Radiographic analysis of diabetic midfoot charcot neuroarthropathy with and without midfoot ulceration

Outcomes Following Surgical Correction of Talocalcalcaneal Joint Dislocation in Diabetes Associated Charcot Foot Arthropathy

BACKGROUND

Growing clinical interest in the treatment of acquired foot deformity due to diabetes-associated Charcot foot arthropathy has led to multiple reports of favorable clinical outcomes in patients when their acquired deformity is at the midfoot level. Clinical failures and less than optimal clinical outcomes are achieved when the deformity is at the hindfoot or ankle levels.

METHODS

A retrospective review was performed of all patients who underwent surgical correction of diabetes-associated Charcot foot arthropathy with talocalcaneal dislocation over an 18-year period. Reduction of the talocalcaneal dislocation, and maintenance of the correction with percutaneous pins and circular external fixation after subtalar joint preparation for fusion, was used as the method of surgically achieving a clinically plantigrade foot. Clinical outcomes were based on resolution of infection, limb salvage, and the ability to ambulate with commercially available therapeutic footwear.

RESULTS

Forty-three feet in 39 patients were included. A favorable clinical outcome was achieved in 32 of 43 feet (74%) with 26 (60%) considered to have an "excellent" result with minimal shoeing issues and 6 (14%) considered to have a "good" outcome based on their need for a custom shoe modification and/or some form of short ankle-foot orthosis. Eleven feet (26%) were judged to have a "poor" clinical outcome and among those 11 feet, 6 underwent partial, or whole-foot amputation, 2 had persistent wounds, and 5 required the use of a standard ankle foot orthosis or Charcot Restraint Orthotic Walker (CROW).

CONCLUSION

Subtalar dislocation in Charcot arthropathy is a complex clinical problem. In our series, reduction and maintenance of the reduction after subtalar dislocation was essential for a favorable clinical outcome.

Effect of denosumab on inflammation and bone health in active Charcot foot: A phase II randomised controlled trial

AIMS

We aimed to investigate the effect of denosumab on pedal bone health and clinical resolution in active Charcot foot (CN).

METHODS

This multicentre open-label phase 2 randomised controlled trial recruited adults with diabetes mellitus and active CN within 3 months of onset. Participants were randomised to standard care alone, or with denosumab 60 mg subcutaneously. Denosumab was administered at baseline and again at 6 months, unless foot temperature had normalised (i.e. <2 °C compared to contralateral foot). Co-primary outcomes were change in calcaneal Stiffness Index and foot temperature normalisation over 18 months.

RESULTS

Twelve participants per group were analysed; mean age 58 ± 11 years, 83 % male and 92 % had type 2 diabetes. Active CN duration was median 8 (IQR 7-12) weeks. Ninety-two percent were Eichenholtz stage 1 and 96 % involved the midfoot. After 1-month, median decline in Stiffness Index was less in the denosumab verses standard care group (0.5 [IQR -1.0 to 3.9] vs -2.8 [-8.5 to -1.0], p = 0.008). At 18-months, 92 % of the denosumab group attained foot temperature normalisation versus 67 % of the standard care group (p = 0.13).

CONCLUSIONS

Denosumab ameliorated the early decline in calcaneal Stiffness Index associated with active CN. However, no difference in normalisation of foot temperature was observed.

Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review

BACKGROUND

There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin.

METHODS

We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted.

RESULTS

We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission.

CONCLUSIONS

There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease.

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

The 1989 Saint Vincent Declaration established a goal of halving global diabetes-related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro-osteoarthropathy is more prevalent than previously thought. Most cases respond well to non-removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline-based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.

Establishment of a Neurodegenerative Charcot Mouse Model

BACKGROUND

This study aimed to mimic the changes from Charcot neuropathic arthropathy in humans by examining the effects of exposing diet-induced obese (DIO) mice to neurotrauma through a regimented running protocol.

METHODS

Forty-eight male wild-type C57BL/6J mice were obtained at age 6 weeks and separated into 2 groups for diet assignment. After a 1-week acclimation period, half of the mice consumed a high-fat diet (60% fat by kcal) ad libitum to facilitate neuropathic diet-induced obesity whereas the other half were control mice and consumed an age-matched standard low-fat control diet (10% fat by kcal). At age 12 weeks, half of the animals from each group were subjected to a high-intensity inclined treadmill running protocol, which has been previously demonstrated to induce neurotrauma. Sensory testing and radiographic analyses were periodically performed. Histopathologic analyses were performed post killing.

