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Kavarthapu V, Haldar A. Reconstruction of unstable ankle charcot deformity using a 3-D printed titanium porous block and hindfoot nail - A case report. Foot (Edinb) 2024; 60:102116. [PMID: 39047358 DOI: 10.1016/j.foot.2024.102116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 06/11/2024] [Accepted: 06/22/2024] [Indexed: 07/27/2024]
Abstract
Charcot neuroarthropathy (CN) of the ankle joint can cause marked bone resorption of the talus resulting in severe deformity and instability. The utilisation of a 3-D printed bespoke titanium porous block that allows the use of an intramedullary calcaneo-tibial nail is an attractive option in such cases that has been reported for use in post-trauma deformities, following tumour resections, in avascular necrosis of talus and for revision of failed total ankle replacements, however has not previously been reported for Charcot ankle reconstructions. We present a novel case and surgical technique illustrating the use of a 3-D printed titanium porous block and hindfoot nail for reconstruction of a deformed and unstable Charcot hindfoot.
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Affiliation(s)
- Venu Kavarthapu
- Consultant Orthopaedic Surgeon, Dept of Trauma & Orthopaedics, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
| | - Anil Haldar
- Senior Fellow Trauma and Orthopaedics, Dept of Trauma & Orthopaedics, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Kavarthapu V, Giddie J, Kommalapati V, Casey J, Bates M, Vas P. Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction. J Clin Med 2023; 12:jcm12093239. [PMID: 37176679 PMCID: PMC10179343 DOI: 10.3390/jcm12093239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m2 (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.
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Affiliation(s)
- Venu Kavarthapu
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Jasdeep Giddie
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Varun Kommalapati
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Joanne Casey
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Maureen Bates
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Prashanth Vas
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
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Bajuri MY, Manas AM, Zamri KS. Functional outcomes of tibiotalocalcaneal arthrodesis using a hindfoot arthrodesis nail in treating Charcot's arthropathy deformity. Front Surg 2023; 9:862133. [PMID: 36743890 PMCID: PMC9895943 DOI: 10.3389/fsurg.2022.862133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023] Open
Abstract
Background Tibiotalocalcaneal arthrodesis or hindfoot fusion is a salvage surgical option used to treat symptomatic or severe deformity as a result of Charcot's arthropathy. It is an internal fixation that utilizes nails to stabilize the hindfoot after surgical correction of the deformity. This study intends to measure the change in functional outcomes of patients with Charcot's arthropathy using this technique and the time taken to achieve fusion. Method This study presents a series of 40 cases of Charcot's arthropathy where hindfoot fusion was done using a hindfoot arthrodesis nail. A retrospective analysis was done where these patients' functional scores had been evaluated preoperatively and postoperatively (serially) with the Short-Form Health Survey 36 (SF-36), American Orthopedic Foot and Ankle Society (AOFAS), Foot and Ankle Outcome Score (FAOS), and Foot Function Index (FFI). Along with its complication, the length of time required for the fusion is also reported. Results This study consists of 40 patients (13 men, 27 women; mean age 60.5 years; age range 52-68 years) with a mean follow-up of 64 months (range 24-108 months). The mean time taken for fusion was 5.1 months. All patients showed improvement in functional scoring (SF-36, AOFAS, FFI, and FAOS) postoperatively. We establish that the improvements were gradual over 2 years. Approximately 37.5% of patients had a minor complication and 2.5% had a major complication. Conclusion Hindfoot fusion using a hindfoot arthrodesis nail results in improved functional outcome with an acceptable fusion time and acceptable complication rate. Level of evidence Level III.
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Morasiewicz P, Dejnek M, Orzechowski W, Szelerski Ł. Subjective and Objective Outcomes of Ankle Joint Arthrodesis with Either Ilizarov or Internal Fixation. J Foot Ankle Surg 2022; 62:39-44. [PMID: 35450767 DOI: 10.1053/j.jfas.2022.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 03/18/2022] [Accepted: 03/26/2022] [Indexed: 02/03/2023]
Abstract
After arthroplasty, arthrodesis of the ankle joint is the most common method to treat advanced ankle osteoarthritis. The goal of the study was to assess the subjective and objective outcomes in 2 different types of fixation for ankle joint arthrodesis. We retrospectively assessed 47 patients who had undergone ankle joint arthrodesis with fixation either via an Ilizarov apparatus (group 1) (n = 21) or cannulated screws (group 2) (n = 26). The outcomes were measured by: (1) the quantity of analgesics administered, (2) the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) general patient satisfaction, (4) the patients' decision to undergo the same procedure given another chance, and (5) the necessity of blood transfusion during hospitalization. Data was collected at the last postoperative follow-up visit. The AOFAS scores in group 1 and group 2 patients were 73.9 ± 13 and 72.7 ± 14.3, respectively. In group 1, 17 patients (81%) were very satisfied with the results, while in group 2, 19 patients (73%) were very satisfied with the results (p = .043). Two group 1 patients (10%) and four group 2 patients (15.3%) reported that they were satisfied with the outcomes (p = .035). Two patients (10%) from group 1 and three patients (11%) from group 2 were fairly satisfied. Seventeen patients (81%) after arthrodesis with Ilizarov fixation and 21 patients (81%) after arthrodesis with internal fixation would choose the same procedure given the opportunity to choose again. In group 1 there were no patients who required blood transfusion; in group 2 one patient (4%) required blood transfusion; the difference was statistically significant (p = .039). Nineteen group 1 patients (90%) were administered an analgesic preoperatively, while postoperatively only 6 (29%) required analgesics. In group 2, 24 patients (92%) were administered analgesics preoperatively, with 8 (31%) of them still requiring analgesics postoperatively. Ankle arthrodesis patients from both group 1 and group 2 achieved good subjective and objective results of treatment. We noted slightly better results in the Ilizarov apparatus group.
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Affiliation(s)
- Piotr Morasiewicz
- Department of Orthopedic and Trauma Surgery, University of Opole, University Hospital in Opole, Institute of Medical Sciences, Opole, Poland; Wroclaw Medical University, Department and Clinic of Orthopedic and Traumatologic Surgery, Wrocław, Poland.
| | - Maciej Dejnek
- Wroclaw Medical University, Department and Clinic of Orthopedic and Traumatologic Surgery, Wrocław, Poland; Wroclaw Medical University, Department of Trauma and Hand Surgery, Wroclaw, Poland
| | - Wiktor Orzechowski
- Wroclaw Medical University, Department and Clinic of Orthopedic and Traumatologic Surgery, Wrocław, Poland
| | - Łukasz Szelerski
- Medical University of Warsaw, Department of Orthopedics and Musculoskeletal Traumatology, Warsaw, Poland
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Rosemberg DL, Sposeto RB, Godoy-Santos AL. Arthrodesis in the Deformed Charcot Foot. Foot Ankle Clin 2022; 27:835-846. [PMID: 36368800 DOI: 10.1016/j.fcl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Charcot neuroarthropathy (CN) is a systemic disease that causes fractures, dislocations, and deformities involving the foot and ankle, resulting in substantial risk of ulceration, infection, and function loss. Early recognition and prevention of collapsing foot and ankle are still the best options for the management of patients with diabetic CN. For a successful arthrodesis procedure, the principles of adequate joint preparation, deformity correction, and soft tissue protection and care are essentials, associated with robust fixation (internal and/or external), use of different biological graft options in segmental losses, and prolonged off-loading.
