An analysis of iatrogenic complications from the total contact cast

Operative Management of Charcot Neuropathy of the Foot and Ankle: A Retrospective Cohort Study of Long-Term Outcomes

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the main treatment, but surgical intervention has gained interest to improve poor long-term outcomes. Few long-term outcome studies exist on operative management of CN. A retrospective chart review was performed to analyze demographics, comorbidities, complications, and outcomes of operative management of CN. Patients were divided into two cohorts for analysis: limited surgical intervention (LSI) and reconstructive surgery (RS). Fifty-eight patients with CN treated surgically over 11 years were identified. Average follow-up was 46 months (range, 1 to 173 months). The mean age was 60.2 (range, 29 to 81) years, and the average body mass index was 34.3. Diabetes caused CN in 72.4% (42/58) of patients. The LSI cohort (n = 32) had significantly higher rates of presenting infection (59.4%; 19/32) and ulceration (87.5%; 28/32) compared with the RS cohort (n = 26; 23.1% [6/26] and 50% [13/26], respectively). Rates of postoperative infection and ulceration were lower in the LSI group (25% [8/32] and 34.4% [11/32], respectively) than the RS group (42.3% [11/26] and 42.3% [11/26], respectively). The amputation rate for the LSI cohort was 21.9% (7/32) compared with 23.1% (6/26) for RS. This large, single-center study of operatively treated CN patients showed no significant difference between LSI and RS. This study provides data to help surgeons counsel patients on expected outcomes.

Charcot neuro-osteoarthropathy: a review of key concepts and an evidence-based surgical management algorithm

Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.

Surgical Outcomes in Charcot Arthropathy

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.

Polymethylmethacrylate (PMMA) Augmentation Enhances the Mechanical Characteristics of Midfoot Beam Constructs in Charcot Neuroarthropathy Cadaver Model

BACKGROUND

Even with the best conservative care, patients with Charcot neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has been associated with risk of recurrent ulceration, potentially due to poor bone quality prone to recurrent deformity and ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation.

METHODS

A protocol was developed to create characteristic CN midfoot fragmentation both visually and fluoroscopically in each of 12 matched-pair cadaveric feet. Afterward, the pairs were divided into 2 groups: (1) midfoot beam fusion surgery alone, and (2) midfoot beam fusion surgery augmented with PMMA. A solid 7.0-mm beam was placed into the medial column and a solid 5.5-mm beam was placed across the lateral column. In the PMMA group, 8 to 10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded.

RESULTS

One specimen in the beam alone group failed before reaching the 1800th cycle and was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared with the PMMA group, P < .05. The maximum force (N), stiffness (N/mm), and toughness (Nmm) were all significantly greater in the group augmented with PMMA, P < .05.

CONCLUSION

In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared with midfoot beams alone.

CLINICAL RELEVANCE

The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct. This increased mechanical toughness may help reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.

Evolution in Casting Techniques: A Narrative Review of Casting Methods, Techniques, and Innovation

Orthopedic casting has seen a remarkable evolution from ancient practices to cutting-edge innovations. Beginning with ancient Egyptian methods employing bark, linen, and bandages, casting techniques have progressed through historical milestones, including the adoption of plaster of Paris in the 19th century and the introduction of synthetic materials like fiberglass and thermoplastics in the 20th century. Historical progressions transitioned from primitive materials to more sophisticated techniques, such as resin-soaked bandages and starch-based casts. While thermoplastics showcased benefits like adjustability and comfort, widespread adoption faced hurdles due to cost and water resistance limitations. The emergence of 3D printing introduced patient-specific casts with improved ventilation but faced challenges in accessibility, cost, and immediate immobilization. FlexiOH presents as a groundbreaking foam cast by Orthoheal, offering customizable fit, lightweight design, improved ventilation, and moisture resistance. Its potential to reduce ER visits, enhance patient comfort, and streamline application procedures positions it as a promising technology for the future. This paper discusses each casting generation's advantages and drawbacks, highlighting the potential of innovative technologies like FlexiOH to revolutionize orthopedic casting practices, promising improved outcomes, reduced costs, and enhanced efficiency.

Radiographic Bone Healing in Minimally Invasive Floating Metatarsal Osteotomy for Neuropathic Plantar Metatarsal Head Ulcers - A Retrospective Cohort Study

Minimally invasive floating metatarsal osteotomy is an option for treating neuropathic ulcers under the metatarsal heads. This study presents the radiographic results of the floating metatarsal osteotomy. We reviewed files and radiographs at least 4 months after a floating metatarsal osteotomy in patients with diabetic neuropathy. In 71 osteotomies in 54 patients with late onset diabetes (mean age 61 ± 9, mean HbA1c 7.9 ± 1.9%), the primary ulcer healed within 3.5 ± 1.4 weeks. Of 66 osteotomies where radiographs were available 10 had non-union (15%, all asymptomatic), 15 (23%) had hypertrophic callus formation and 41 (62%) had normal union. One patient developed an ulcer under the hypertrophic callus. This necessitated callus resection. Asymptomatic non-union may happen in 15% of floating osteotomies, but the osteotomies appear to be relatively safe and effective for neuropathic plantar metatarsal head ulcers. Hypertropic callus causing local re-ulceration is rare and can be managed surgically.

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.