RESULTS

DIO mice had significantly higher bodyweights, higher body fat percentages, and lower bone mineral density than wildtype control mice that were fed a normal diet throughout the experiment (P < .001 for each). DIO mice displayed significantly reduced sensory function in week 1 (P = .005) and this worsened over time, requiring 20.6% more force for paw withdrawal by week 10 (P < .001). DIO mice that ran demonstrated greater midfoot subluxation and tarsal instability over all time points compared with normal-diet mice that ran (P < .001). Histopathologic analyses revealed that DIO mice that ran demonstrated significant changes compared with controls that ran (P < .001 for each parameter).

CONCLUSION

Changes akin to the earliest changes observed in or before joint destruction identified in diabetic Charcot neuropathic arthropathy in humans were observed.

CLINICAL RELEVANCE

There is currently no standard of treatment for patients with Charcot neuropathic arthropathy. This study establishes a protocol for an animal model that can be used to study and compare interventions to treat this disease.

Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.

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.

Risk Factors and Outcomes After Surgical Reconstruction of Charcot Neuroarthropathy in Fracture Versus Dislocation Patterns

The primary aim of this study is to compare the preoperative risk factors and postoperative outcomes between Charcot neuroarthropathy patients with dislocation versus purely fracture pattern breakdown. The secondary aim is to compare the same factors between Charcot neuroarthropathy patients with dislocation versus fracture-dislocation pattern breakdown. A total of 55 patients with forefoot, midfoot, or hindfoot Charcot Neuroarthopathy were assessed at a mean follow up of 2.99 years. Bivariate analysis compared preoperative risk factors and postoperative outcomes, and segmented multivariable regression analysis was performed. Dislocation pattern Charcot had statistically significant higher rates of broken hardware (p = .05), mean age (p = .01), and revisional exostectomy (p = .01) compared to pure fracture pattern Charcot. Dislocation pattern Charcot was 12 times more likely to have revisions exostectomy (odds ratio [OR] 12.0, 95% confidence interval [CI] 1.84-78.37), and was 8 times more likely to have osteomyelitis (OR 7.8, 95% CI 1.4-42.7, p = .02) compared to the fracture-dislocation pattern Charcot. The patients with pure fracture pattern Charcot were 58.8 times more likely to have Charcot breakdown involvement of the talonavicular joint compared to the dislocation pattern cohort (OR 58.83, 95% CI 1.1-3220.3). Involvement of the talonavicular joint, in the fracture pattern Charcot associate with medial column collapse occurring at the onset of Charcot breakdown. The dislocation pattern in Charcot Neuroarthropathy demonstrated a higher propensity for residual collapse as demonstrated by the higher rates of broken hardware, osteomyelitis, and need for revisional exostectomy.

Animal model detects early pathologic changes of Charcot neuropathic arthropathy

Charcot neuropathic arthropathy is a degenerative, debilitating disease that affects the foot and ankle in patients with diabetes and peripheral neuropathy, often resulting in destruction, amputation. Proposed etiologies include neurotraumatic, inflammatory, and neurovascular. There has been no previous animal model for Charcot. This study proposes a novel rodent model of induced neuropathic arthropathy to understand the earliest progressive pathologic changes of human Charcot. High-fat-diet-induced obese (DIO) Wild-type C57BL/6J mice (n = 8, diabetic) and age-matched low-fat-diet controls (n = 6) were run on an inclined high-intensity treadmill protocol four times per week for 7 weeks to induce mechanical neurotrauma to the hind-paw, creating Charcot neuropathic arthropathy. Sensory function and radiologic correlation were assessed; animals were sacrificed to evaluate hindpaw soft tissue and joint pathology. With this model, Charcot-DIO mice reveals early pathologic features of Charcot neuropathic arthropathy, a distinctive subchondral microfracture callus, perichondral/subchondral osseous hypertrophy/osteosclerosis, that precedes fragmentation/destruction observed in human surgical pathology specimens. There is intraneural vacuolar-myxoid change and arteriolosclerosis. The DIO mice demonstrated significant hot plate sensory neuropathy compared (P < 0.01), radiographic collapse of the longitudinal arch in DIO mice (P < 0.001), and diminished bone density in DIO, compared with normal controls. Despite exercise, high-fat-DIO mice increased body weight and percentage of body fat (P < 0.001). This murine model of diet-induced obesity and peripheral neuropathy, combined with repetitive mechanical trauma, simulates the earliest changes observed in human Charcot neuropathic arthropathy, of vasculopathic-neuropathic etiology. An understanding of early pathophysiology may assist early diagnosis and intervention and reduce patient morbidity and mortality in Charcot neuropathic arthropathy.