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Affiliation(s)
- Dov Lagus Rosemberg
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Dr. Ovídio Pires de Campos, 333 - Cerqueira César, São Paulo, São Paulo 05403-010, Brazil; Hospital Israelita Albert Einstein, São Paulo, Av. Albert Einstein, 627/701 - Morumbi, São Paulo - SP, 05652-900, Brazil; International Scholar at the Midwest Orthopedics at Rush (MOR), 1620 W. Harrison St., Chicago, IL, 6012, USA; RUSH-IBTS International Fellowship Program, 1620 W. Harrison St., Chicago, IL, 6012, USA.
| | - Rafael Barban Sposeto
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Dr. Ovídio Pires de Campos, 333 - Cerqueira César, São Paulo, São Paulo 05403-010, Brazil
| | - Alexandre Leme Godoy-Santos
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Dr. Ovídio Pires de Campos, 333 - Cerqueira César, São Paulo, São Paulo 05403-010, Brazil; Hospital Israelita Albert Einstein, São Paulo, Av. Albert Einstein, 627/701 - Morumbi, São Paulo - SP, 05652-900, Brazil
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Hester T, Kavarthapu V. Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy. Foot Ankle Clin 2022; 27:583-594. [PMID: 36096553 DOI: 10.1016/j.fcl.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.
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Affiliation(s)
- Thomas Hester
- Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Venu Kavarthapu
- Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Muacevic A, Adler JR. Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing. Cureus 2022; 14:e28036. [PMID: 36120283 PMCID: PMC9473675 DOI: 10.7759/cureus.28036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 01/26/2023] Open
Abstract
Introduction The treatment for severe fixed hindfoot osteoarthritis secondary to Charcot-Marie-Tooth disease (CMT) is tibiotalocalcaneal (TTC) arthrodesis. In our centre, we have noticed a disproportionate rate of periprosthetic fractures in CMT patients following TTC arthrodesis with retrograde hindfoot nailing. The aim of this study was to test this hypothesis by evaluating our local cohort of TTC arthrodesis with retrograde hindfoot nailing. Methods A retrospective review of patients who had TTC arthrodesis with intramedullary nailing was conducted over a seven-year period. Results There were 45 patients (30 male, 15 female) in our cohort. Forty-one patients achieved radiological and clinical fusion of their TTC arthrodesis. All three patients who had CMT sustained periprosthetic fracture at the tip of the nail at an average of four (range: 2.5-6) months from index operation. In comparison, no patients in the rest of the cohort sustained periprosthetic fractures. The nail position of the patients with CMT was central in both planes in all three patients. None of the patients with CMT had abutment of the cortex on either plane. Conclusion We found that there was a disproportionate rate of periprosthetic fractures in CMT patients in our cohort of TTC arthrodesis with retrograde hindfoot nailing. This suggests that CMT is a significant risk factor. The authors propose a longer nail to reduce the lever arm, with a long period of protected weight bearing till union, followed by consideration of elective removal of the nail to prevent this phenomenon from occurring.
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Nsekpong TB, Amin AS, Ali SR, Beasley BJ, Panchbhavi V, Jupiter DC. Comparative Analysis of Secondary Outcomes in Treatment of Charcot Neuropathy: A Systematic Review. Foot Ankle Spec 2022:19386400221106635. [PMID: 35778875 DOI: 10.1177/19386400221106635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) is commonly associated with diabetic neuropathy and can predispose patients to amputations. Management remains a challenge, with no definitive treatment. This study examines major postoperative complications associated with open reduction with internal (intramedullary) nails, fixation, external fixation, or combined internal and external fixation for correction of the deformity. METHODS We reviewed available literature using PubMed, OvidSP, Scopus, and Cochrane and searched bibliographies of the included studies to identify additional pertinent references. After review and agreement among 4 raters, a total of 15 studies were included in this analysis. RESULTS Hardware removal rates were 0.133 for intramedullary nails, 0.007 for external fixators, and 0.050 for combined fixation. Rates of hardware complication were 0.182 for intramedullary nails and 0.007 for external fixators. Wound dehiscence occurred at rates of 0.059 for intramedullary nails and 0.216 for combined fixation. The rate of deep infections was 0.031 for intramedullary nails, 0.032 for external fixators, and 0.113 for combined fixation. The rate of irrigation and debridement was 0.007 for external fixators. CONCLUSION Rates of hardware removal (13.3%) and complications (18.2%) were high with intramedullary nails. Dehiscence (21.6%) and deep infection (11.3%) were high in combined fixation. Other complications occurred relatively rarely. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Atish S Amin
- The University of Texas Medical Branch, Galveston, Texas
| | - Shahrukh R Ali
- The University of Texas Medical Branch, Galveston, Texas
| | | | - Vinod Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Daniel C Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, Texas
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Chalak A, Singh S, Ghodke A, Kale S, Hussain J, Mishra R. Ilizarov Ankle Arthrodesis: A Simple Salvage Solution for Failed and Neglected Ankle Fractures. Indian J Orthop 2022; 56:1587-1593. [PMID: 36052393 PMCID: PMC9385916 DOI: 10.1007/s43465-022-00669-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Infection around the ankle joint after fracture fixation, or septic arthritis with active discharging sinuses is often challenging to manage with conventional procedures of arthrodesis. The Ilizarov method of arthrodesis gives a better alternative for salvage in such cases. METHODS This was a retrospective study including 20 patients who were subjected to tibiotalar arthrodesis with Ilizarov method. The major pathologies included internal fixation of ankle fractures complicated by infection, posttraumatic infected ankle arthritis, and osteomyelitis. The patients were evaluated on the basis of Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. The aim of the surgery was to achieve plantigrade, stable, and painless foot with no signs of infection. RESULTS A total of 20 patients were operated and reviewed at our institute. The study comprised of 15 male and 5 female patients with a mean age of 43.9 years (range 33-55 years). Out of 20 patients, 4 patients had complications of pin-tract infection and one had wire breakage of the forefoot ring. According to the ASAMI criteria, 17 patients had excellent bone scores and 18 patients had good functional scores. Union was achieved in all patients with resolution of infection and the mean limb length discrepancy was 1.92 cm (range 1-2.5 cm). CONCLUSIONS The Ilizarov fixator for ankle arthrodesis provides an excellent way for strong bone fusion, infection eradication, early weight-bearing, and the added benefits of compression at the arthrodesis site post-operatively.
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Affiliation(s)
- Ajit Chalak
- Department of Orthopaedics, Dr. D Y Patil Medical College and Hospital, Sector 7, Nerul, Navi Mumbai, Maharashtra 400706 India
| | - Sushmit Singh
- Department of Orthopaedics, Dr. D Y Patil Medical College and Hospital, Sector 7, Nerul, Navi Mumbai, Maharashtra 400706 India
| | - Ashok Ghodke
- Department of Orthopaedics, MGM Medical College Hospital, Kamothe, Navi Mumbai, India
| | - Sachin Kale
- Department of Orthopaedics, Dr. D Y Patil Medical College and Hospital, Sector 7, Nerul, Navi Mumbai, Maharashtra 400706 India
| | - Javed Hussain
- Department of Orthopaedics, Dr. D Y Patil Medical College and Hospital, Sector 7, Nerul, Navi Mumbai, Maharashtra 400706 India
| | - Ronak Mishra
- Department of Orthopaedics, Dr. D Y Patil Medical College and Hospital, Sector 7, Nerul, Navi Mumbai, Maharashtra 400706 India
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Najefi AA, Zaidi R, Chan O, Hester T, Kavarthapu V. Predictors of metalwork failure and nonunion after hindfoot Charcot reconstruction. Bone Joint J 2022; 104-B:703-708. [PMID: 35638210 DOI: 10.1302/0301-620x.104b6.bjj-2022-0127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. METHODS We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded. RESULTS There were 70 patients with mean follow-up of 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). CONCLUSION Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703-708.