Ventral Windowed Total Contact Casts Safely Offload Diabetic Feet and Allow Access to the Foot

BACKGROUND

Irremovable total contact casts (TCCs) are the gold standard to offload diabetic foot ulcers (DFUs) and to immobilize feet with active Charcot neuro-osteoarthropathy (CN). They do not allow checks of the foot and are contraindicated in people with peripheral arterial disease (PAD). Frequently, removable TCCs and other removable devices are used because they allow wound care, modifications of the inner surface of the cast, and checks of the foot. The authors propose TCCs with ventral windows (VW-TCCs) whenever patients with high-risk conditions show poor adherence to wearing a removable cast all the time and access to the foot is necessary.

METHODS

This retrospective study compares treatments with bivalved, removable TCCs applied prior to the introduction of the novel design (from 1 January 2016 to 1 July 2017, "c") to treatments in the following period (t) with both bivalved removable TCCs and VW-TCCs in use.

RESULTS

Forty-five treatments after introduction (17 with the VW-TCC) showed a 52.8% lower median time to reach remission of the DFS than 41 controls (128/267 days, log-rank test P = .013). Reasons given for not using the novel design were: sufficient offloading with a removable TCC (16), patient preference (six), anatomical conditions (two), casts applied as a service for other facilities (three), and calf ulcers (one). Adverse effects from both designs were uncommon and not severe.

CONCLUSIONS

VW-TCCs combine advantages of both removable and irremovable TCCs. Complications do not limit the use, even in patients with PAD.

Diagnosis and treatment of Charcot arthropathy in diabetic patients

Background: Charcot joint or neurogenic arthropathy in diabetes is a late complication invading the foot and ankle that results in dislocation, instability, and deformity of the affected area. Sensory neuropathy leads to numbness and malalignment of the foot and ankle or inadequate post-traumatic response, which results in progressive fractures, multiple joint dislocations, ulcerations, osteomyelitis, and amputation. Because of such serious consequences, understanding of pathophysiology is important in determining treatment strategies. Early diagnosis and appropriate treatment can prevent this destructive process.Current Concepts: The number of adults diabetic patients continuously increases. Health care and life expectancy will continue to improve with the development of medicine. As a result, the incidence of diabetes-related complications will increase. Diabetic Charcot joint will have a serious negative impact on the quality of life and financial burden on the diabetic patients. The goal of treatment for Charcot joint is not to build a normal foot, but to make a stable plantigrade foot that can be worn shoes. Therefore, it would be most important to understand the progress and characteristics of the disease and to develop an appropriate plan in order to select the appropriate treatment method.Discussion and Conclusion: Understanding Charcot joint and familiarization with its appropriate treatment should reduce the number of the cases of diabetic Charcot joint patients with disabilities or amputations.

Bilateral Charcot Arthropathy Treated with Bolt-Beam Constructs in the Setting of Unilateral Foot Ulcers: A Report of 2 Cases

CASE

Two type-2 diabetic patients presented with bilateral Charcot arthropathy with midfoot collapse and presence of foot ulcerations on one side. The ulcerated extremity in each patient was treated surgically with fusion bolt, beam, and plate constructs in the setting of open ulceration. Bilateral extremities were treated surgically and went on to bony union and wound healing.

CONCLUSION

Charcot arthropathy with open ulcers can be managed acutely with debridement, resection of bone, and arthrodesis. Waiting for ulcers to heal before internal fixation is performed may not be necessary in all situations.

Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

BACKGROUND

Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies.

METHODS

This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher's exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated.

RESULTS

Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants.

CONCLUSIONS

The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.

Effect of Mini-invasive Floating Metatarsal Osteotomy on Plantar Pressure in Patients With Diabetic Plantar Metatarsal Head Ulcers

BACKGROUND

Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study's purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers.

METHODS

We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year.

RESULTS

Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa (P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s (P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics.

CONCLUSION

This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence.

LEVEL OF EVIDENCE

Level III, retrospective case series of prospectively collected data.

Trans-calcaneal retrograde nailing for secondary-displaced traumatic ankle fractures in diabetics with insensate feet: a less-invasive salvage-arthrodesis technique

PURPOSE

Secondary displacement of traumatic ankle fractures with subsequent soft-tissue breakdown is a troublesome issue after inappropriate conservative treatment among non-compliant diabetic patients with severe peripheral neuropathy. This study was conducted to evaluate the results of a less-invasive arthrodesis procedure as an alternative to osteosynthesis in these complex scenarios.

METHODS

A total of 46 diabetics, who underwent fluoroscopy-assisted trans-calcaneal retrograde nailing-based ankle arthrodesis between 2012 and 2018 for salvaging secondary-displaced diabetic ankle fractures in their insensate feet, were evaluated in this retrospective study. All fractures were associated with uninfected mechanical ulcers overlying malleoli, without Charcot changes, after failed conservative cast immobilization. The patients (mean age: 52.52 ± 3.70 years; 18 males; 46 feet) were evaluated radiologically for union and clinically for limb salvage, modified American Orthopedic Ankle and Foot Scale (AOAFS), and the overall subjective patients' satisfaction.