Predictive Radiographic Values for Foot Ulceration in Persons with Charcot Foot Divided by Lateral or Medial Midfoot Deformity

Background: To identify differences in radiographic outcomes in weight-bearing lateral X-ray to predict the probability of ulceration in patients with midfoot Charcot neuroarthropathy (CN) differentiated by lateral and medial column deformities. Methods: Thirty-five patients who suffered from CN midfoot deformity participated in this 1 year prospective study in a specialized diabetic foot unit. Lateral talar-first metatarsal angle, calcaneal pitch, and cuboid height were performed by digital radiographs in the weight-bearing lateral view. Patients were followed up for 1 year or until an ulcer ulceration event occurred in the midfoot region. Results: ROC analyses showed that all patients with medial pattern deformity that developed a midfoot ulcer had a lateral talar-first metatarsal angle greater (negative) than −27.5 degrees (°). All patients with lateral pattern deformity that developed a midfoot ulcer had a calcaneal pitch greater (more negative) than −5° and a cuboid height greater (more negative) than −1.5°. Conclusions: Lateral talar-first metatarsal angle was the greatest predictor of midfoot ulceration, with greater than −27.5° measurement correlating with ulceration occurrence in patients with medial deformity. Calcaneal pitch and cuboid height were the greatest predictors of midfoot ulceration with greater than −5 and −1.5°, respectively in patients with CN lateral deformity.

A fully automatic system to assess foot collapse on lateral weight-bearing foot radiographs: A pilot study

BACKGROUND

Foot collapse is primarily diagnosed and monitored using lateral weight-bearing foot x-ray images. There are several well-validated measurements which aid assessment. However, these are subject to inter- and intra-user variability.

OBJECTIVE

To develop and validate a software system for the fully automatic assessment of radiographic changes associated with foot collapse; automatically generating measurements for calcaneal tilt, cuboid height and Meary's angle.

METHODS

This retrospective study was approved by the Health Research Authority (IRAS 244852). The system was developed using lateral weight-bearing foot x-ray images, and evaluated against manual measurements from five clinical experts. The system has two main components: (i) a Random Forest-based point-finder to outline the bones of interest; and (ii) a geometry-calculator to generate the measurements based on the point positions from the point-finder. The performance of the point-finder was assessed using the point-to-point error (i.e. the mean absolute distance between each found point and the equivalent ground truth point, averaged over all points per image). For assessing the performance of the geometry-calculator, linear mixed models were fitted to estimate clinical inter-observer agreement and to compare the performance of the software system to that of the clinical experts.

RESULTS

A total of 200 images were collected from 79 subjects (mean age: 56.4 years ±12.9 SD, 30/49 females/males). There was good agreement among all clinical experts with intraclass correlation estimates between 0.78 and 0.86. The point-finder achieved a median point-to-point error of 2.2 mm. There was no significant difference between the clinical and automatically generated measurements using the point-finder points, suggesting that the fully automatically obtained measurements are in agreement with the manually obtained measurements.

CONCLUSIONS

The proposed system can be used to support and automate radiographic image assessment for diagnosing and managing foot collapse, saving clinician time, and improving patient outcomes.

Diabetes mellitus and hearing loss: A review

Diabetes (type 2) and sensorineural hearing loss are common health problems manifested with ageing. While both type 1 and type 2 diabetes have been associated with hearing loss, a causal link has been difficult to establish. Individuals with diabetes have twice the incidence of hearing loss compared to those without diabetes and those with prediabetes have a 30% higher rate of hearing loss. Whether hearing loss is associated with diabetes independent of glycemic control remains to be determined. Hearing loss has its own set of risk factors and shares others with diabetes. This review will summarize the complex relationship between diabetes and sensorineural hearing loss.

A Systematic Review of Angular Deformities in Charcot Neuroarthropathy

Charcot neuroarthropathy of the foot and ankle is associated with periarticular deformities and progressive radiographic changes. There have been studies analyzing the radiographic angulations and deformity progression in Charcot neuroarthropathy deformity. The aim of this paper is to provide systematic review of studies that evaluate foot and ankle radiographic parameters in patients with Charcot neuroarthropathy. A multidatabase search including, medline, EMBASE, Google Scholar, Cochrane Library, Clinicaltrials.gov and reference lists of included studies, was performed from 1980 to 2020. A total of 7 articles were included that analyzed radiographic angulations in Charcot neuroarthropathy deformity. The articles could be categorized into nonoperative angulation measurements, and pre- versus postoperative angulation measurements. The presence of ulcerations and the severity of the Charcot neuroarthropathy deformity were found to result from predominantly sagittal plane deformity. The deformity initiates with medial column collapse and progresses to continual lateral column collapse. Surgical intervention resulting in immediate postoperative improvement in angular measurements, however, without beaming of both the medial and lateral column, there was recurrence of the lateral column deformity. This systematic review of articles analyzing angular deformities in Charcot neuroarthropathy patients, demonstrates the progressive sagittal plane breakdown patterns of Charcot as well as the benefits of surgical intervention.