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Affiliation(s)
- Ali-Asgar Najefi
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Razi Zaidi
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Oliver Chan
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Thomas Hester
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Venu Kavarthapu
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
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Bajuri MY, Ong SL, Das S, Mohamed IN. Charcot Neuroarthropathy: Current Surgical Management and Update. A Systematic Review. Front Surg 2022; 9:820826. [PMID: 35345422 PMCID: PMC8957099 DOI: 10.3389/fsurg.2022.820826] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCharcot neuroarthropathy of the ankle and the hindfoot is a complex clinical entity with a high risk of amputation. Charcot neuroarthropathy limb reconstruction has been proposed as a limb-salvaging procedure. However, there was a lack of information on the various available reconstruction methods, including the outcomes and complications. The present study aimed to evaluate the current literature and update on the trends regarding the surgical management of Charcot neuroarthropathy of the ankle and the hindfoot.MethodsAll data published from January 2010 to January 2020 that investigated the methods of fixation and their respective outcomes for the surgical reconstruction in Charcot neuroarthropathy were analyzed. The union rate, amputation rates, and complications associated with these techniques were taken for statistical analysis.ResultsA total of 16 studies fit the inclusion criteria of this study, with four Level-III studies and 12 Level-IV studies were included. Ten studies utilized internal fixation only; five used a combination of internal fixation and circular external fixator, whereby there are three comparative studies between internal and external fixations, and two studies applied combined technique of internal and external fixations (hybrid fixation). One study describes the usage of circular external fixation only.ConclusionsThe use of retrograde intramedullary nail as a treatment of choice in the reconstruction of Charcot neuroarthropathy ankle is recommended before an ulcer occurrence. Hydroxyapatite (HA)- coated screws are recommended for the locking mechanism to prevent migration in Charcot neuroarthropathy due to poor bony quality. Hybrid fixation is recommended for reconstruction in a condition of ulceration and more complex deformity as it provides a higher rate of limb salvage with less soft tissue irritation.
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Affiliation(s)
- Mohd Yazid Bajuri
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
- *Correspondence: Mohd Yazid Bajuri
| | - Shir Lee Ong
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Srijit Das
- Department of Human Clinical Anatomy, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Isa Naina Mohamed
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Management of Ankle Charcot Neuroarthropathy: A Systematic Review. J Clin Med 2021; 10:jcm10245923. [PMID: 34945220 PMCID: PMC8707751 DOI: 10.3390/jcm10245923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Charcot neuroarthropathy is a non-infective, destructive process occurring in patients rendered insensate by peripheral neuropathy, which is caused mainly by diabetes. Repetitive trauma from standing and walking provides a neuro-traumatic stimulus that leads to dislocation, or peri-articular fracture, or both, within the ankle. This review concentrates on the management protocols regarding the ankle only. Methods: A Pubmed search for clinical trials performed to manage ankle Charcot neuroarthropathy and a systematic review of these articles were undertaken. Results: Twenty papers met the inclusion criteria: four of them describe non-surgical management, while the rest show different surgical management options of ankle Charcot neuroarthropathy. Conclusions: Surgical algorithms for the treatment of CN of the ankle are based almost entirely on level four. There is inconclusive evidence concerning the timing of treatment and the use of different fixation methods. Instability and ulceration are the main precursors for surgical interventions. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.
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13
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Moonot P, Sharma G, Kadakia A. Functional outcome in patients with Charcot neuropathy with almost complete loss of talus treated by tibio-talo calcaneal nail: A cross-sectional study. Foot (Edinb) 2021; 49:101833. [PMID: 34687980 DOI: 10.1016/j.foot.2021.101833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 04/30/2021] [Accepted: 05/22/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Tibio-talo-calcaneal (TTC) fusion is a successful surgery for Charcot neuropathy affecting the hindfoot. A case series of Charcot neuropathy is presented with almost complete loss affecting hindfoot treated with tibio-talo-calcaneal nail. MATERIAL AND METHODS Seven patients with Charcot neuropathy of the hindfoot having varying degrees of talus loss underwent tibio-talo-calcaneal nailing between January 2014 and Feb 2016 at a tertiary care hospital by a single surgeon. All the patients were type 3a as per Brodsky classification. Patients with active infection, fractures and avascular necrosis of talus was excluded from the study. The final outcome was measured using the AOFAS and FADI scores at the end of 2 years. RESULTS The mean duration of diabetes was 8.16 ± 3.12 years. Two patients (28.6%) had total and 5 (71.4%) patients had subtotal talus loss. Anterior approach was used in four, and lateral approach was used in three cases respectively. The talus was reconstructed by using the iliac crest or the graft from the distal fibula wherever appropriate. The average surgical duration was 93.28 ± 4.84 min. One patient had deep infection, 2 years after the surgery which was treated by implant removal and antibiotics. No patients had non-union. The pre-operative AOFAS scores improved from 32.2 ± 2.58 to 73.4 ± 3.36 at 2-year follow-up (p < 0.0001). Similarly, the pre-operative FADI scores were 31.74 ± 1.98 which improved to 65.94 ± 3.68 at the end of 2 years (p < 0.0001). CONCLUSION Retrograde tibio-talo-calcaneal nail is a good option for limb salvage in patients with severe talus loss with good functional outcome. LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Pradeep Moonot
- Mumbai Knee Foot Ankle clinic & Sir HN Reliance foundation hospital, Prarthana samaj, Girgaon, Mumbai-400004, India.
| | - Gaurav Sharma
- Department of Orthopaedics, Mahatma Gandhi Mission Institute of Medical Sciences, Kamothe, Navi-Mumbai 410209, Maharashtra, India.
| | - Anish Kadakia
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
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14
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Rana B, Patel S. Results of Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy - A retrospective analysis of 44 patients. J Clin Orthop Trauma 2021; 23:101637. [PMID: 34824972 PMCID: PMC8600528 DOI: 10.1016/j.jcot.2021.101637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 07/26/2021] [Accepted: 10/08/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The role of arthrodesis as a salvage procedure in Diabetic Charcot Neuroarthropathic deformities of the Foot and Ankle is controversial due to relatively high complication rates reported in literature. We intend to present our experience with a retrospective analysis of Ankle and Hindfoot arthrodesis in deformities due to Diabetic Charcot Neuroarthropathy. STUDY DESIGN A retrospective observational analysis of selected Diabetic Neuropathic Ankle and Hindfoot cases operated at a single centre. PATIENTS AND METHODS In a study duration extending 7.5 years, 46 operated sites in 44 patients were included in the study. These patients were treated by one of the following procedures: Tibiotalocalcaneal arthrodesis, Pantalar arthrodesis, Ankle arthrodesis, Triple arthrodesis and isolated subtalar arthrodesis. The results were analysed with regard to wound healing and its complications, clinical and radiological progress of union and non-union rates and deformity correction (i.e. whether a plantigrade foot could be achieved and a standard foot wear could be worn post correction). RESULTS There were four superficial and two deep infections (13%). Symptomatic radiological non-union at one or more joints was seen in 12 cases (26%). Thirty cases united primarily (65%) and showed radiological fusion at an average time of 6.8 months post-surgery. Four cases (8.5%) had asymptomatic radiological partial non union at one or more joints but showed clinical union. Five patients (8.3%) had a low energy spiral fracture of the tibia proximal to the locking plate used for TTC fusion. Complete deformity correction with plantigrade foot was achieved in 32 cases (69.5%). CONCLUSION Despite a high complication rate associated with Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy, an eventually successful fusion can be achieved in two-third patients.
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Affiliation(s)
- Balvinder Rana
- Max Super Specialty Hospital, Press Enclave Marg, Saket, New Delhi and Max Hospital, B Block, Sushant Lok, Gurgaon, Haryana, 122001, India,Corresponding author.
| | - Sandeep Patel
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160012, India
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15
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Kavarthapu V, Budair B. Two-stage reconstruction of infected Charcot foot using internal fixation : a promising functional limb salvage technique. Bone Joint J 2021; 103-B:1611-1618. [PMID: 34587806 DOI: 10.1302/0301-620x.103b10.bjj-2021-0339.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. METHODS We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months' follow-up. RESULTS We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. CONCLUSION Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of 'long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion' is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611-1618.
