Surgical Management of Charcot Deformity for the Foot and Ankle-Radiologic Outcome After Internal/External Fixation

External Versus Internal Fixation Techniques for Ankle Arthrodesis: A Systematic Review and Meta-analysis

Ankle arthrodesis is an effective surgical intervention for end-stage arthritis or severe ankle joint deformity. Both internal (IF) and external fixation (EF) techniques are valid options, but there is controversy regarding the most effective technique. This study compares the safety and efficacy of EF and IF fixation techniques for ankle arthrodesis. A systematic review and meta-analysis was conducted according to the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) Guidelines. A literature search of electronic databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL), was performed to identify all studies directly comparing the two techniques. Both fixed and random effects models of analysis were used depending on heterogeneity. Odds of union in the EF and IF groups were comparable (OR = 0.60, CI 0.36-1.02, p = .06) however, EF was associated with greater odds of deep hardware infections (OR = 3.67, 1.97-6.83, p < .05) and amputations (OR = 3.17, CI 1.06-9.54, p = .04). Odds of revision surgery and superficial wound complications were similar between groups. EF techniques had significantly longer operation times (MD = 31.23, CI-25.11-37.34, p < .05) and intraoperative blood loss (MD = 44.1, CI 28.77-59.43, p < .05). No significant difference was noted in pain and functionality scores. IF and EF techniques have reasonable union rates with similar postoperative outcomes.

Safety and Complication Rate of Ring External Fixation in the Foot and Ankle

External fixation is a powerful tool for foot and ankle surgeons. Currently, there is no consensus on true complication rate. The purpose of this study was to report our institution's complication rate of ring external fixation performed by a single surgeon. We retrospectively evaluated electronic medical record of 224 patients with 238 circular frames between 2009 and 2021 at a single institution. Minor complications were defined as a frame managed without early frame removal or return to operating room. Major complications were defined as early return to operative room or early removal defined by our institution as less than 2 months. We recorded over 1642 Ilizarov wires and 278 half pins; 10% (n = 163) of wires and 7% (n = 19) of half pins had a complication. We recorded 44% (n = 104) minor complications and 9% (n = 22) major complications. Minor complications average (mean) onset was 4 weeks, 89% (n = 93) involved wires, and 73% resolved without additional care. Major complications average (mean) onset was 3.7 weeks. Of these, 32% (n = 7) went on to successful revision. This revealed a significant correlation between minor complications and history of osteomyelitis (p < .05). While minor complications do appear high, this was due to wire irritation and local erythema which resolved without additional intervention. To better assess complications with external fixation the authors believe that wire irritation and pin site erythema should be recognized as an expected outcome. A better understanding of ring external fixation in foot and ankle surgery is vital to appropriate perioperative management and patient care.

No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy

BACKGROUND

The cause of Charcot neuro-osteoarthropathy (CN) is diabetes in approximately 75% of patients. Most reports on the clinical course and complications of CN focus on diabetic CN, and reports on nondiabetic CN are scarce. No study, to our knowledge, has compared the clinical course of patients initially treated nonoperatively for diabetic and nondiabetic CN.

QUESTIONS/PURPOSES

Among patients with CN, are there differences between patients with diabetes and those without in terms of (1) the frequency of major amputation as ascertained by a competing risks survivorship estimator; (2) the frequency of surgery as ascertained by a competing risks survivorship estimator; (3) frequency of reactivation, as above; or (4) other complications (contralateral CN development or ulcers)?

METHODS

Between January 1, 2006, and December 31, 2018, we treated 199 patients for diabetic CN. Eleven percent (22 of 199) were lost before the minimum study follow-up of 2 years or had incomplete datasets and could not be analyzed, and another 9% (18 of 199) were excluded for other prespecified reasons, leaving 80% (159 of 199) for analysis in this retrospective study at a mean follow-up duration since diagnosis of 6 ± 4 years. During that period, we also treated 78 patients for nondiabetic Charcot arthropathy. Eighteen percent (14 of 78) were lost before the minimum study follow-up and another 5% (four of 78 patients) were excluded for other prespecified reasons, leaving 77% (60 of 78) of patients for analysis here at a mean of 5 ± 3 years. Patients with diabetic CN were younger (59 ± 11 years versus 68 ± 11 years; p < 0.01), more likely to smoke cigarettes (37% [59 of 159] versus 20% [12 of 60]; p = 0.02), and had longer follow-up (6 ± 4 years versus 5 ± 3 years; p = 0.02) than those with nondiabetic CN. Gender, BMI, overall renal failure, dialysis, and presence of peripheral arterial disease did not differ between the groups. Age difference and length of follow-up were not considered disqualifying problems because of the later onset of idiopathic neuropathy and longer available patient follow-up in patients with diabetes, because our program adheres to the follow-up recommendations suggested by the International Working Group on the Diabetic Foot. Treatment was the same in both groups and included serial total-contact casting and restricted weightbearing until CN had resolved. Then, patients subsequently transitioned to orthopaedic footwear. CN reactivation was defined as clinical signs of the recurrence of CN activity and confirmation on MRI. Group-specific risks of the frequencies of major amputation, surgery, and CN reactivation were calculated, accounting for competing events. Group comparisons and confounder analyses were conducted on these data with a Cox regression analysis. Other complications (contralateral CN development and ulcers) are described descriptively to avoid pooling of complications with varying severity, which could be misleading.