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.

Outcomes of Tendo-Achilles lengthening and weight-bearing total contact cast for management of early midfoot charcot neuroarthropathy

AIM OF STUDY

To report outcomes of tendo-Achilles lengthening (TAL) followed by weight-bearing total contact cast (TCC) in the out-patient setting for patients presented with midfoot Charcot neuroarthropathy (CN) and, develop a new classification system for midfoot CN based on this experience.

PATIENT AND METHODS

Published evidence suggests that tight Achilles-gastrocnemius-soleus complex is the deforming force in the initiation and progression of midfoot CN and TAL has shown to improve the range of ankle dorsiflexion and reduction of midfoot plantar pressures. We utilised this technique in the out-patient setting followed by weight-bearing TCC for all new patients who presented with a diagnosis of midfoot CN from February 2018.We report their outcomes after a 12 months follow-up and propose a new classification system based on the clinical and radiographic parameters.

RESULTS

TAL followed by weight-bearing TCC was performed in 33 feet. In 30 feet, the disease progression either stopped or receded to a lower stage on the new classification system. The procedure was well tolerated by patients in an out-patient setting and there were no reported complications such as wound healing, complete transaction of tendon or deep vein thrombosis. At 12 months follow-up, 30 of 33 pts returned to their pre-procedure level of mobilisation with their usual walking aids or customised shoes. The inter-observer agreement was k = 0.86 for read 1 and k = 0.96 for read 2; and intra-observer agreement ranged from 0.93 to 1.00 for the double read indicating excellent inter-observer and intra-observer agreement.

CONCLUSION

TAL followed by weight-bearing TCC is a safe and well tolerated procedure when performed in an out-patient setting. The Charcot disease of the midfoot slowed in the early stages of midfoot CN and in some cases, receded. The new classification system is easy to use, reliable, reproducible and sensitive enough to detect changes in the disease progression.

Clinical insights into Charcot foot

Charcot neuropathic arthropathy (CN) is a devastating condition resulting in non-reducible foot deformity that places patients with distal peripheral neuropathy at risk for the development of chronic neuropathic foot ulcers, major lower extremity amputation, and even death. The condition is often misdiagnosed early in its presentation because of a lack of knowledge among members of the medical community. Consequently, initial therapies for the condition are fewer and patients who present in more advanced stages of the condition are more difficult to manage. We now understand that CN is a multifactorial process resulting in unregulated osteoclastogenesis and bony destruction. Classically, the patient will present with an edematous, erythematous foot with increased temperature. These non-specific findings lead to a multitude of differential diagnoses. However, there are no diagnostic biomarkers or pathognomonic clinical signs to distinguish this condition from other common foot ailments seen in the context of peripheral neuropathy. Advancing our understanding of this condition, while educating the medical community about its devastating impact, is needed to advance and improve outcomes for patients affected by CN.

Treatment of Ankle and Hindfoot Charcot Arthropathy

It is now well accepted that diabetic patients with clinically and radiographically nonplantigrade Charcot foot arthropathy are best managed with correction of the acquired deformity. Several investigations have demonstrated a high probability for a favorable clinical outcome when the deformity is in the midfoot. Unstable deformity at the subtalar or ankle joints portends a far worse clinical outcome. The goal of this discussion was to describe the author's approach to this highly challenging clinical problem.

An Approach to Managing Midfoot Charcot Deformities

We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.

Charcot Reconstruction: Understanding and Treating the Deformed Charcot Neuropathic Arthropathic Foot

With worsening diet and increasing prevalence of diabetes, patient encounters with Charcot neuropathic arthropathy (CNA) are expected to increase. Without intervention, the pathology progresses with further subluxation/dislocation and fracture, placing soft tissues at risk of preulceration or formal ulceration, infection, and potentially major amputation. The need to avoid amputation is of paramount importance. Although a formal single eradicating tool for CNA is lacking, there is capacity to intervene in ways that may curtail the pace of destruction. This article reviews understanding of the disease process and provides guidance to surgical reconstruction of the deformity.

Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management

Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.

Plantar Approach for Midfoot Wedge Resection to Reconstruct the Rocker Bottom Foot

Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was -25° and improved to -5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot.