RESULTS

The mean follow-up was 29.5 ± 3.1 months. All ulcers have healed with local care only with 100% limb salvage. Four patients experienced minor wound healing problems at posterior heel, and another one developed acute Charcot changes that was successfully managed by offloading and repeat surgery. Forty patients (86.96%) had fully consolidated fusions with a mean time to fusion 15.78 ± 2.58 weeks, while the other six cases had stable fibrous-union. At the final follow-up, the mean modified-AOFAS was 76.85 ± 6.0 from 86 total points. All, but four patients (91.30%) were completely satisfied while the other four patients were partially satisfied.

CONCLUSIONS

The presented less-invasive arthrodesis technique is reproducible and effective alternative for salvaging unstable diabetic ankle fractures in the insensate feet when standard surgical procedures would be more risky.

LEVEL OF EVIDENCE

IV, retrospective case series.

Risk of Complications With the Total Contact Cast in Diabetic Foot Disorders

The custom-fabricated total contact cast is commonly used in the treatment of diabetic foot disorders. This resource-consuming treatment option has been associated with iatrogenic morbidity as well as the need for urgent cast removal and inspection of the underlying limb when potential problems arise. Over a 10-year period, 381 diabetic patients had 2265 total contact cast applications by certified orthopaedic technologists, in a university orthopaedic practice, under the supervision of university faculty. Patients were stratified by glycemic control based on hemoglobin A1c levels, and obesity based on body mass index (BMI). Complications were grouped as (1) development of a new ulcer or wound, (2) new or increasing odor or drainage, (3) wound infection, (4) gangrene, (5) newly identified osteomyelitis, and (6) pain or discomfort necessitating cast change or removal. At least 1 complication was observed in 159 of 381 patients. The odds of experiencing a cast-related event for patients with a BMI greater than 30 kg/m² was 1.55 times greater than patients with a BMI less than 25 kg/m². As compared to patients with good glycemic control, the odds of experiencing a cast-associated complication was 1.27 times greater in patients with moderate glycemic control and 1.48 times greater in patients with poor glycemic control. The total contact cast is commonly used in the treatment of diabetic foot morbidity. Treatment-associated morbidity may well be greater than previously appreciated. Complications are more likely in patients who have poor glycemic control and are morbidly obese. This information will hopefully stimulate interest in developing commercially available nonrigid alternatives that retain the attributes of the resource-consuming rigid device, with the potential advantage of avoiding the associated morbidity.Levels of Evidence: Level IV, retrospective chart review.

An overview of Charcot's neuroarthropathy

Charcot's neuroarthropathy is a destructive complication of the joints, which is often found in people with diabetes with peripheral neuropathy. Despite the fact that its description was published almost 130 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be described. Thanks to the use of bone remodelling, new therapeutic classes have emerged, we hope that this review will shed light on the pathology from its discovery through to the current state of knowledge on its classification, diagnosis and treatment methods.

Bone cement spacer: a novel technique for treating a complicated case of developmental dysplasia of the hip with an injured acetabulum: Case report with 7-year follow-up

RATIONALE

Developmental dysplasia of the hip (DDH) has an incidence of 5 per 1000 newborns and its management depends on various factors. We present a rare case of DDH with soft tissue obliteration and a bony prominence in the center of the acetabulum after failed open reduction and acetabuloplasty.

PATIENT CONCERNS

A 20-month-old girl presented to our clinic with right hip stiffness after undergoing open reduction and acetabuloplasty at another hospital.

DIAGNOSES

The diagnosis of DDH was made using a computed tomography scan that revealed a right hip dislocation with soft tissue obliteration and a bony prominence in the center of the acetabulum.

INTERVENTIONS

We used a novel technique for treating the rare presentation of complicated DDH with massive soft tissue obliteration and bony prominence in the center of the acetabulum after failed open reduction and acetabuloplasty. The right hip was surgically explored. The acetabulum was deepened and resurfaced. Bone cement was applied over the acetabulum to prevent future ankylosis.

OUTCOMES

At the follow-up 7 years after the last surgery, the patient had regained full range of motion and a properly reduced right hip with optimal acetabular coverage on radiographs.

LESSONS

Care must be taken in any patient with DDH who presents with hip redislocation after open reduction. If deepening and resurfacing of the acetabulum are required, bone cement could be used as a temporary spacer for 8 weeks; this was key in treating our patient.

Results of Simple Conservative Treatment of Midfoot Charcot Arthropathy

Background

Traditionally, conservative management with an offloading orthosis, such as total contact cast (TCC), has been the standard of care for midfoot Charcot arthropathy. Considering complications of TCC and surgery, we treated midfoot Charcot arthropathy without TCC in our patients. The purpose of this study was to report clinical and radiological outcomes of conservative management of midfoot Charcot arthropathy.

Methods

A total of 34 patients (38 feet) who were diagnosed as having midfoot Charcot arthropathy between 2006 and 2014 were included. Patients started full weight bearing ambulation in a hard-soled shoe immediately after diagnosis. Outcomes such as progression of arch collapse, bony prominence, ulcer occurrence, limb amputation, and changes in Charcot stage were evaluated.

Results

Of 38 feet, arch collapse was observed in four while progression of bottom bump of the midfoot was observed in five feet. Foot ulcers related to bony bumps were found in two feet.

Conclusions

Conservative treatment without restriction of ambulation is recommended for midfoot Charcot arthropathy because it is rarely progressive, unlike hindfoot-ankle arthropathy. In some cases, simple bumpectomy can be required to prevent catastrophic infection.

