their composition and function remain heterogeneous. These findings provide an opportunity to evaluate current practice and, to initiate strategies aimed to improve outcomes of patients with DFD.

New Concepts in the Management of Charcot Neuroarthropathy in Diabetes

Charcot Neuroarthropathy (CN) is an uncommon, debilitating and often underdiagnosed complication of chronic diabetes mellitus though, it can also occur in other medical conditions resulting from nerve injury. Till date, the etiology of CN remains unknown, but enhanced osteoclastogenesis is believed to play a central role in the pathogenesis of CN, in the presence of neuropathy. CN compromises the overall health and quality of life. Delayed diagnosis can result in a severe deformity that can act as a gateway to ulceration, infection and in the worst case, can lead to limb loss. In an early stage of CN, immobilization with offloading plays a key role to a successful treatment. Medical therapies seem to have limited role in the treatment of CN.In case of severe deformity, proper footwear or bracing may help prevent further deterioration and development of an ulcer. In individuals with a concomitant ulcer with osteomyelitis, soft tissue infection and severe deformity, where conservative measures fall short, surgical intervention becomes the only choice of treatment. Early diagnosis and proper management at an early stage can help prevent the occurrence of CN and amputation.

Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail-The Kings' Experience

BACKGROUND

Corrective fusion for the unstable deformed hind foot and mid foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams.

METHODS

We present a follow up to our initial report with a series of 42 hind foot corrections in 40 patients from a tertiary level teaching hospital in the United Kingdom. The mean patient age was 59 (33-82). 17 patients had type1diabetes mellitus, 23 had type 2. 23 feet in 22 patients had chronic ulceration despite offloading. 17 patients were ASA 2 and 23 were ASA grade 3. All patients had hind foot nail fusion performed through a standard technique by the senior author and managed perioperatively by the multidisciplinary team.

RESULTS

At a mean follow up of 42 months (12-99) we achieved 100% limb salvage initially and a 97% fusion rate. One patient with persisting non-union of ankle and subtalar joint with difficulty in bracing has been offered below-knee amputation. We achieved deformity correction in 100% and ulcer healing in 83%. 83% patients are able to mobilize and manage independent activities of daily living. There were 11 patients with one or more complications including metal work failure, infection and ulcer reactivation. There have been nine repeat procedures including one revision fixation and one vascular procedure.

CONCLUSION

Single stage corrective fusion for hind foot deformity in CN is an effective procedure when delivered by a skilled multidisciplinary team.

New trends in the orthopaedic management of diabetic foot

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.

Surgical Treatment Options for the Diabetic Charcot Hindfoot and Ankle Deformity

Charcot neuroarthropathy is associated with progressive, noninfectious, osteolysis-induced bone and joint destruction. When the ankle and/or hindfoot is affected by the destruction process, management is further complicated with collapse and destruction of the talar body, which increases instability around the ankle. In this patient population, arthrodesis is the most commonly used surgical procedure. Internal fixation, external fixation, or a combination of both can be used for the treatment. Decision making between them should be individualized according to the patient characteristics.

Modern Orthopedic Inpatient Care of the Orthopedic Patient With Diabetic Foot Disease

In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 admissions (19 emergency, 11 elective) were included. The pathways were coordinated by a multidisciplinary team and comprised initial assessment and investigation and a series of key events, which consisted of emergency and elective surgery together with the introduction, and change of intravenous antibiotics when indicated. Patients had rigorous microbiological assessment, in the form of deep ulcer swabs, operative tissue specimens, joint aspirates, and blood cultures according to their clinical presentation as well as close clinical and biochemical surveillance, which expedited the prompt institution of key events. Outcomes were assessed using amputation rates and patient satisfaction. In the emergency group, there were 5.6 ± 3.0 (mean ± SD) key events per admission, including 4.2 ± 2.1 antibiotic changes. In the elective group, there were 4.8 ± 1.4 key events per inpatient episode, with 3.7 ± 1.3 antibiotic changes. Overall, there were 3 minor amputations, and no major amputations. The podiatric and surgical tissue specimens showed a wide array of Gram-positive, Gram-negative, aerobic and anaerobic isolates and 15% of blood cultures showed bacteremia. When 9 podiatric specimens were compared with 9 contemporaneous surgical samples, there was concordance in 2 out of 9 pairs. We have described the successful modern care of the orthopedic diabetic foot patient, which involves close clinical, microbiological, and biochemical surveillance by the multidisciplinary team directing patients through emergency and elective pathways. This has enabled successful surgical intervention involving debridement, pressure relief, and stabilization, with low rates of amputation.

The diabetic foot in 2015: an overview

In 2015, it can be said that the diabetic foot is no longer the Cinderella of diabetic complications. Thirty years ago there was little evidence-based research taking place on the diabetic foot, and there were no international meetings addressing this topic. Since then, the biennial Malvern Diabetic Foot meetings started in 1986, the American Diabetes Association founded their Foot Council in 1987, and the European Association for the Study of Diabetes established a Foot Study Group in 1998. The first International Symposium on the Diabetic Foot in The Netherlands was convened in 1991, and this was soon followed by the establishment of the International Working Group on the Diabetic Foot that has produced useful guidelines in several areas of investigation and the management of diabetic foot problems. There has been an exponential rise in publications on diabetic foot problems in high impact factor journals, and a comprehensive evidence-base now exists for many areas of treatment. Despite the extensive evidence available, it, unfortunately, remains difficult to demonstrate that most types of education are efficient in reducing the incidence of foot ulcers. However, there is evidence that education as part of a multi-disciplinary approach to diabetic foot ulceration plays a pivotal role in incidence reduction. With respect to treatment, strong evidence exists that offloading is the best modality for healing plantar neuropathic foot ulcers, and there is also evidence from two randomized controlled trials to support the use of negative-pressure wound therapy in complex post-surgical diabetic foot wounds. Hyperbaric oxygen therapy exhibits the same evidence level and strength of recommendation. International guidelines exist on the management of infection in the diabetic foot. Many randomized trials have been performed, and these have shown that the agents studied generally produced comparable results, with the exception of one study in which tigecycline was shown to be clinically inferior to ertapenem ± vancomycin. Similarly, there are numerous types of wound dressings that might be used in treatment and which have shown efficacy, but no single type (or brand) has shown superiority over others. Peripheral artery disease is another major contributory factor in the development of ulceration, and its presence is a strong predictor of non-healing and amputation. Despite the proliferation of endovascular procedures in addition to open revascularization, many patients continue to suffer from severely impaired perfusion and exhaust all treatment options. Finally, the question of the true aetiopathogenesis of Charcot neuroarthropathy remains enigmatic, although much work is currently being undertaken in this area. In this area, it is most important to remember that a clinically uninfected, warm, insensate foot in a diabetic patient should be considered as a Charcot foot until proven otherwise, and, as such, treated with offloading, preferably in a cast.

[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.

Confronting a dramatic situation: the charcot foot complicated by osteomyelitis

Charcot osteoarthropathy is a serious complication of diabetic neuropathy. Its prevalence in the diabetic population varies in the literature in relation to certain variables, such as the method of assessment, clinical or instrumental; the population studied; and the scope of the selection. This article is intended as a review of the recent literature concerning Charcot osteoarthropathy in its evolution and complications characterized by the development of ulceration and subsequent bone infection. Diagnosis and treatment strategies--either medical or surgical--are discussed both for Charcot arthropathy and osteomyelitis.

Diabetic neuropathy and foot complications

Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.