Optimizing Results in Diabetic Charcot Reconstruction

Reconstruction of the diabetic Charcot foot can be a challenge even for the most experienced foot and ankle surgeon. The first portion of this article discusses the preoperative evaluation with an emphasis on factors that can be modified before surgical reconstruction to help optimize surgical results. The second portion of the article focuses on intraoperative methods and techniques to help improve postoperative outcomes. Surgeons should strive to provide high-quality, cost-effective care by optimizing patient selection and perioperative care. Objective measures of patient outcomes will become increasingly important with the transition from volume-based to value-based care.

Early Foot Structural Changes After Lateral Column Exostectomy in Patients With Charcot Foot

Although exostectomy for chronic midfoot plantar ulcers in Charcot foot is apparently effective, with healing rates of nearly 75%, a subset of patients develop recurrent ulceration and show an unstable foot position, especially after undergoing exostectomy confined to the lateral column. The reasons for this failure have not been investigated. The main objective of this study was to evaluate the early changes in radiographic alignment after an exostectomy in patients with Charcot neuropathic osteoarthropathy (rocker bottom) and plantar ulcer located in the lateral column. The present study evaluated retrospectively changes in radiographic alignment after an exostectomy in 12 Charcot feet (rocker bottom) with plantar ulcer located in the lateral column. Indication for plantar exostectomy was the treatment of ulcer affected by osteomyelitis. We evaluated the early changes in the alignment of the foot on weight-bearing lateral radiographs 6 months after exostectomy. Paired sample Wilcoxon test was used to calculate the differences between preoperative and postoperative measurements. Furthermore, the relationship between revision surgery and early changes in radiographic angular measurements was determined by using the Mann-Whitney U test. After exostectomy, the inclination of the calcaneal bone decreased ( P = .003; r = 0.849) and declination of talus bone increased ( P = .041; r = 0.589). The change in calcaneal inclination was associated with revision surgery ( P = .042; r = 0.586). The present case series demonstrates that exostectomy procedure for the lateral column in patients with Charcot foot results in radiological changes in the hindfoot over the sagittal plane. The inversion of the calcaneal pitch angle suggests the possibility of further adverse events and the need for revision surgery.

Deformity and Clinical Outcomes Following Operative Correction of Charcot Ankle

BACKGROUND:

Deformity associated with Charcot foot arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following operative correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot foot arthropathy involving the ankle joint.

METHODS:

Fifty-six consecutive patients underwent operative reconstruction of Charcot foot deformity involving the ankle joint by a single surgeon over a 14-year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single-stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years.

RESULTS:

One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty-eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between pre- or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome.

CONCLUSIONS:

Operative correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly comorbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques.

LEVEL OF EVIDENCE:

Level IV, case series.

Reliability of the Measurement of Cuboid Height in Midfoot Charcot Neuroarthropathy

Cuboid height is a quantitative radiographic measurement of the relationship of the inferior cuboid to the plantar osseous plane of the lateral column of the foot and might be associated with poor clinical outcomes in patients with midfoot Charcot neuroarthropathy. We evaluated the reliability of the cuboid height measured by a group of foot and ankle surgeons on subjects with midfoot Charcot neuroarthropathy. Ten board-certified foot and ankle surgeons, 10 residents, and 10 medical students measured the cuboid height on 11 lateral weightbearing radiographic projections of subjects with midfoot Charcot neuroarthropathy. Cuboid height measurements were grouped categorically with calculation of an intraclass correlation coefficient (ICC). Ten unique images were used, with 1 repeated image to provide a measure of intrarater agreement. The overall measure of reliability of cuboid height measurement was an ICC of 0.997. Specifically, the ICC was 0.987 for surgeons, 0.992 for residents, and 0.989 for students. Participants were in agreement with the repeated measure in 24 (80.0%) of 30 cases. Specifically, each group (surgeons, residents, and students) were each in agreement for 8 (80.0%) of 10 repeated measurements. In conclusion, these results demonstrate excellent reliability for radiographic measurement of cuboid height on subjects with midfoot Charcot neuroarthropathy. To the best of our knowledge, this is the first investigation to provide a measure of reliability for this radiographic outcome, which is potentially related to clinical outcomes in the evaluation and treatment of this challenging patient cohort.

Dynamic contrast-enhanced magnetic resonance imaging for differentiating osteomyelitis from acute neuropathic arthropathy in the complicated diabetic foot

OBJECTIVE

The main purpose of this study was to investigate the diagnostic value of dynamic contrast-enhanced MRI (DCE-MRI) in differentiating osteomyelitis from acute neuropathic arthropathy in the diabetic foot.