Mortality and complications after treatment of acute diabetic Charcot foot

AIMS

Charcot foot is a rare but disabling complication to diabetic neuropathy, and can cause permanent, limb-threatening deformities. The aim of this study was to investigate a population of patients a Charcot foot on a case-by-case basis, in order to assess the consequences of an acute Charcot foot and its complications.

METHODS

The study was conducted a retrospective study of patients admitted to the Copenhagen Wound Healing Center between 1996 and 2015 with the diagnosis of Charcot foot (DM14.6) and diabetes mellitus type 1 or 2 (DE10.X and DE11.X). Physical and electronic records were used, and compared to data from the Danish Diabetes Registry.

RESULTS

In total 392 patients were identified of which 173 were included. There were 26% with type 1 diabetes (initial HbA1c 81.7 ± 21.4 mmol/mol) and 74% with type 2 diabetes (initial HbA1c 66.5 ± 20.3 mmol/mol). Primary off-loading was with a removable walker in 95% of the cases (average off-loading time 8.3 months). The 5-year mortality was 14% with a mean survival time of 12.7 years. There was an association between lack of compliance and occurrence of foot complications, as well as between having a Charcot foot and leaving the workforce.

CONCLUSION

More patients had type 1 diabetes compared to the background population, and they had a higher HbA1c than the general population of diabetes patients. A total of 67% developed complications such as ulcers, while patients non-compliant to treatment did significantly worse than those being compliant. The 5-year mortality was low, 14%, and comparable to diabetes patients without Charcot foot.

A review of bone metabolism and developments in medical treatment of the diabetic Charcot foot

Charcot foot is a rare but severe, and possibly limb-threatening, complication to neuropathy and diabetes mellitus. The current treatment consists of long-term off-loading, and has a large negative impact on the patient's life. Much research has gone into understanding the condition and its biochemical mechanisms, however, the underlying pathogenesis of a Charcot foot is not yet fully understood. In the recent decades several key advances in our understanding of the Charcot foot have been made, both in regards to the changes in bone metabolism and structure an acute Charcot foot can cause, and to the molecular pathways involved in this. This review summerizes the available research into the bone metabolism around a Charcot foot, with an emphasis on the biochemical profile. The existing data regarding attempts at medical treatment is also reviewed, including novel trials targetting specific inflammatory pathways upregulated in the acute diabetic Charcot foot.

A Narrative Review of the Benefits and Risks of Total Contact Casts in the Management of Diabetic Foot Ulcers

Total contact casts are recognized as the gold standard treatment for neuropathic plantar diabetic foot ulceration, endorsed by all national and international consensus papers. Despite this, research has shown that there is a dichotomy between the existing evidence which supports the use of total contact casts in the management of diabetic foot ulcers and its use in clinical practice. This article aims to highlight the benefits, risks, and barriers associated with total contact cast use in the management of diabetic foot ulcers in the clinical setting, with an emphasis on existing research carried out in this field to encourage change in clinical practice and utilization of this effective treatment modality.

Minimally Invasive Distal Metatarsal Diaphyseal Osteotomy (DMDO) for Chronic Plantar Diabetic Foot Ulcers

BACKGROUND

The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes.

METHODS

A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out ( P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%).

RESULTS

All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points ( P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time.

CONCLUSION

Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications.

LEVEL OF EVIDENCE

IV, case series.

Outcomes Achieved With Use of a Prefabricated Roll-On Total Contact Cast

BACKGROUND

The total contact cast (TCC) is considered the gold standard for offloading of plantar diabetic foot ulcerations, yet its use remains suboptimal for a variety of reasons. Prefabricated TCC systems have been developed to help enhance TCC use. The primary objective of this study was to determine if healing rates obtained with use of a prefabricated roll-on TCC were similar to those reported with conventional TCC use. Secondary outcomes measured were the incidence of iatrogenic ulceration, amputation, and recurrent ulceration, and patient tolerance of the device.

METHODS

A retrospective chart review was performed on all patients in whom TCC was used for treatment of an ulceration at our institution from April 2013 to December 2016. Seventy patients (132 ulcerations) were identified.

RESULTS

An 85.6% healing rate was achieved. Five subjects (7.1%) sustained 11 iatrogenic ulcerations. All resolved with local treatment and continued casting. Thirteen subjects (18.6%) underwent amputation. No amputation occurred because of TCC application technique or use. Fifteen ulcerations (12 subjects, 17.1%) recurred. Greater than 70% resolved with re-initiation of TCC use. Forty-three subjects (61.4%) tolerated use of the prefabricated roll-on TCC.

CONCLUSION

Similar healing rates and reduced rates of iatrogenic ulceration, amputation, and recurrent ulceration were attained with use of a prefabricated roll-on TCC. These results, good patient tolerance, and the reduced administrative and clinical time related to supply acquisition, training, and proper application supports use of this device as a viable alternative to a conventional TCC for treatment of plantar neuropathic foot ulcerations.

LEVEL OF EVIDENCE

Level IV, case series.