RESULTS

The risk of major amputation (defined as an above-ankle amputation), estimated using a competing risks survivorship estimator, was not different between the diabetic CN group and nondiabetic CN group at 10 years (8.8% [95% confidence interval 4.2% to 15%] versus 6.9% [95% CI 0.9% to 22%]; p = 0.4) after controlling for potentially confounding variables such as smoking and peripheral artery disease. The risk of any surgery was no different between the groups as estimated by the survivorship function at 10 years (53% [95% CI 42% to 63%] versus 58% [95% CI 23% to 82%]; p = 0.3), with smoking (hazard ratio 2.4 [95% CI 1.6 to 3.6]) and peripheral artery disease (HR 2.2 [95% CI 1.4 to 3.4]) being associated with diabetic CN. Likewise, there was no between-group difference in CN reactivation at 10 years (16% [95% CI 9% to 23%] versus 11% [95% CI 4.5% to 22%]; p = 0.7) after controlling for potentially confounding variables such as smoking and peripheral artery disease. Contralateral CN occurred in 17% (27 of 159) of patients in the diabetic group and in 10% (six of 60) of those in the nondiabetic group. Ulcers occurred in 74% (117 of 159) of patients in the diabetic group and in 65% (39 of 60) of those in the nondiabetic group.

CONCLUSION

Irrespective of whether the etiology of CN is diabetic or nondiabetic, our results suggest that orthopaedic surgeons should use similar nonsurgical treatments, with total-contact casting until CN activity has resolved, and then proceed with orthopaedic footwear. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach.

LEVEL OF EVIDENCE

Level III, prognostic study.

Salvage of Hindfoot Charcot with Osteomyelitis and Ulceration: A Case Report

Diabetic Charcot arthropathy of the ankle, due to the presence of multiplanar deformities, and associated medical comorbidities, poses a challenge for treating physicians. The situation becomes more complicated when accompanied by ulceration and osteomyelitis, leaving limited salvage options. We present a case of advanced Charcot ankle arthropathy with osteomyelitis and ulcerated hindfoot. It was managed by talectomy and antibiotic-impregnated cement beads, followed by hindfoot arthrodesis using a retrograde intramedullary nail six weeks later. This two-stage reconstruction approach resulted in an ulcer-free, stable, plantigrade foot at one-year postoperative follow-up.

Arthrodesis in the Deformed Charcot Foot

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.

Circular Fixation in Charcot

Static circular fixation is a valuable tool for patients with Charcot foot and ankle deformities. The versatility of circular fixators allows for dynamic adjustments over time and can allow for off-loading of flaps or ulcers. The circular fixator can be used as a primary fixation device in cases of osteomyelitis or to facilitate lengthening when a segmental bone defect exists such as loss of the talus. As a secondary fixation device it can protect the internal fixation or be used when there is a compromised soft tissue envelope.

Long-term follow-up of conservative treatment of Charcot feet

BACKGROUND

Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN.

METHODS

A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development.

RESULTS

Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations.

CONCLUSIONS

With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking.

LEVEL OF EVIDENCE

III, long-term retrospective cohort study.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.

Nonoperative Treatment of Charcot Neuro-osteoarthropathy

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.

Charcot Neuroarthropathy: Current Surgical Management and Update. A Systematic Review

Background

Charcot 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.

Methods

All 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.

Results

A 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.

Conclusions

The 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.

Complications from ankle arthrodesis in diabetes-related Charcot foot syndrome

INTRODUCTION

Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes.

METHODS

The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared.

RESULTS

Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001).

CONCLUSION

Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN.

LEVEL OF EVIDENCE

Cohort study; Level of evidence, 3.