MATERIALS AND METHODS

This prospective study was carried out on 30 diabetic foot patients, with a mean age of 51 years. The patients all underwent clinical examinations, laboratory examinations and DCE-MRI. The DCE-MRI parameters (K^trans, K_ep and V_e) of the regions of acute neuropathic arthropathy and osteomyelitis were calculated. Receiver operating characteristic curves (ROCs) were used to identify the DCE-MRI parameters that showed the highest accuracy in differentiating the acute neuropathic arthropathy from the osteomyelitic regions. Pearson correlation coefficients were used to assess the correlations among the DCE-MRI parameters, the level of C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR).

RESULTS

The K^trans, K_ep and V_e values of the osteomyelitic regions were higher than those of the acute neuropathic arthropathy regions, and significant differences were found between the two groups (P = 0.000, P = 0.000, P = 0.000). The ROC analysis showed that K^trans and V_e performed best in differentiating osteomyelitis from acute neuropathic arthropathy, both with an area under the curve of 0.938. The Pearson correlation coefficients showed that the DCE-MRI parameters correlated significantly with the level of CRP and ESR (P = 0.000, P = 0.014, P = 0.000; P = 0.000, P = 0.000, P = 0.013).

CONCLUSIONS

Our results showed that DCE-MRI may provide reproducible parameters that can reliably differentiate osteomyelitis from acute neuropathic arthropathy.

Updates on Diabetic Foot and Charcot Osteopathic Arthropathy

PURPOSE OF REVIEW

Diabetes mellitus affects approximately 30.8 million people currently living in the USA. Chronic diabetes complications, including diabetic foot complications, remain prevalent and challenging to treat. We review clinical diagnosis and challenges providers may encounter when managing diabetic foot ulcers and Charcot neuroarthropathy.

RECENT FINDINGS

Mechanisms controlling these diseases are being elucidated and not fully understood. Offloading is paramount to heal and manage diabetic foot ulcers and Charcot neuroarthropathy. Diabetic foot ulcers recur and the importance of routine surveillance and multidisciplinary approach is essential. Several predictors of failure in Charcot foot include a related diabetic foot ulcer, midfoot or rearfoot location of the Charcot event, and progressive bony changes on interval radiographs. Patients with diabetic foot ulcer and/or Charcot neuroarthropathy are in need of consistent and regular special multidisciplinary care. If not diagnosed early and managed effectively, morbidity and mortality significantly increase.

Treatment of complex Charcot foot by single stage surgery with static circular fixation. Case series report

OBJECTIVE

We present a case series report of patients with Charcot foot treated by single-stage surgery with static circular fixation.

MATERIAL AND METHOD

Retrospective review of 10 cases treated with static circular external fixation since 2016, with the following inclusion criteria: 1) Deformity with any of the following: ulcers, osteoporosis, osteomyelitis or instability 2) peripheral neuropathy, 3) failed orthopaedic treatment.

EXCLUSION CRITERIA

1) peripheral vascular obstruction without revascularization, 2) inability to comply with treatment, 3) non-ambulatory patients, 4) medical contraindication for surgery. Of the 10patients, 7men and 3women, 6had involvement of the left foot and 4of the right one. The average age of our patients was 58 years (range 39-71). We also evaluated Eichenholtz and Brodsky classification, presence of ulcers, osteomyelitis and instability. All were treated with circular external fixation with a medium follow up of 17 months (11-24 months). Postoperatively we evaluated limb salvation, ulcer healing, stability and re-ulcerations.

RESULTS

In all patients a functional plantigrade foot was achieved, cutaneous ulcer healed without recurrence. Four cases presented superficial pin infection, solved with local wound care. We had wire ruptures in 2 cases, which did not require replacement. We had a traumatic tibial fracture after frame removal, orthopedically solved. All patients were satisfied and would opt for the same technique, if necessary.

CONCLUSIONS

of the study In Charcot foot, the objectives are to avoid amputation and achieve a functional plantigrade foot, without ulcer. Single-stage surgery with static circular external fixation is reproducible in our country, and also a valid technique for those cases in which internal fixation may not be the best option.

Relationship of Cuboid Height to Plantar Ulceration and Other Radiographic Parameters in Midfoot Charcot Neuroarthropathy