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Affiliation(s)
- Venu Kavarthapu
- Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, UK.,University of Southern Denmark, Odense, Denmark
| | - Basil Budair
- Trauma & Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Aston University School of Engineering and Applied Science, Birmingham, UK
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16
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Martin B, Chow J. The use of circular frame external fixation in the treatment of ankle/hindfoot Charcot Neuroarthropathy. J Clin Orthop Trauma 2021; 16:269-276. [PMID: 33717964 PMCID: PMC7932891 DOI: 10.1016/j.jcot.2021.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Brian Martin
- Nepean Foot and Ankle Reconstruction Unit, Nepean Hospital, Derby Street, Kingswood, 2747, NSW, Australia
| | - Jason Chow
- Nepean Foot and Ankle Reconstruction Unit, Nepean Hospital, Derby Street, Kingswood, 2747, NSW, Australia
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17
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Liu K, Cai F, Liu Y, Abulaiti A, Ren P, Yusufu A. Risk factors of ankle osteoarthritis in the treatment of critical bone defects using ilizarov technique. BMC Musculoskelet Disord 2021; 22:339. [PMID: 33836698 PMCID: PMC8035717 DOI: 10.1186/s12891-021-04214-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/30/2021] [Indexed: 01/18/2023] Open
Abstract
Background Distraction osteogenesis using the Ilizarov external circular fixator has been applied in lower limb reconstructive surgery widely. The increasing ankle osteoarthritis (OA) progression and severity are often associated with the period of external fixator and the greater relative instability of the ankle joint, but few studies have quantified risk factors directly during this technique. Methods The study was conducted on 236 patients who underwent bone transport surgery for tibias using the Ilizarov external circular fixator from 2008 to 2018. The cumulative incidence of ankle OA diagnoses in patients after the Ilizarov technique treatment was calculated and stratified by risk factors from preoperative and postoperative management. After the data were significant through the Mann-Whitney U test analyzed, odds ratios were calculated using logistic regression to describe factors associated with the OA diagnosis including gender, age, BMI, location of bone defect, diabetes, hypertension, osteoporosis, the history of metal allergy and glucocorticoid intake, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-HF scale scores, defect size (DS), the type of bone transport, the bone union time, external fixator time (EFT), and external fixator index (EFI). Results There were 199 males and 37 females with a mean age of 47 years (range 28–59 years). Out of 236 patients, 49 had an additional treatment for ankle OA after the Ilizarov technique treatment of bone defects (average follow-up time 2.1 years, range 1.6–4.2 years). The incidence of postoperative ankle OA was 20.8 %, with 19 patients classified as K&L grade 3 and seven patients as grade 4. The top five risk factors included double-level bone transport (OR3.79, P = 0.005), EFI > 50days/cm (OR3.17, P = 0.015), age > 45years (OR2.29, P = 0.032), osteoporosis (OR1.58, P < 0.001), BMI > 25 (OR1.34, P < 0.001). Male, BMI > 25, diabetes, osteoporosis, and AOFAS ankle-HF scale scores are the independent risk factors. Conclusions Ilizarov external circular fixator is a safe and effective method of treatment for critical bone defects. The double level bone transport, EFI > 50days/cm, age > 45years, osteoporosis, BMI > 25 are the top five relevant risk factors of ankle OA. The probability of developing ankle OA among patients having three or more risk factors is 50–70 %.
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Affiliation(s)
- Kai Liu
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, 830054, Urumqi, Xinjiang, China
| | - Feiyu Cai
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, 830054, Urumqi, Xinjiang, China
| | - Yanshi Liu
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, 830054, Urumqi, Xinjiang, China
| | - Alimujiang Abulaiti
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, 830054, Urumqi, Xinjiang, China
| | - Peng Ren
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, 830054, Urumqi, Xinjiang, China.
| | - Aihemaitijiang Yusufu
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, 830054, Urumqi, Xinjiang, China.
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18
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Kavarthapu V, Hester T. Charcot hindfoot deformity reconstruction using a hindfoot nail- surgical technique. J Clin Orthop Trauma 2021; 16:277-284. [PMID: 33738236 PMCID: PMC7937564 DOI: 10.1016/j.jcot.2021.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/29/2022] Open
Abstract
Various techniques of reconstruction of deformed Charcot hindfoot using different internal fixation devices have been described in the literature. We present our surgical technique using specific principles that has resulted in improved outcomes to allow correction of deformity, obtain stability and allow progression to weightbearing in orthotic shoes. We describe our preoperative evaluation, planning and surgical timing. We also hope to share some technical pearls and details on the finer points to achieve a satisfactory correction and reduce the learning curve.
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Affiliation(s)
- Venu Kavarthapu
- Consultant Orthopaedic Surgeon, Department of Trauma & Orthopaedics, King’s College Hospital Denmark Hill, London, SE5 9RS, UK,Associate Professor, University of Southern Denmark, King’s College Hospital Denmark Hill, London, SE5 9RS, UK,Corresponding author.
| | - Thomas Hester
- Consultant Orthopaedic Surgeon, Department of Trauma & Orthopaedics, King’s College Hospital Denmark Hill, London, SE5 9RS, UK
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19
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Current concepts and challenges in managing ankle fractures in the presence of diabetes: A systematic review of the literature. J Clin Orthop Trauma 2021; 17:44-53. [PMID: 33717970 PMCID: PMC7919966 DOI: 10.1016/j.jcot.2021.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options. METHODS Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing. RESULTS A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or "complicated" diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy. CONCLUSION Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of 'ORIF plus' techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.
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20
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Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a prospective cohort study at a minimum five year follow-up. INTERNATIONAL ORTHOPAEDICS 2021; 45:2299-2305. [PMID: 33443596 DOI: 10.1007/s00264-020-04904-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/03/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE To evaluate prospectively the functional outcomes of tibiotalocalcaneal (TTC) arthrodesis with a contemporary retrograde intramedullary nail after a minimum follow-up of five years. METHODS Sixty-one patients with a mean age of 51.3 (range, 18-79) years were included in the study. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS), Short-Form 12-item Health Survey (SF12), and visual analog scales (VAS) for both pain and patient satisfaction. Radiographic evaluation was also assessed. RESULTS The mean post-operative follow-up was 6.8 (range, 5-8) years. Mean AOFAS and SF12 scores significantly improved at the final follow-up (p < 0.001), and the mean VAS for pain significantly decreased (p < 0.001). At the final follow-up, only five (8.2%) patients gave an AOFAS score of less than 50, 52 (85.2%) were satisfied with their surgery, and 32 (52.4%) returned to their employment. There were two tibiotalar joint nonunions that required re-operations, and another patient required re-operation for screw removal. There was no deep infection. CONCLUSIONS The retrograde intramedullary nail provided a stable TTC arthrodesis with a high union rate, acceptable functional outcomes, and a low severe complication rate. This procedure appears to offer a reliable salvage option for TTC arthrodesis in patients with severe ankle and hindfoot degeneration.