Treatment Failures in Diabetic Foot Osteomyelitis Associated with Concomitant Charcot Arthropathy: The Role of Underlying Arteriopathy

OBJECTIVE

Therapy for diabetic foot osteomyelitis (DFO) with Charcot neuroosteoarthropathy is challenging. In patients with diabetic Charcot osteomyelitis (DCO), both the anatomic deformity and infection must be addressed. This study assessed the outcomes of DCO therapy and variables associated with treatment failure and compared them with outcomes of DFO cases.

METHODS

A single-center, retrospective, case-control study was performed to compare 93 DCO episodes with 530 DFO episodes, using Kaplan-Meier survival curves and multivariate Cox regression analyses.

RESULTS

Clinical failure occurred in 21.5% of DCO compared with 22.3% in DFO episodes (p=0.89) and was associated with peripheral arterial disease (PAD) stages 3 or 4 (HR 6.1; CI 2.0-18.1) and chronic treatment with immunosuppressives (HR 7.4; CI 2.0-27.1). Major amputations were significantly more frequent in DCO (28% versus 13.6%; p<0.01) and associated with PAD stages 3 and 4 (HR 8.0; CI 2.2-29.4), smoking (HR 5.4; CI 1.2-24.6), alcohol abuse (HR 3.5; CI 1.1-10.6), and renal dialysis (HR 4.9; CI 1.3-18.9).

CONCLUSIONS

Clinical treatment failures did not differ between DCO and DFO. However, patients with DCO underwent major amputation twice as often as those with DFO. Unlike widespread belief, treatment failure in DCO patients may, similar to DFO, be associated with a striking epidemiological link to severe PAD.

Success and Survivorship Following Charcot Reconstruction: A Review of 151 Cases

Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal deformity and pedal ulceration in the insensate foot. Results are often poor and no clear guidelines for surgical management exist. Additionally, amputation rates vary widely making it difficult to accurately inform patients of risks. Few studies have assessed outcomes to identify patients for whom reconstruction is likely to fail. The literature is limited, with small sample sizes and mortality infrequently addressed. We performed a retrospective observational study of patients with Charcot neuroarthropathy to assess overall amputation and mortality rates at 30 days, 1 year, and 3 years postreconstruction and evaluated associated risk factors. Rates of infection, re-ulceration, and return to walking were also assessed. We identified 151 patients over a 5-year period. Demographic and clinical characteristics were collected. Descriptive statistics, Cox proportional hazard model, and logistic regression were used. Overall, 22 (14.6%) patients died, and 23 (15.2%) patients advanced to limb amputation postoperatively. End-stage renal disease, peripheral vascular disease, reconstruction during active phase Charcot process, and reconstruction at the ankle or subtalar joint were all associated with poor outcomes. The risk of mortality was 2.5 times higher in patients with end-stage renal disease, and 3.4 times higher among patients with peripheral vascular disease. Patients with ankle or subtalar joint reconstruction were 70% less likely to return to walking compared to medial column reconstruction. Due to these findings, we suggest that patients with such comorbidities be advised of increased risk for complications including failure to return to walking, amputation, and death.

The use of circular frame external fixation in the treatment of ankle/hindfoot Charcot Neuroarthropathy

Charcot Neuroarthropathy (CN) of the ankle/hindfoot is a devastating condition that results in a loss of alignment, bony malleolar protrusions and frequently leads to ulceration, infection, and amputation. Major limb amputations in this patient population has a 5-year mortality rate approximating 39%-68%. The treatment goal for CN of the ankle/hindfoot is to provide stability with a plantigrade foot that is infection free, shoeable and allows independent weight bearing. The use of a circular frame external fixator is often required when treating patients with CN of the ankle/hindfoot because they often present late with deformity, soft tissue compromise and infection which are contraindications to primary internal fixation. These patients require urgent surgical attention to salvage the limb or risk amputation. In this narrative review article we will discuss the indications, management options, surgical technique, evidence and describe our experience in the use of circular frame external fixation in patients with ankle/hindfoot Charcot Neuroarthropathy.

Mid-term walking ability after Charcot foot reconstruction using the Ilizarov ring fixator

BACKGROUND

Failed conservative treatment and complications are indications for foot reconstruction in Charcot arthropathy. External fixation using the Ilizarov principles offers a one-stage procedure for deformity correction and resection of osteomyelitic bone. The aim of this study was to determine whether external fixation with an Ilizarov ring fixator leads reliably to walking ability.

MATERIALS AND METHODS

29 patients treated with an Ilizarov ring fixator for Charcot arthropathy were retrospectively analyzed. Radiologic fusion at final follow up was assessed separately on conventional X-rays by two authors. The association between walking ability and the presence of osteomyelitis at the time of reconstruction, and the presence of fusion at final follow up was investigated using Fisher's exact test.