The objective of the present investigation was to examine the effect of cuboid height on the presence of plantar midfoot ulceration and the relationship of cuboid height to other commonly performed radiographic parameters during evaluation of midfoot Charcot neuroarthropathy. A retrospective analysis was performed of 68 feet in 60 subjects who met the inclusion criteria. We did not observe statistically significant differences in the presence of a plantar midfoot ulceration when considering a cuboid height threshold of 0.0 mm, 2.0 mm, -2.0 mm, or -5.0 mm nor was the cuboid height a robust predictor for the presence of plantar midfoot ulceration when considering the positive predictive value, negative predictive value, sensitivity, or specificity. We observed a significant negative association between a negative cuboid height and the presence of Sanders Type 2 deformities (76.2% of those with negative height versus 50.0% of those with positive height had type 2 deformities; p = .0036), the absence of radiographic visualization of the lateral tarsometatarsal joint (71.4% of those with negative height versus 26.9% of those with positive height had an absence of radiographic visualization; p = .005), and lower calcaneal inclination angles (6.06° versus 15.08°; p < .001). We further observed significant positive correlations between the cuboid height and the calcaneal-fifth metatarsal angle (0.655; p < .000), calcaneal inclination angle (0.591; p < .001), calcaneal-cuboid angle (0.254; p = .038), medial column height (0.264; p = .029), and first metatarsal inclination angle (0.245; p = .047). We also observed negative correlations with Meary's angle (-0.475; p < .001) and the talar declination angle (-0.387; p < .001). These findings showed a general trend toward a decreasing cuboid height and increasing sagittal plane deformity involving both the medial and the lateral columns. The results of the present investigation provide evidence against a single radiographic parameter being associated with the presence of plantar midfoot ulceration.

Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment

BACKGROUND

The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life.

METHODS

Over a 12-year period, 214 patients (9 bilateral) underwent reconstruction of the acquired deformity associated with midtarsal Charcot foot arthropathy. Over time, 3 patterns of deformity were observed based on weight-bearing pattern, relationship of the forefoot to the hindfoot, and integrity of the talocalcaneal joint. A valgus deformity pattern was present in 138, varus in 48, and dislocation of the talocalcaneal joint in 37. A consistent operative strategy was employed. Surgery included percutaneous tendon-Achilles lengthening, resection of infection when present, attempted correction of the structural deformity by wedge resection at the apex of the deformity, and immobilization with a 3-level static circular external fixator. Additional deformity pattern-specific procedures were added over time. Clinical outcomes were based on the historic metrics of limb salvage and resolution of infection and the functional metric of the ability to walk with commercially available therapeutic footwear.

RESULTS

Seven patients died within a year of surgery, and 15 underwent partial- or whole-foot amputation. Overall, 173 of 223 feet (77.6%) achieved a favorable clinical outcome. Patients with a valgus deformity pattern were most likely to achieve a favorable clinical outcome (120 of 138, 87.0%). Patients with a dislocation pattern were less likely to achieve a favorable clinical outcome (26 of 37, 70.3%), and those with a varus deformity pattern were least likely to achieve a favorable clinical outcome (27 of 48, 56.3%).

CONCLUSIONS

Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient population. This realistic appreciation of outcome expectations should both be helpful in counseling patients on the risk-benefit ratio associated with surgery and provide a benchmark to measure newer strategies of treatment.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Diagnostic performance of diffusion-weighted MR imaging in differentiation of diabetic osteoarthropathy and osteomyelitis in diabetic foot

PURPOSE

To study the diagnostic performance of diffusion weighted MR imaging in differentiation of diabetic osteoarthropathy and osteomyelitis in diabetic foot.

PATIENTS AND METHODS

This prospective study was carried out on 41 patients with diabetic foot, 22 males and 19 females with mean age of 51 years. They underwent diffusion-weighted MR imaging of the foot. The apparent diffusion coefficient (ADC) values of the bony lesions were calculated by two reviewers and correlated with the surgical findings or biopsy. The kappa statistic (k) was used to estimate the proportion of inter-observer agreement of two reviewers.

RESULTS

The mean ADC of acute diabetic osteoarthropathy was 1.27±0.19×10^-3mm²/s for reviewer 1 and 1.26±0.21×10^-3mm²/s for reviewer 2. The mean ADC value in diabetic osteomyelitis was 0.86±0.11×10^-3mm²/s for reviewer 1 and 0.85±0.12×10^-3mm²/s for reviewer 2. There was excellent inter-observer agreement of ADC value of bony lesions in diabetic foot by both reviewers (K=0.93). There was statistically significant difference in the ADC values of both groups (P=0.001). The cut-off point of ADC value of both reviewers used in differentiating acute diabetic osteoarthropathy and osteomyelitis were 0.98×10^-3mm²/s and 1.04×10^-3mm²/s with an accuracy of 94% and 93% and area under the curve of 0.94 and 0.93 respectively.

CONCLUSION

We conclude that the ADC value is a non-invasive imaging parameter that can help in differentiation of diabetic osteoarthropathy from osteomyelitis with excellent inter-observer agreement.

Comparison of Diabetic Charcot Patients With and Without Foot Wounds

BACKGROUND

The primary aim of this study was to evaluate the outcomes of a series of patients with Charcot neuroarthropathy (CN) who were evaluated in a tertiary care setting. We hypothesized that those patients with CN who presented with a Charcot-related foot wound would have lower rates of successful limb salvage than patients who presented without a wound.