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21
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Multidisciplinary Approach for the Management and Treatment of Diabetic Foot Infections with a Resorbable, Gentamicin-Loaded Bone Graft Substitute. J Clin Med 2020; 9:jcm9113586. [PMID: 33172111 PMCID: PMC7694758 DOI: 10.3390/jcm9113586] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022] Open
Abstract
Diabetic patients are at increased risk of developing foot ulcers which may cause bone infections associated with a high probability of both amputation and mortality. Therefore, prompt diagnosis and adequate treatment are of key importance. In our Diabetic Foot Unit, effective multidisciplinary treatment of osteomyelitis secondary to diabetes involves the application of a gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute to fill residual bone voids after debridement. The data of all patients treated with the gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute for diabetic foot infections with ulcer formation and osteomyelitis at metatarsals, calcaneus and hindfoot at our institute from July 2013 to September 2016 were retrospectively collected and evaluated. A total of 35 patients were included in this retrospective single-arm case series and were either continuously followed up for at least one year or until healing was confirmed. Nineteen lesions affected the distal row of tarsus/talus, ten the calcaneus and a further six were located at the metatarsals. While all of the metatarsal lesions had healed at 1-year follow-up, the healing rate in the hindfoot region was lower with 62.5% at the calcaneus and 72.2% at the distal tarsus and talus at 12 months, respectively. The overall cure rate for ulcerous bone infection was 81.3%. In two calcaneal lesions (25%) and two lesions of distal tarsus/talus (11.1%) amputation was considered clinically necessary. Promising results were achieved in the treatment of diabetic foot infections with soft tissue ulcers by a multidisciplinary approach involving extensive debridement followed by adequate dead space management with a resorbable gentamicin-eluting bone graft substitute.
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22
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Cianni L, Bocchi MB, Vitiello R, Greco T, De Marco D, Masci G, Maccauro G, Pitocco D, Perisano C. Arthrodesis in the Charcot foot: a systematic review. Orthop Rev (Pavia) 2020; 12:8670. [PMID: 32913602 PMCID: PMC7459387 DOI: 10.4081/or.2020.8670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022] Open
Abstract
The Charcot foot is a condition characterized by a progressive derangement of the foot. The type of deformity and patient clinical conditions will lead to the proper surgical approach among exostectomy, arthrodesis (through external and/or internal fixation) and amputation. Many authors report good clinical outcomes performing the arthrodesis in Charcot foot; however, the choice of the most appropriate hardware is still an issue. The aim of this study is to analyze the outcomes of different hardware in midfoot and hindfoot Charcot arthrodesis.
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Affiliation(s)
- Luigi Cianni
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Maria Beatrice Bocchi
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Raffaele Vitiello
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Tommaso Greco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Davide De Marco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Giulia Masci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Dario Pitocco
- Diabetes Care Unit, Institute of Endocrinology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Perisano
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
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23
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Ramanujam CL, Stuto AC, Zgonis T. Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review. J Wound Care 2020; 29:S19-S28. [PMID: 32530758 DOI: 10.12968/jowc.2020.29.sup6.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C Stuto
- LVPG Orthopedics and Sports Medicine, Lehigh Valley Health Network, Bethlehem, PA, US
| | - Thomas Zgonis
- Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
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24
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Ha J, Hester T, Foley R, Reichert IL, Vas PR, Ahluwalia R, Kavarthapu V. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma 2020; 11:357-368. [PMID: 32405193 PMCID: PMC7211810 DOI: 10.1016/j.jcot.2020.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
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Affiliation(s)
- Joon Ha
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Thomas Hester
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Robert Foley
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Ines L.H. Reichert
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Prashanth R.J. Vas
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
- King’s Diabetic Foot Clinic, King’s College College Hospital, London
| | - Raju Ahluwalia
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Venu Kavarthapu
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
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25
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Morasiewicz P, Dejnek M, Orzechowski W, Urbański W, Kulej M, Dragan SŁ, Dragan SF, Pawik Ł. Clinical evaluation of ankle arthrodesis with Ilizarov fixation and internal fixation. BMC Musculoskelet Disord 2019; 20:167. [PMID: 30975120 PMCID: PMC6460534 DOI: 10.1186/s12891-019-2524-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 03/24/2019] [Indexed: 12/11/2022] Open
Abstract
Background Ankle arthrodesis may have internal or external stabilization. We assessed whether the type of stabilization after ankle arthrodesis will affect: (1) functional outcome in Foot and Ankle Ability Measure (FAAM) scale, (2) pain level, (3) period of hospitalization, (4) rate of complications. Methods We retrospectively studied 47 individuals after ankle arthrodesis with Ilizarov fixation (group 1, n = 21) and internal stabilization (group 2, n = 26) at our institution in years 2007–2015. Clinical outcomes were measure by: (1) functional outcome in FAAM scale, (2) pain level, (3) period of hospitalization, (4) rate of complications. Results Total number of complications in Ilizarov group was 13, which corresponded to 0.62 complications per patient on average. In group 2 there were 15 complications, which corresponded to 0.58 complications per patient on average. The intergroup difference in rate of complications was not statistically significant (p = 0.066). In group 1 the mean VAS pain level before treatment was 4.69 and after treatment was 1.5 (p = 0.037). In group with internal stabilization the mean VAS pain level before treatment was 4.71 and after treatment was 2.9 (p = 0.044). In group 1 the mean period of hospitalization was 5.29 days, in group 2 was 5.71 days (p = 0.517). In group 1 the mean functional outcome in FAAM scale was 79.38, in group 2 was 70.11 (p = 0.458). Conclusions Ankle arthrodesis with Ilizarov stabilization is associated with lower prevalence of VAS pain level after surgery than after internal screws stabilization. Rate of complications, FAAM functional score and period of hospitalization were not statistically significant between group 1 and 2. Clinical outcome was satisfactory in group 1 and 2, but outcomes in Ilizarov group were slightly better than after internal stabilization.
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Affiliation(s)
- Piotr Morasiewicz
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland.
| | - Maciej Dejnek
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Wiktor Orzechowski
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Wiktor Urbański
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Mirosław Kulej
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Szymon Łukasz Dragan
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Szymon Feliks Dragan
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Łukasz Pawik
- Department of Physiotherapy and Occupational Therapy in Motor Disorders and Dysfunctions, University of Physical Education, Al. IJ Paderewskiego 35, Wroclaw, Poland
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Tomczak C, Beaman D, Perkins S. Combined Intramedullary Nail Coated With Antibiotic-Containing Cement and Ring Fixation for Limb Salvage in the Severely Deformed, Infected, Neuroarthropathic Ankle. Foot Ankle Int 2019; 40:48-55. [PMID: 30264587 DOI: 10.1177/1071100718800836] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The severely deformed, infected, and unstable neuroarthropathic ankle is challenging to treat. We evaluated our preliminary experience and results of combined internal and external ring fixation for a complex neuropathic population. METHODS: We retrospectively reviewed medical records and radiographs for 8 patients with unilateral severely deformed ankle neuroarthropathy associated with infection and ulceration. Treatment included single-stage reconstruction arthrodesis with an interlocked intramedullary nail coated with antibiotic-containing cement combined with ring fixation. Taylor Spatial Frame™ technology was used when the deformity was not amenable to acute correction (5 patients). Protected postoperative weightbearing was permitted. Their mean age averaged 55.6 (range, 42-66) years with an average body mass index of 38.4 (range, 28.7-49.6) kg/m2. RESULTS: Seven patients achieved limb preservation. Average time for fusion healing was 15.2 (range, 12.2-22.2) weeks, frame time was 17.7 (range, 12.2-23.0) weeks, and follow-up was 34.1 (range, 24.1-68.8) months. All presenting wounds and infection successfully resolved. Reinker and Carpenter scale was excellent for 2 patients, good for 2 patients, and fair for 3 patients. Foot and Ankle Ability Measure averaged 59.0% (range, 39.3%-87.5%). One patient developed a recalcitrant calcaneal ulcer with osteomyelitis that required a transtibial amputation 17 months after successful ankle arthrodesis. CONCLUSIONS: Combined use of interlocked intramedullary nail and ring external fixation for neuroarthropathic ankle arthrodesis achieved a functional and clinically stable salvaged lower limb for most patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Affiliation(s)
| | | | - Serene Perkins
- 2 Legacy Institute for Surgical Education & Innovation, Legacy Research Institute, Portland, OR, USA
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Morasiewicz P, Konieczny G, Dejnek M, Morasiewicz L, Urbański W, Kulej M, Dragan SŁ, Dragan SF, Pawik Ł. Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation. Biomed Eng Online 2018; 17:174. [PMID: 30477523 PMCID: PMC6258158 DOI: 10.1186/s12938-018-0608-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 11/22/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads. METHODS Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform. RESULTS In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant. CONCLUSIONS Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.
