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

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint

INTRODUCTION

Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge.

METHODS

This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score.

RESULTS

Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002).

CONCLUSION

This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.

Alteration of the calf strength by heel cord lengthening, gastrocnemius recession through tenotomy or fasciotomy. A retrospective clinical force analysis before and after surgery

BACKGROUND

Indications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called 'functional pes equinus' and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension.

METHODS

This study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended.

RESULTS

The operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant CONCLUSION: A correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established.

LEVEL OF EVIDENCE

Level III: retrospective cohort study.

Management of the Charcot Foot and Ankle: Nonreconstructive Surgery

Diabetic neuroarthropathy is a complication of diabetes mellitus that results in instability of the foot, structural deformity, and soft-tissue breakdown. Commonly, midfoot collapse of the medial, lateral, or both longitudinal arches may result in increased plantar pressures and subsequent midfoot ulceration. Many of these wounds can be successfully managed with local wound care and off-loading; however, surgical intervention becomes necessary in cases of osteomyelitis or when the wound fails to heal despite conservative efforts. In cases where surgical reconstruction may not be indicated, nonreconstructive surgical efforts have shown effectiveness in resolving wounds and allowing patients to return to ambulatory lifestyles. This article serves as an update to current treatment recommendations for the nonreconstructive surgical management of Charcot neuroarthropathy.

The Use of Hexapod External Fixation in the Management of Charcot Foot and Ankle Deformities

Charcot neuroarthropathy (CN) and its sequela is a disabling pathology in the foot and ankle. The 2-stage computer hexapod-assisted technique is an effective tool to address midfoot Charcot and ankle-hindfoot deformities to restore function and decrease the risk of amputation secondary to ulceration and infection. Although this is not the only technique available, it is an excellent option in cases with significant angular deformity or subluxation, need to reduce shortening of the foot, and in the presence of soft tissue defects, with or without concurrent soft tissue or bone infection.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy

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

Changes in Muscle Morphology Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Cohort Imaging Study

Background. The purpose of this study was to evaluate changes in posterior compartment muscle volume and intramuscular fat content following gastrocnemius recession in people with Achilles tendinopathy (AT). Methods. Eight patients diagnosed with unilateral recalcitrant AT and an isolated gastrocnemius contracture participated in this prospective cohort study. Magnetic resonance imaging was performed on both limbs of each participant before and 6 months following an isolated gastrocnemius recession. Involved limb muscle volumes and fat fractions (FFs) of the medial gastrocnemius, lateral gastrocnemius, and soleus muscle were normalized to the uninvolved limb. Preoperative to postoperative comparisons were made with Wilcoxon signed-rank tests. Results. Soleus or lateral gastrocnemius muscle volumes or FFs were not significantly different between study time points. A significant difference was found in medial gastrocnemius muscle volume (decrease; P = .012) and FF (increase; P = .017). Conclusion. A major goal of the Strayer gastrocnemius recession, selective lengthening of the posterior compartment while preserving soleus muscle morphology, was supported. The observed changes isolated to the medial gastrocnemius muscle may reduce ankle plantarflexion torque capacity. Study findings may help inform selection of surgical candidates, refine anticipated outcomes, and better direct postoperative rehabilitation following gastrocnemius recession for AT.Levels of Evidence: Level IV: Prospective cohort study.

Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review

OBJECTIVE

A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes.

METHOD

A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded.

RESULTS

A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction.

CONCLUSION

Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.

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.

Gastrocnemius tightness: A population based observational study

BACKGROUND

Gastrocnemius tightness is believed to be associated with multiple musculoskeletal pathologies such as back pain, plantar fasciitis and metatarsalgia. Although surgical treatment of gastrocnemius tightness is gaining popularity the objective definition of a gastrocnemius contracture has not been determined. The aim of our study was therefore to quantify gastrocnemius tightness in a normal population.

METHODS

Adult participants with no obvious foot and ankle pathology were recruited. Gastrocnemius tightness was quantified using a weightbearing lunge test. Maximal ankle-foot dorsiflexion was measured on participants with the knee in full extension and flexed to 20° using a digital inclinometer. The ankle-foot dorsiflexion index or ADI (difference in ankle dorsiflexion with the knee extended and flexed) was calculated. The ADI values were plotted on a histogram to identify the distribution of values and were compared according to participant demographics.

RESULTS

800 limbs from 400 participants were examined. There was a wide distribution of absolute values of maximal ankle-foot dorsiflexion ranging from 8 to 52°. The ADI ranged from 0 to19° and approximated to a normal distribution. The mean ADI was 6.04±3.49° and was positively correlated with age (r=0.132, P<0.001) and negatively correlated with physical activity (r=-0.88, P=0.015).

CONCLUSION(S)

Our study is the first to quantify gastrocnemius tightness in a large healthy adult population with differences observed by age and physical activity. We have defined an easy and reproducible weightbearing test that can be used in both research and clinical settings. The majority of the population have some degree of gastrocnemius tightness and values of ADI greater than 13° (>2 SD of the mean), as measured by the lunge test, may be considered abnormal.

Lengthen, Alignment, and Beam Technique for Midfoot Charcot Neuroarthropathy

Charcot neuroarthropathy is a disabling pathology in the foot and ankle. Midfoot Charcot is most common and results in progressive deformity. We describe a 2-step approach to surgical reconstruction, referred to as the lengthen, alignment, and beam technique. There is an initial surgery involving acute equinus correction through Achilles tendon lengthening and gradual correction with hexapod external fixation to align the deformity, followed by minimally invasive medial and lateral column beaming. This surgical protocol allows for adequate reduction of deformity. The second stage allows for rigid intramedullary fixation extending beyond the pathologic joints via a minimally invasive technique.

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.

Surgical Correction of the Achilles Tendon for Diabetic Foot Ulcerations and Charcot Neuroarthropathy

Achilles tendon pathologic conditions are implicated in contributing to the development of many diabetic foot complications including diabetic foot ulceration and Charcot neuroarthropathy. Surgical correction of the diabetic equinus deformity has been studied as an isolated or adjunctive treatment when dealing with difficult-to-close diabetic foot ulcerations or when surgically addressing the diabetic Charcot neuroarthropathy foot or ankle. This article reviews the most common indications, complications, and surgical procedures for equinus correction by either a tendo-Achilles lengthening or gastrocnemius recession for the management of diabetic foot conditions.

Gastrocnemius Contracture in Patients With and Without Foot Pathology

BACKGROUND

Several studies report performing a recession of the gastrocnemius tendon as surgical treatment of foot and ankle pain related to an isolated gastrocnemius contracture. Few report ankle range of motion using a validated measurement device or report a control group. All previous studies reporting measurements using a validated device have been small in number.

METHODS

Using a previously validated device, 66 patients presenting with foot or ankle pain and 66 controls were measured for ankle range of motion and isolated gastrocnemius contractures. Clinical and goniometer measurement of ankle range of motion was also performed.

RESULTS

The foot and ankle pain group had a mean dorsiflexion of 11.6 degrees compared with a mean of 17.2 degrees in the control group (P < .0001). No patients in either group had less than 15 degrees of motion with the knee flexed. The difference in dorsiflexion was less using a goniometer than using the validated device, which may be due to measurement technique and external landmarks.

CONCLUSION

Patients with foot and ankle pain had less ankle dorsiflexion than the control group. This is the largest study to date using a validated measurement device as well as a control group and supports the findings of previous authors.

LEVEL OF EVIDENCE

Level II, prospective cohort study.