Charcot Arthropathy Versus Osteomyelitis: Evaluation and Management

Charcot arthropathy of the foot and ankle is a severe complication of peripheral neuropathy and is most commonly seen in the developed world in association with diabetes mellitus. Correct diagnosis and differentiation from osteomyelitis of the foot and ankle are critical to guide treatment. It can exist concomitantly with osteomyelitis, typically in the setting of an advanced midfoot ulcer. Simple plain radiographs and contrasted MRI studies often yield inconclusive or confusing data. Correct use of imaging studies and a clinical algorithm can be effective tools to help make accurate and early diagnoses and guide clinical interventions for these conditions.

Evaluating Iatrogenic Complications of the Total-Contact Cast: An 8-Year Retrospective Review at Cleveland Clinic

BACKGROUND

Total-contact casting is an effective method to treat various pathologic abnormalities in patients with diabetic neuropathy, but its use is frequently associated with iatrogenic complications.

METHODS

The largest retrospective review to date of iatrogenic complications of total-contact casts was conducted over an 8-year period at Cleveland Clinic.

RESULTS

In the past 8 years, 23% of patients developed complications, and the most common complication was a new heel ulcer formation. Of these complications, 92.1% resolved, 6.4% were lost to follow-up, and 1.4% resulted in a partial foot amputation. Mean cast duration was 10.3 days for patients who developed a total-contact cast iatrogenic complication. The most common indication for the use of a total-contact cast was a neuropathic foot ulceration.

CONCLUSIONS

The results of this study support the use of total-contact casting in the insensate patient with diabetes. However, adequate staff training in total-contact cast application is recommended to reduce complications.

Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients

Background

Charcot neuropathic arthropathy (CN) is a chronic, progressive, destructive, non-infectious process that most frequently affects the bone architecture of the foot in patients with sensory neuropathy. We evaluated the outcome of protected weightbearing treatment of CN in unilaterally and bilaterally affected patients and secondarily compared outcomes in protected versus unprotected weightbearing treatment.

Methods

Patient records and radiographs from 2002 to 2012 were retrospectively analyzed. Patients with Type 1 or Type 2 diabetes with peripheral neuropathy were included. Exclusion criteria included immunosuppressive or osteoactive medication and the presence of bone tumors. Ninety patients (101 ft), mean age 60.7 ± 10.6 years at first diagnosis of CN, were identified. Protected weightbearing treatment was achieved by total contact cast or custom-made orthosis. Ulcer, infection, CN recurrence, and amputation rates were recorded. Mean follow-up was 48 (range 1–208) months.

Results

Per the Eichenholtz classification, 9 ft were prodromal, 61 in stage 1 (development), 21 in stage 2 (coalescence) and 10 in stage 3 (reconstruction). Duration of protected weightbearing was 20 ± 21 weeks and 22 ± 29 weeks in patients with unilateral and bilateral CN, respectively. In bilaterally affected patients, new ulcers developed in 9/22 (41%) feet. In unilaterally affected patients, new ulcers developed in 5/66 (8%) protected weightbearing feet and 4/13 (31%) unprotected, full weightbearing feet (p = 0.036). The ulceration rate was significantly higher in bilaterally versus unilaterally affected patients with a protected weightbearing regimen (p = 0.004). Soft tissue infection occurred in 1/13 (8%) unprotected weightbearing feet and 1/66 (2%) protected weightbearing feet in unilaterally affected patients, and in 1/22 (4%) protected weightbearing feet of bilaterally affected patients. Recurrence and amputation rates were similar across treatment modalities.

Conclusions

Bilateral CN results in significantly more ulcers than unilateral CN and leads to slightly higher soft tissue infections. Protected weightbearing in an orthopedic device can reduce the risk for complications in acute CN of the foot and ankle.

Complication assessment and prevention strategies using midfoot fusion bolt for medial column stabilization in Charcot's osteoarthropathy

In Charcot's osteoarthropathy stabilization of the medial column of the foot was introduced in order to establish a stable foot and reduce the risk for amputation. This study was performed to analyze postoperative complications, define risk factors for those and develop strategies for prevention. Since bolt dislocation takes place frequently, it was aimed to predict an appropriate time point for bolt removal under the condition that osseous healing has occurred. Fourteen consecutive patients with neuroosteoarthropathy of the foot and arch collapse were treated with open reduction and stabilization using midfoot fusion bolt and lateral lag screws. Age, gender, presence of preoperative osteomyelitis or ulcer, number of complications and operative revisions, Hba1c value, consolidation of arthrodesis, presence of a load-bearing foot and period to bolt dislocation was assessed. The mean follow-up was 21.4±14.6 (mean±SDM) months, 64% of patients suffered from diabetes with a preoperative Hba1c of 8.5±2.4. The mean number of revisions per foot was 3.6±4.1. Bolt dislocation was seen in 57% of the patients following 11.3±8.5 months; in 75% of these patients bony healing occurred before dislocation. There was a significant association between preoperative increased Hba1c value, presence of preoperative ulcer and wound infection. Healing of arthrodesis was demonstrated in 57% and a permanent weight-bearing foot without recurrent ulcer was achieved in 79%. The early and late postoperative complications could be controlled in general. A fully load-bearing and stable foot was obtained, despite osseous consolidation was not detected in all of these cases. Once a stable foot has established early removal of fusion bolt should be considered. To decrease the risk of infection Hba1c should be adjusted and ulcers should be treated before the operation.