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Affiliation(s)
- Piotr Morasiewicz
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Grzegorz Konieczny
- Faculty of Health Sciences and Physical Education, Witelon State University of Applied Sciences, Legnica, Poland
| | - Maciej Dejnek
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Leszek Morasiewicz
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Wiktor Urbański
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Mirosław Kulej
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Szymon Łukasz Dragan
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Szymon Feliks Dragan
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Łukasz Pawik
- Department of Physiotherapy and Occupational Therapy in Motor Disorders and Dysfunctions, University of Physical Education, Al. IJ Paderewskiego 35, Wroclaw, Poland
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Abstract
Acute Charcot foot is a diagnostic challenge. The exact pathophysiology is not fully understood. Acute Charcot foot is often present with a history of trauma or cellulitis which does not respond to antibiotics. The condition is best managed within a multidisciplinary team. The mainstay of the treatment is mechanical off-loading and total contact casting. Surgery is reserved for select cases.
Cite this article: EFORT Open Rev 2018;3:568-573. DOI: 10.1302/2058-5241.3.180003
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Affiliation(s)
- Sohail Yousaf
- Kingston Hospital NHS Foundation Trust, UK.,University of Brighton, UK
| | - Edward J C Dawe
- Western Sussex Hospitals NHS Foundation Trust, UK.,Brighton and Sussex Medical Schools, UK
| | - Alan Saleh
- Kingston Hospital NHS Foundation Trust, UK
| | - Ian R Gill
- Kingston Hospital NHS Foundation Trust, UK
| | - Alex Wee
- Frimley Health NHS Foundation Trust, UK
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Vasukutty N, Jawalkar H, Anugraha A, Chekuri R, Ahluwalia R, Kavarthapu V. Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail-The Kings' Experience. Foot Ankle Surg 2018; 24:406-410. [PMID: 29409204 DOI: 10.1016/j.fas.2017.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 04/05/2017] [Accepted: 04/14/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corrective fusion for the unstable deformed hind foot and mid foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams. METHODS We present a follow up to our initial report with a series of 42 hind foot corrections in 40 patients from a tertiary level teaching hospital in the United Kingdom. The mean patient age was 59 (33-82). 17 patients had type1diabetes mellitus, 23 had type 2. 23 feet in 22 patients had chronic ulceration despite offloading. 17 patients were ASA 2 and 23 were ASA grade 3. All patients had hind foot nail fusion performed through a standard technique by the senior author and managed perioperatively by the multidisciplinary team. RESULTS At a mean follow up of 42 months (12-99) we achieved 100% limb salvage initially and a 97% fusion rate. One patient with persisting non-union of ankle and subtalar joint with difficulty in bracing has been offered below-knee amputation. We achieved deformity correction in 100% and ulcer healing in 83%. 83% patients are able to mobilize and manage independent activities of daily living. There were 11 patients with one or more complications including metal work failure, infection and ulcer reactivation. There have been nine repeat procedures including one revision fixation and one vascular procedure. CONCLUSION Single stage corrective fusion for hind foot deformity in CN is an effective procedure when delivered by a skilled multidisciplinary team.
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Affiliation(s)
- N Vasukutty
- Diabetic Foot Unit, Kings College Hospital NHS Foundation Trust, United Kingdom.
| | - H Jawalkar
- Diabetic Foot Unit, Kings College Hospital NHS Foundation Trust, United Kingdom
| | - A Anugraha
- Diabetic Foot Unit, Kings College Hospital NHS Foundation Trust, United Kingdom
| | - R Chekuri
- Diabetic Foot Unit, Kings College Hospital NHS Foundation Trust, United Kingdom
| | - R Ahluwalia
- Diabetic Foot Unit, Kings College Hospital NHS Foundation Trust, United Kingdom
| | - V Kavarthapu
- Diabetic Foot Unit, Kings College Hospital NHS Foundation Trust, United Kingdom
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30
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Shazadeh Safavi P, Jupiter DC, Panchbhavi V. A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot. J Foot Ankle Surg 2018; 56:1249-1252. [PMID: 28778632 DOI: 10.1053/j.jfas.2017.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.
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Affiliation(s)
| | - Daniel C Jupiter
- Assistant Professor, Preventative Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, TX
| | - Vinod Panchbhavi
- Professor of Orthopedic Surgery, Chief, Division of Foot & Ankle Surgery, and Director, Foot & Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch, Galveston TX
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31
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Abstract
Congenital insensitivity to pain (CIP) is a rare autosomal recessive genetic disease caused by mutation in several different genes. The diagnosis requires the combined skills and cooperation of pediatricians, neurologists, radiologists, pathologists, and orthopedic surgeons. Orthopedic manifestations of CIP include delayed diagnosis of fractures, nonunions, Charcot arthropathy, avascular necrosis, osteomyelitis, joint dislocations, and heterotopic ossifications. We present case reports of two brothers with CIP with various orthopedic manifestations and methods of surgical treatment with 10 years of follow-up.
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32
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El-Mowafi H, El-Hawary A, Kandil Y. Functional pedal construct achieved by combined operative treatment in peritalar complex Charcot arthropathy: A prospective study of 38 feet. Foot Ankle Surg 2018; 24:236-241. [PMID: 29409253 DOI: 10.1016/j.fas.2017.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/21/2017] [Accepted: 02/14/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Charcot arthropathy of the peritalar complex carries a high risk of amputation if not properly managed. Our aim is to assess the functional outcome of severe Charcot arthropathy of the peritalar complex following enblock resection of the ulcer, massive debridement and stabilizing all the elements of the peritalar complex. METHODS We prospectively studied 38 feet in 35 patients with peritalar complex Charcot arthropathy. All Feet underwent intense debridement and fusion using a combination of (Ilizarov) external fixation, and (plate and locked nail) internal fixation. Thirty two feet were graded as Eichenholtz 2, and six feet were graded as Eichenholtz 3. The mean follow up was 35.9months. RESULTS The mean AOFAS score was significantly elevated from 25.4±9.1 preoperatively to 67.6±5.7 at the most recent follow-up (p<0.001). Complete bony fusion was achieved in 28 feet. Unsound bony fusion occurred in 8 feet. Two feet required below knee amputation. CONCLUSION Peritalar complex Charcot arthropathy is not uncommon variety. Such cases carry high risk of complications and amputation is not excluded. The proper timing of surgery is crucial. Massive debridement and rigid fixation with strict follow up is mandatory to achieve the ultimate goal of obtaining a plantigrade, stable, mechanically sound, painless and infection free pedal construct.