METHODS

Two hundred forty-five patients (280 feet) were identified with diabetic CN during the time period from January 1, 2005, to June 1, 2015. This consecutive cohort of patients was treated by a single surgeon and had a mean age of 57.9 ± 10.0 years. Our CN patients were divided into 2 groups for the purpose of our analysis. Our study group included those patients who presented to our clinic with a Charcot-related foot wound. Our control group was composed of CN patients who presented without a Charcot-related foot wound.

RESULTS

Overall, 78 feet (27.9%) were successfully treated nonoperatively and 202 feet (72.1%) required some type of surgery. Of the 202 feet that received surgery, 22 (10.9%) were not felt to be suitable for reconstruction and underwent a definitive transtibial amputation without an attempt at reconstruction. An additional 18 patients underwent soft tissue surgery, which included drainage of infection, posterior muscle group lengthening, or soft tissue reconstructive flap surgery. The remaining 162 feet underwent osseous surgery, which included ostectomies for osteomyelitis, exostectomies, osteotomies, and arthrodesis. Eighteen of the 180 limbs (10.0%) that underwent soft tissue or osseous reconstruction ultimately required a transtibial amputation, resulting in a successful limb salvage rate of 90.0%. Thirty-five amputations were performed in 164 feet (21.3%) with Charcot-related foot wounds compared with 5 amputations in 116 feet (4.5%) without Charcot-related foot wounds (OR 6.02, 95% CI 2.28-15.91, P < .0001).

CONCLUSION

The presence of a Charcot-related foot wound at presentation increased the likelihood of a major lower extremity amputation by a factor of 6. Other risk factors that were associated with major amputation in patients included active infection at presentation, nonunion/instability after reconstruction, and a postoperative wound problem. The overall rate of successful limb salvage in patients deemed reconstructive candidates was 90%.

LEVEL OF CLINICAL EVIDENCE

Level III, retrospective, case-control study.

Circular External Fixation as a Primary or Adjunctive Therapy for the Podoplastic Approach of the Diabetic Charcot Foot

Numerous techniques have been described for surgical management of the diabetic Charcot foot. External fixation has become a main surgical tool for the reconstructive foot and ankle surgeon when dealing with the ulcerated diabetic Charcot foot. In the presence of an open wound and/or osteomyelitis, staged reconstruction with circular external fixation becomes ideal for salvage of the diabetic lower extremity. Also, circular external fixation can provide simultaneous compression and stabilization, correct the underlying osseous or soft tissue deformities, and surgically offload the diabetic Charcot foot. This article describes a variety of circular external fixation applications for the diabetic Charcot foot.

Medical Imaging in Differentiating the Diabetic Charcot Foot from Osteomyelitis

Diabetic Charcot neuroarthropathy (DCN) poses a great challenge to diagnose in the early stages and when plain radiographs do not depict any initial signs of osseous fragmentation or dislocation in a setting of a high clinical index of suspicion. Medical imaging, including magnetic resonance imaging, computed tomography, and advanced bone scintigraphy, has its own unique clinical indications when treating the DCN with or without concomitant osteomyelitis. This article reviews different clinical case scenarios for choosing the most accurate medical imaging in differentiating DCN from osteomyelitis.

Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction

Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group.

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Charcot Neuroarthropathy in Patients With Diabetes: An Updated Systematic Review of Surgical Management

Charcot neuroarthropathy (CN) of the foot and ankle is a demanding clinical dilemma, and surgical management can be very complicated. Historically, the evidence guiding surgical management of CN has been small retrospective case series and expert opinions. The purpose of the present report was to provide a systematic review of studies published from 2009 to 2014 and to review the indications for surgery. A Medline search was performed, and a systematic review of studies discussing the surgical management of CN was undertaken. Thirty reports fit the inclusion criteria for our study, including 860 patients who had undergone a surgical procedure for the treatment of CN. The surgical procedures included amputation, arthrodesis, debridement of ulcers, drainage of infections, and exostectomy. The midfoot was addressed in 26.9% of cases, the hindfoot in 41.6%, and the ankle in 38.4%. Of the 30 studies, 24 were retrospective case series (level 4), 4 were controlled retrospective studies (level 3), and 2 were level II studies. The overall amputation rate was 8.9%. The quality of the published data on the surgical management of CN has improved during the past several years. Evidence concerning the timing of treatment and the use of different fixation methods remains inconclusive.

Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates

INTRODUCTION

Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates.

MATERIALS/METHODS

21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis.

RESULTS

A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially.

CONCLUSION

Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.