Preliminary Results of Primary Gastrocnemius-Soleus Recession for Midfoot Charcot Arthropathy

Background Treatment of Charcot arthopathy of the foot can be challenging. The goal of this investigation was to determine whether primary gastrocnemius-soleus recession could decrease rate of new ulcers, progression of deformity, and amputation in patients with Charcot arthropathy of the midfoot.Methods A retrospective chart review revealed 28 feet in 24 diabetic patients with radiographic evidence of Charcot arthropathy of the midfoot. They were treated with primary gastrocnemius-soleus recession. Eleven feet in 11 patients had concurrent plantar midfoot ulcers. Three feet in 3 patients were lost to follow-up. Twenty-five feet in 21 patients were followed for an average of 37 months postoperatively (range = 18-79).Results A favorable outcome was defined as healing of existing ulcers, no new ulcers, no obvious progression of deformity, and no amputation. Favorable outcomes were obtained in 22 of 25 feet (18 of 21 patients). Only one patient had a persistent ulcer after gastrocnemius-soleus recession. The other 10 patients with preexisting ulcers healed. Deformity of midfoot progressed in one patient, leading ultimately to transtibial amputation. Another patient developed a knee joint infection and had a transfemoral amputation at another institution.Discussion These preliminary data suggest that primary gastrocnemius-soleus recession is followed by a much lower rate of persistent, recurrent, and new ulceration than previously reported studies. Gastrocnemius-soleus recession seems to aid in the treatment of Charcot arthropathy of the midfoot.

LEVELS OF EVIDENCE

Level IV.

[Surgical treatment of the Charcot foot : long-term results and systematic review]

BACKGROUND

Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.

OBJECTIVES

The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.

MATERIALS AND METHODS

In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.

RESULTS

After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.

CONCLUSION

Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.

[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.

A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Cast-saw injuries: assessing blade-to-skin contact during cast removal. Does experience or education matter?

BACKGROUND

Cast-saw injuries are sustained during cast removal or splitting of a cast when a hot cast-saw blade touches the patient's skin inadvertently during cast removal. Other studies have evaluated risk factors associated with saw-blade temperature, however, none have documented the number and duration of blade-to-skin contacts during cast removal.

METHODS

Using a pediatric long-arm model capable of detecting cast-saw blade contact, we tested the ability of health care providers to apply and remove casts before and after a brief education module. The total number and duration of "touches" between the saw and the model's "skin" were recorded. Correlations between user "touches," and experience and comparisons between pre- and post-education "touches" were performed.

RESULTS

Of the 18 study participants, 16 touched the model surface with the cast saw; 7 of the 18 participants maintained blade contact with the skin for > 1 second 22 times during the testing process. Participants with less experience averaged 20 (± 16) touches, whereas more experienced participants averaged 24 (± 19) touches (P = 0.7). Average number of touches was similar-before 22 (± 20) and after 25 (± 22); P = 0.5-participants completed an education module. No correlation between experience or participation in the education program was found with decreased number of blade-to-skin touches.

CONCLUSION

Nearly all clinicians inadvertently contacted the underlying skin with the cast-saw blade. In our limited sample size, experience and education did not prevent this; therefore, minimizing time of contact and blade temperature may be more important factors in minimizing cast-saw injuries.

Charcot foot and ankle with osteomyelitis

This paper presents a review of the current literature discussing topics of Charcot osteoarthropathy, osteomyelitis, diagnosing osteomyelitis, antibiotic management of osteomyelitis, and treatment strategies for management of Charcot osteoarthropathy with concurrent osteomyelitis.

Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker

OBJECTIVE

Recent literature on acute diabetic Charcot osteoarthropathy (CA) reports unusually long periods of off-loading. Data suggest that this might increase the re-currence rate. Subsequently we evaluated the influence of duration of off-loading on the risk of required re-casting.

RESEARCH DESIGN AND METHODS

In this retrospective consecutive series from 2000 to 2005, 56 people with diabetes and an acute Charcot foot were included. The inclusion criteria were an initial persistent temperature difference more than 2°C between the two feet, oedema, and typical hot spots on a bone scintigram, radiology, and a typical clinical course. Treatment was off-loading in a removable cast and 2 crutches. In-door walking was allowed. Gradually augmented weight bearing was prescribed when the skin temperature difference had decreased to a level less than 2°C and edema had subsided. Re-casting was required for immediate exacerbation during re-load as well as for recurrence - defined as new swelling and skin temperature difference of more than 2°C in the same foot occurring after a stable interval of at least one month after full weight bearing.

RESULTS

The duration of off-loading for all patients was 141±21 days (mean±SD). Three patients (5%) were re-casted immediately for exacerbation after re-load and 7 patients (12 %) after recurrence of the CA. Duration of re-casting was 79±44 days. The primary period of off-loading was not statistically significantly different for those not requiring versus those requiring re-casting: 142±24 days compared to 134±41 days. Neither were the differences in demographic data, metabolic regulation, BMI or localization of CA.

CONCLUSIONS

Patients with risk of exacerbation or recurrence of CA could not be identified in the present study and there was no relation to the duration of off-loading. Nevertheless off-loading periods with immobilisation should be kept as short as possible, due to other side effects. This can be obtained by early gradual augmented re-loading.

A retrospective review of iatrogenic skin and soft tissue injuries

BACKGROUND

Even though the quality of medical and surgical care has improved remarkably over time, iatrogenic injuries that require surgical treatment including injuries caused by cast and elastic bandage pressure, extravasation, and dopamine-induced ischemia still frequently occur. The goal of this study was to estimate the incidence and analyze the distribution of iatrogenic injuries referred to our department.