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Affiliation(s)
- Hani El-Mowafi
- Mansoura University Hospital, Mansoura Faculty of Medicine, 35516 Mansoura, Egypt.
| | - Ahmed El-Hawary
- Mansoura University Hospital, Mansoura Faculty of Medicine, 35516 Mansoura, Egypt
| | - Yasser Kandil
- Mansoura University Hospital, Mansoura Faculty of Medicine, 35516 Mansoura, Egypt
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33
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Affiliation(s)
- Andrew Dodd
- Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Emara KM, Ahmed Diab R, Amr Hemida M. Tibio-calcaneal fusion by retrograde intramedullary nailing in charcot neuroarthropathy. Foot (Edinb) 2018; 34:6-10. [PMID: 29175717 DOI: 10.1016/j.foot.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 10/29/2017] [Accepted: 11/01/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Charcot's neuroarthropathy of ankle leads to instability, destruction of the joint with significant morbidity that may require an amputation. Aim of surgical treatment is to achieve painless stable plantigrade foot through arthrodesis. Achieving surgical arthrodesis in Charcot's neuroarthropathy has a high failure rate. We assess the outcomes of retrograde intramedullary interlocked nailing in tibio-talar arthrodesis for Charcot's neuroarthropathy. MATERIALS AND METHODS 42 diabetic patients with a mean age of 49 year underwent ankle tibio-talar arthrodesis using retrograde nailing for Charcot's neuroarthropathy. The postoperative complications have been discussed and their management outlined. The outcomes were measured radiologically and clinically. Follow up was done after 6 weeks, 3 months, 6 months and 1 year. RESULTS 14 patients (33.3%) achieved uneventful uncomplicated fusion. Thirty three patients had varus deformity. Nine patients had valgus deformity. Using Paired t test, it showed statistically significant improvement in the functional outcomes (AOFAS& EQ-5D-5L) over the follow up time, despite of the mild deterioration of radiological angles in the final follow up visit compared to the postoperative radiological findings. CONCLUSION Retrograde nailing is one of the best options for tibio-talo-calcaneal arthrodesis in the high-risk Charcot's neuroarthropathy population. It could be done through small incisions with lower soft tissue complications, its load-sharing properties allows a considerable compression across the ankle and talocalcaneal joints with early weight bearing and with satisfactory functional outcomes.
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35
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Chraim M, Krenn S, Alrabai HM, Trnka HJ, Bock P. Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot. Bone Joint J 2018; 100-B:190-196. [DOI: 10.1302/0301-620x.100b2.bjj-2017-0374.r2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up. Patients and Methods We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70). Results The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) – Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS). Conclusion The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190–6.
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Affiliation(s)
- M. Chraim
- Orthopaedic Hospital Speising, Speisingerstrasse
109, A-1130, Vienna, Austria
| | - S. Krenn
- Orthopaedic Hospital Speising, Speisingerstrasse
109, A-1130, Vienna, Austria
| | - H. M. Alrabai
- King Saud University, P.
O. Box 7805, Riyadh 11472, Saudi
Arabia
| | - H-J. Trnka
- Fusszentrum Wien, Alserstrasse
43/8d, 1080, Vienna, Austria
| | - P. Bock
- Orthopaedic Hospital Speising, Speisingerstrasse
109, A-1130, Vienna, Austria
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New Fixation Methods for the Treatment of the Diabetic Foot: Beaming, External Fixation, and Beyond. Clin Podiatr Med Surg 2018; 35:63-76. [PMID: 29156168 DOI: 10.1016/j.cpm.2017.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Surgical correction of complex foot and ankle deformities secondary to Charcot neuroarthropathy remains a significant surgical challenge. New technological advancements in hardware have allowed for the use of augmented fixation techniques in midfoot deformity correction, including the use of indication-specific locking plates and beaming techniques that offer enhanced stability. Severe hindfoot deformity management can employ the use of internal fixation, including intramedullary hindfoot nails and circular external fixation frames for limb salvage.
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El-Mowafi H, Abulsaad M, Kandil Y, El-Hawary A, Ali S. Hybrid Fixation for Ankle Fusion in Diabetic Charcot Arthropathy. Foot Ankle Int 2018; 39:93-98. [PMID: 29035584 DOI: 10.1177/1071100717735074] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle fusion is difficult to achieve in the diabetic Charcot ankle Brodsky type 3a because of the poor quality of the bone and the inability to achieve a stable biomechanical construct. The aim of this study was to report the outcome of ankle fusion using a combination of an intramedullary nail and a circular external fixator in patients with diabetic Charcot arthropathy. METHODS We prospectively studied 24 patients with diabetic Charcot arthropathy of the ankle who were treated by fusion of the tibiotalar joint using a combined retrograde intramedullary nail and Ilizarov external fixator. Their mean age was 50.7 ± 6.9 (range, 43-62) years. The mean follow-up after surgery was 36.4 ± 5.8 (range, 24-98) months. RESULTS Twenty-two patients (92%) achieved clinical and radiographic solid bony fusion. No patients in this series needed amputation. All the patients were pain free, and the mean American Orthopaedic Foot & Ankle Society Score (AOFAS) improved significantly from 34.6 ± 6.8 to 66.4 ± 4.5 at the last follow-up. Two patients developed an ulcer over the heel due to a prominent nail. The ulcer healed after nail removal. Eight patients developed pin tract infection. CONCLUSION We report a successful outcomes of ankle fusions using combined intramedullary nail locked only proximally and ring external fixator (hybrid fixation) in patients with diabetic Charcot arthropathy. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Hani El-Mowafi
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Mazen Abulsaad
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Yasser Kandil
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Ahmed El-Hawary
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Samer Ali
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
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Radiological evaluation of ankle arthrodesis with Ilizarov fixation compared to internal fixation. Injury 2017; 48:1678-1683. [PMID: 28438418 DOI: 10.1016/j.injury.2017.04.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We asked whether the type of ankle joint arthrodesis stabilization will affect: (1) rate of union, (2) rate of adjacted-joint arthritis, (3) malalignment of the ankle joint. MATERIAL AND METHODS We retrospectively radiological studied 62 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1,n=29) or internal stabilization (group 2,n=33) from 2006 to 2015. Radiologic outcomes were mesure by: (1) rate of union, (2) rate of adjacent-joint arthritis, (3) malalignment of the ankle joint. The Levene's test,Mann-Whitney U test and Students t-test were used to the statistical analyses. RESULTS Ankle fusion was achieved in 100% of patients treated with external fixation and in 88% with internal stabilization. Desired frontal plane alignment was achieved in 100% of patients with external fixation and 76% with internal stabilization. Desired sagittal plane alignment was achieved in 100% of external fixation and 85% of internal stabilization. A total of 14 (48.3%) patients from group 1 showed a radiographic evidence of pre-existing adjacent-joint OA. The radiographic evidence of pre-existing adjacent-joint OA was also found in 27(81.8%) subjects from group 2. Alterations of adjacent joints were also found on postoperative radiograms of 19 (65.5%) patients subjected to Ilizarov fixation and in all 33 patients from group 2. DISCUSION Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of adjacent-joint OA and ankle joint misalignment,and with higher fusion rates than after internal fixation.Although achieving a complex ankle fusion is generally challenging,radiological outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization.