RESULTS

Mean follow up was 35 months (range 5.3-107) months; mean time of external fixation was 113 days. Ten patients (34.5%) reached fusion, but 19 did not (65.5%). Two patients needed below knee amputation. 26 of the remaining 27 patients maintained walking ability, 23 of those without assistive devices. Walking ability was independent from the presence of osteomyelitis at the time of reconstruction and from the presence of fusion.

CONCLUSION

Foot reconstruction with an Ilizarov ring fixator led to limb salvage in 93%. The vast majority (96.3%) of patients with successful limb salvage was ambulatory, independent from radiologic fusion, and presence of osteomyelitis at the time of reconstruction. These findings encourage limb salvage and deformity correction in this difficult-to-treat disease, even with underlying osteomyelitis.

Charcot foot reconstruction outcomes: A systematic review

BACKGROUND

Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications.

METHODS

We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques.

RESULTS

A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation.

CONCLUSIONS

Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.

Intramedullary nail versus external fixator for ankle arthrodesis in Charcot neuroarthropathy: A meta-analysis of comparative studies

PURPOSE

Ankle Charcot neuroarthropathy presents a great challenge for treatment. While conservative treatments yield poor results, arthrodesis is considered the treatment of choice for unstable Charcot ankles. There are two methods used for ankle fusion: retrograde intramedullary nail (IMN) and external fixator (EF). Literature reports inconclusive results on which method is better for arthrodesis.

METHODS

The aim of this meta-analysis is to look for significant difference between the two techniques in terms of fusion rate and complications. Four comparative studies including 117 patients (117 interventions) were located and analyzed.

RESULTS

IMN was found to yield double fusion rate than EF ( p = 0.2) with 5 weeks less time to heal ( p = 0.4). While no significance was noted for revision surgery and amputation rates, EF yielded higher rates of hardware infection ( p = 0.01) and wound infection ( p = 0.01). The IMN method seems to offer quicker and better fusion rate when compared to EF with significantly lower postoperative infection rates.

CONCLUSION

In the clinical context of high-risk patients such as the diabetic population, IMN technique could be a better option in the case of ulcer-free ankles/feet or in the presence of medial/lateral ulcers. In case of presence of plantar ulcers, EF might be a better choice to avoid the plantar approach for nail insertion. Future research with bigger sample sized and randomized studies are warranted for validation.

Combined Intramedullary Nail Coated With Antibiotic-Containing Cement and Ring Fixation for Limb Salvage in the Severely Deformed, Infected, Neuroarthropathic Ankle

BACKGROUND:

The severely deformed, infected, and unstable neuroarthropathic ankle is challenging to treat. We evaluated our preliminary experience and results of combined internal and external ring fixation for a complex neuropathic population.

METHODS:

We retrospectively reviewed medical records and radiographs for 8 patients with unilateral severely deformed ankle neuroarthropathy associated with infection and ulceration. Treatment included single-stage reconstruction arthrodesis with an interlocked intramedullary nail coated with antibiotic-containing cement combined with ring fixation. Taylor Spatial Frame™ technology was used when the deformity was not amenable to acute correction (5 patients). Protected postoperative weightbearing was permitted. Their mean age averaged 55.6 (range, 42-66) years with an average body mass index of 38.4 (range, 28.7-49.6) kg/m².

RESULTS:

Seven patients achieved limb preservation. Average time for fusion healing was 15.2 (range, 12.2-22.2) weeks, frame time was 17.7 (range, 12.2-23.0) weeks, and follow-up was 34.1 (range, 24.1-68.8) months. All presenting wounds and infection successfully resolved. Reinker and Carpenter scale was excellent for 2 patients, good for 2 patients, and fair for 3 patients. Foot and Ankle Ability Measure averaged 59.0% (range, 39.3%-87.5%). One patient developed a recalcitrant calcaneal ulcer with osteomyelitis that required a transtibial amputation 17 months after successful ankle arthrodesis.

CONCLUSIONS:

Combined use of interlocked intramedullary nail and ring external fixation for neuroarthropathic ankle arthrodesis achieved a functional and clinically stable salvaged lower limb for most patients.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

New Fixation Methods for the Treatment of the Diabetic Foot: Beaming, External Fixation, and Beyond

Surgical correction of complex foot and ankle deformities secondary to Charcot neuroarthropathy remains a significant surgical challenge. New technological advancements in hardware have allowed for the use of augmented fixation techniques in midfoot deformity correction, including the use of indication-specific locking plates and beaming techniques that offer enhanced stability. Severe hindfoot deformity management can employ the use of internal fixation, including intramedullary hindfoot nails and circular external fixation frames for limb salvage.

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.