METHODS

A retrospective clinical review was performed from April 2006 to November 2010. In total, 196 patients (116 females and 80 males) were referred to the plastic surgery department for the treatment of iatrogenic injuries. We analyzed the types and anatomic locations of iatrogenic complications, along with therapeutic results.

RESULTS

An extravasation injury (65 cases, 37.4%) was the most common iatrogenic complication in our study sample, followed by splint-induced skin ulceration, dopamine-induced necrosis, prefabricated pneumatic walking brace-related wounds and elastic bandage-induced wounds. Among these, prefabricated pneumatic walking brace-related complication incidence increased the most during the 5-year study period.

CONCLUSIONS

The awareness of the very common iatrogenic complications and its causes may allow physicians to reduce their occurrence and allow for earlier detection and referral to a plastic surgeon. We believe this is the first study to analyze iatrogenic complications referred to a plastic surgery department in a hospital unit.

Diabetic foot: the orthopedic surgery angle

As diabetes takes on pandemic proportions, it is crucial for the orthopedic surgeon to be aware of the issues involved in diabetic foot. Ulceration is related to neuropathy and to arterial disease, a vital prognostic factor for healing; infection plays an aggravating role, increasing the risk of amputation. At-risk feet need to be screened for. Ulcer classification is essential, to set treatment strategy and determine prognosis. Before any treatment is decided on, neuropathy, vascular insufficiency and infection should individually be assessed by clinical examination and appropriate additional work-up. Despite the International Consensus on the Diabetic Foot recommendations, management of diabetic foot in Europe still varies greatly from country to country, very few of which have established reference centers. Management of diabetic foot remains multidisciplinary; but it has been shown that the orthopedic surgeon should play a central role, providing a biomechanical perspective so as to avoid complications recurrence. Strategy notably includes prevention of at-risk foot, revascularization surgery (which should systematically precede orthopedic surgery in case of critical vascular insufficiency), and treatment of ulcers, whether these latter are associated with osteitis or not. Indications for "minor" amputation should be adequate, and meticulously implemented. "Acute foot" is a medical emergency, entailing massive empirically selected I.V. antibiotics to "cool" the lesion. Prophylactic surgery to limit further risks of ulceration is to be indicated with caution and only when clearly justified. France urgently requires accredited specialized multidisciplinary centers to manage severe lesions: deep and infected ulceration, advanced arteriopathy, and Charcot foot arthropathy.

Optimizing the offloading properties of the total contact cast for plantar foot ulceration

AIMS

Total contact casting is the gold standard offloading treatment for plantar foot ulceration, but the optimal technique and preferred materials are poorly defined and not readily prescribed in daily practice. We investigated in-cast pressure offloading in two types of total contact casts vs. a control condition, in patients with plantar foot ulceration.

METHODS

In-cast walking pressures were collected using the Novel Pedar-X system in 20 participants with a plantar foot ulcer in two types of total contact casts: a conventional total contact cast and a cushion-modified total contact cast incorporating an inlay of 6 mm slow-rebound cellular urethane and 6 mm soft cellular urethane. Casts were compared with a canvas cast shoe to establish baseline pressure values.

RESULTS

Compared with the cast shoe, the conventional total contact cast significantly reduced peak pressure at the ulcer site by 44%, mean pressure by 47% and pressure-time integral by 37% (P<0.001), while the cushion-modified total contact cast significantly reduced peak pressure at the ulcer site by 70%, mean pressure by 60% and pressure-time integral by 69% (P<0.001). Plantar pressure across the entire foot and each region of the foot was also reduced with the conventional total contact cast compared with the cast shoe, and further reduced by the cushion-modified total contact cast (P<0.05).

CONCLUSIONS

The offloading properties of the total contact cast can be enhanced with a 12 mm cellular urethane cushion modification. Further well-designed trials are required to understand and validate this cast technique and to demonstrate healing rates and safety in different patient populations.

Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of a removable cast walker compared with that of a nonremovable fiberglass off-bearing cast in the treatment of diabetic plantar foot ulcer.

RESEARCH DESIGN AND METHODS

Forty-five adult diabetic patients with nonischemic, noninfected neuropathic plantar ulcer were randomly assigned for treatment with a nonremovable fiberglass off-bearing cast (total contact cast [TCC] group) or walker cast (Stabil-D group). Treatment duration was 90 days. Percent reduction in ulcer surface area and total healing rates were evaluated after treatment.

RESULTS

A total of 48 patients were screened; however, 2 patients in the TCC group and 1 patient in the Stabil-D group did not complete the study and were considered dropouts. There were no significant differences in demographic and clinic characteristics of the 45 patients completing the study. Ulcer surface decreased from 1.41 to 0.21 cm(2) (P < 0.001) in the TCC group and from 2.18 to 0.45 cm(2) (P < 0.001) in the Stabil-D group, with no significant differences between groups (P = 0.722). Seventeen patients (73.9%) in the TCC group and 16 patients (72.7%) in the Stabil-D group achieved healing (P = 0.794). Average healing time was 35.3 +/- 3.1 and 39.7 +/- 4.2 days in the TCC and Stabil-D group, respectively (P = 0.708).

CONCLUSIONS

The Stabil-D cast walker, although removable, was equivalent in efficacy to the TCC in terms of ulcer size reduction and total healing rate. The easier use of Stabil-D may help increase the use of off-loading devices in the management of plantar neuropathic diabetic foot ulcers.

Should one consider primary surgical reconstruction in charcot arthropathy of the feet?

Charcot neuroosteoarthropathy of the feet can induce severe instability and deformity with subsequent plantar ulceration leading to substantial disability or even amputation. Traditionally, nonoperative treatment is regarded as the primary option of treatment while surgery is restricted to treating complications or failure of nonoperative treatment. Failed nonoperative treatment essentially prolongs treatment period. We retrospectively reviewed 22 patients (26 feet) with midfoot (n = 9) or hindfoot (n = 17) neuropathy who underwent primary surgical reconstruction and reorientation arthrodesis due to manifest instability, nonplantigrade foot position, and deformity with overt (n = 8) or what we judged was impending ulceration (n = 9). The minimum followup was 0.5 years (mean, 2.7 years; range 0.5-7 years). All eight ulcers healed without recurrence of ulceration or manifestation of new ulcers during the followup period. We observed complications leading to further surgery in nine patients: five with perioperative hematoma and four with instability. AOFAS scores rose from a preoperative mean of 39 to 70 points (hindfoot cases) and from 51 points to 84 (midfoot cases). Early surgical reconstruction in high-risk patients can provide timely restoration of a plantigrade and stable foot and improved quality of life of the patient at complication rates comparable to those after secondary surgery following failed nonoperative treatment; however we emphasize we had no control group in this small case series for which we could compare nonoperative treatment.

LEVEL OF EVIDENCE

Level IV, therapeutic study (case series). See Guidelines for Authors for a complete description of levels of evidence.

Functional outcome and patient satisfaction after flexor tenotomy for plantar ulcers of the toes

Ulcers of the toes may cause a severe physical burden, especially in patients with diabetes, in whom they occur most frequently. Several treatments have been proposed for the underlying anatomical abnormalities, but they vary in effectiveness. We evaluated our results in using flexor tenotomy to treat ulcers with underlying flexible clawing of the toes. For 42 toes from 23 patients, 15 of whom were diabetic, all ulcers healed. The mean healing time was 4 weeks (range, 1-8 weeks), the mean follow-up was 11 months (range, 1-27 months), and one recurrence and one complication occurred. Postoperative American Orthopaedic Foot Ankle Society Midfoot scores were available for 15 patients: the mean was 77 (range, 43-100). The mean visual analogue scale (VAS) for patient satisfaction increased from 3.9 points (range, 0-10 points) preoperatively to 7.7 (range, 5-10 points) postoperatively. Flexor tenotomy is a simple treatment with low complications and recurrence rates and provides good-to-excellent functional outcomes in treating flexible clawing of the toes and the associated ulceration.

Traction splint: to use or not to use

Traction splints are widely used for immobilisation of fractures of the lower limb. There is brevity of evidence-based research on their efficacy. We present a case of skin complication following traction splint for spiral fracture of femur. It is prudent to identify patients at higher risk of developing complications of immobilisation. In circumstances where delays are inevitable, the indication and appropriateness of continuation of traction splint should be re-evaluated.

Charcot arthropathy of the foot and ankle: modern concepts and management review

Charcot arthropathy (Charcot neuroarthropathy, diabetic neuropathic osteoarthropathy, or neuropathic arthropathy) remains a poorly understood disease, although recent research has improved our level of knowledge regarding its etiology and treatment. The effects of Charcot arthropathy are almost exclusively seen in the foot and ankle, and the diagnosis is commonly missed upon initial presentation. It has been well established that this complication of diabetes mellitus severely reduces the overall quality of life and dramatically increases the morbidity and mortality of patients. However, there are few high-level evidence studies to support management and treatment options at this point in time. The goal of this study is to evaluate the modern concepts of Charcot arthropathy through a review of the available literature and to integrate a perspective of management from the authors' extensive experience.

Midfoot ulcers treated with gastrocnemius-soleus recession

BACKGROUND

Foot ulcers in patients with neuropathy are a common cause of hospital admission for infection sometimes resulting in amputation in patients with neuropathy. Tendon lengthening alone has been reported to be successful in treating neuropathic forefoot ulcers. Tendon lengthening has also been recommended as an adjunct to bony procedures (exostectomy or fusion) for treating midfoot ulcers. The author reports the results of gastrocnemius-soleus recession as the sole treatment of diabetic midfoot ulcers.

MATERIALS AND METHODS

This study evaluated the results of 11 patients with 11 neuropathic plantar midfoot ulcers who were treated primarily with gastrocnemius-soleus recession with an average followup of 39 months. Potentially risky bony procedures were done after tendon lengthening if ulcers did not heal or recurred.

RESULTS

Ten of the ulcers healed but one patient was lost to followup after his ulcer healed. One ulcer did not heal and one ulcer recurred but healed again after midfoot fusion. One patient later had a transfemoral amputation due to gangrene. Two patients later died from medical problems unrelated to their surgery. There were no incision problems, or transfer ulcers.

CONCLUSION

The author believes gastrocnemius-soleus recession as a primary treatment of diabetic midfoot ulcers is a low risk method of promoting ulcer resolution.