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39
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Richman J, Cota A, Weinfeld S. Intramedullary Nailing and External Ring Fixation for Tibiotalocalcaneal Arthrodesis in Charcot Arthropathy. Foot Ankle Int 2017; 38:149-152. [PMID: 27698177 DOI: 10.1177/1071100716671884] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical strategies to address deformities of the ankle and hindfoot in patients with Charcot arthropathy include the use of retrograde intramedullary nails and ring fixators. The literature has not shown superiority of one technique over the other. This study presents a single surgeon's case series of Charcot arthropathy patients treated with either a ring fixator or retrograde intramedullary nail to achieve tibiotalocalcaneal arthrodesis. METHODS We performed a retrospective analysis of 27 consecutive patients with Charcot arthropathy who underwent a tibiotalocalcaneal arthrodesis using either a retrograde intramedullary (IM) nail (n = 16 patients) or a ring fixator (RF) (n = 11 patients) by a single surgeon. We report the rates of limb salvage complications requiring secondary surgery and fusion in both groups. The patient demographics and presence of medical comorbidities known to increase the risk of surgical complications were similar between groups. The mean duration of follow-up for the retrograde nail group was 3.6 years and 2.2 years for the ring fixator group. RESULTS The mean time to discharge from the hospital after the index surgical procedure was 2.7 days for the IM group and 4.6 days for the RF group. For the patients treated with a ring fixator, the mean time to removal of the frame after the initial application was 13.3 ± 1.8 weeks. The limb salvage rate for the RF group was 9 of 11 patients whereas it was 15 of 16 in the IM group. Complications including deep infection, hardware failure, and symptomatic nonunion requiring revision surgery were common in the IM group, with 11 of 16 patients requiring further surgery. Seven patients in the IM group required removal of the implant at a mean of 117.2 weeks after the index procedure because of the development of deep infection or nail cutout. In the RF group, only 1 patient required revision surgery. Fusion rates were similar between both groups, with 10 of 16 patients fusing in the IM group and 7 of 11 in the RF group. CONCLUSION Use of a retrograde intramedullary rod or ring fixator resulted in high rates of successful limb salvage when used for tibiotalocalcaneal arthrodesis in patients with Charcot arthropathy. However, in this study, the need for revision surgery was more frequent in the retrograde nail group compared to the ring fixator group. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- James Richman
- 1 Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
| | - Adam Cota
- 1 Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
| | - Steven Weinfeld
- 1 Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
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Wukich DK, Sadoskas D, Vaudreuil NJ, Fourman M. Comparison of Diabetic Charcot Patients With and Without Foot Wounds. Foot Ankle Int 2017; 38:140-148. [PMID: 27923212 DOI: 10.1177/1071100716673985] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Dane K Wukich
- 1 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Sadoskas
- 2 Baylor Scott and White Healthcare System, Waco, TX, USA
| | - Nicholas J Vaudreuil
- 3 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mitchell Fourman
- 3 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Trieb K. The Charcot foot: pathophysiology, diagnosis and classification. Bone Joint J 2017; 98-B:1155-9. [PMID: 27587513 DOI: 10.1302/0301-620x.98b9.37038] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 04/12/2016] [Indexed: 12/15/2022]
Abstract
Neuropathic changes in the foot are common with a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy is often delayed in diabetic patients with harmful consequences including amputation. The appropriate diagnosis and treatment can avoid an extensive programme of treatment with significant morbidity for the patient, high costs and delayed surgery. The pathogenesis of a Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels. In most cases, changes are due to a combination of both pathophysiological factors. The Charcot foot is triggered by a combination of mechanical, vascular and biological factors which can lead to late diagnosis and incorrect treatment and eventually to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. The clinical diagnostic pathways based on different classifications are presented. Cite this article: Bone Joint J 2016;98-B:1155-9.
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Affiliation(s)
- K Trieb
- Klinikum Wels-Grieskirchen, Grieskirchnerstr. 42, Wels, 4600, Austria
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42
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Ögüt T, Yontar NS. Surgical Treatment Options for the Diabetic Charcot Hindfoot and Ankle Deformity. Clin Podiatr Med Surg 2017; 34:53-67. [PMID: 27865315 DOI: 10.1016/j.cpm.2016.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Charcot neuroarthropathy is associated with progressive, noninfectious, osteolysis-induced bone and joint destruction. When the ankle and/or hindfoot is affected by the destruction process, management is further complicated with collapse and destruction of the talar body, which increases instability around the ankle. In this patient population, arthrodesis is the most commonly used surgical procedure. Internal fixation, external fixation, or a combination of both can be used for the treatment. Decision making between them should be individualized according to the patient characteristics.
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Affiliation(s)
- Tahir Ögüt
- Department of Orthopaedics and Traumatology, Cerrahpasa Medical School, Istanbul University, Fatih, Istanbul 34098, Turkey.
| | - Necip Selcuk Yontar
- Department of Orthopaedics and Traumatology, Istanbul Cerrahi Hospital, Hakkı Yeten Cad., Ferah Sok. No: 22, Fulya, Istanbul 34365, Turkey
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43
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Affiliation(s)
- Patrick K Strotman
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Taylor J Reif
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Bateman AH, Bradford S, Hester TW, Kubelka I, Tremlett J, Morris V, Pendry E, Kavarthapu V, Edmonds ME. Modern Orthopedic Inpatient Care of the Orthopedic Patient With Diabetic Foot Disease. INT J LOW EXTR WOUND 2016; 14:384-92. [PMID: 26680750 DOI: 10.1177/1534734615596114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 admissions (19 emergency, 11 elective) were included. The pathways were coordinated by a multidisciplinary team and comprised initial assessment and investigation and a series of key events, which consisted of emergency and elective surgery together with the introduction, and change of intravenous antibiotics when indicated. Patients had rigorous microbiological assessment, in the form of deep ulcer swabs, operative tissue specimens, joint aspirates, and blood cultures according to their clinical presentation as well as close clinical and biochemical surveillance, which expedited the prompt institution of key events. Outcomes were assessed using amputation rates and patient satisfaction. In the emergency group, there were 5.6 ± 3.0 (mean ± SD) key events per admission, including 4.2 ± 2.1 antibiotic changes. In the elective group, there were 4.8 ± 1.4 key events per inpatient episode, with 3.7 ± 1.3 antibiotic changes. Overall, there were 3 minor amputations, and no major amputations. The podiatric and surgical tissue specimens showed a wide array of Gram-positive, Gram-negative, aerobic and anaerobic isolates and 15% of blood cultures showed bacteremia. When 9 podiatric specimens were compared with 9 contemporaneous surgical samples, there was concordance in 2 out of 9 pairs. We have described the successful modern care of the orthopedic diabetic foot patient, which involves close clinical, microbiological, and biochemical surveillance by the multidisciplinary team directing patients through emergency and elective pathways. This has enabled successful surgical intervention involving debridement, pressure relief, and stabilization, with low rates of amputation.
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Uçkay I, Gariani K, Dubois-Ferrière V, Suvà D, Lipsky BA. Diabetic foot infections. Curr Opin Infect Dis 2016; 29:145-52. [DOI: 10.1097/qco.0000000000000243] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tibiocalcaneal arthrodesis as a limb salvage procedure for complex hindfoot deformities. Arch Orthop Trauma Surg 2016; 136:457-62. [PMID: 26887665 DOI: 10.1007/s00402-016-2420-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Tibiocalcaneal (TC) arthrodesis is a limb salvage method for patients with severe deformities combined with necrosis and/or luxation of the talus. The aim of this study was to examine the clinical and radiological outcome of TC arthrodesis. MATERIALS AND METHODS This retrospective study identified 12 patients with luxation and/or necrosis of the talus, due to charcot neuroarthropathy (83.3 %) or traumatic injuries (16.7 %). All patients underwent TC arthrodesis by an external fixator or nail arthrodesis. The mean follow up was 18 (6-36) months with a mean age of 51.3 (30-66) years. The data were collected using the AOFAS score as well as clinical and radiological examination during regular follow up. RESULTS Seven (58.3 %) patients were treated with an external fixator, four (33.3 %) with nail arthrodesis and one (8.3 %) patient rejected both fixation methods. Four (100 %) patients achieved radiological and clinical bone union after nail arthrodesis and four (57.1 %) patients after external fixation. Three (42.9 %) patients treated by an external fixator showed a radiological moderate bone fusion, but a stable, asymptomatic non-union. One (8.3 %) case ended up in transfemoral amputation. Eleven patients (91.7 %) regained independent mobilization. The mean AOFAS score improved from 24.3 preoperatively to 66.7 postoperatively (p < 0.05). The postoperative satisfaction rate was good to excellent in 83.3 %. CONCLUSION TC arthrodesis is a promising and effective method for the treatment of severe ankle deformities with talus luxation. It allows patient's return to mobility with good to excellent patient satisfaction.
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47
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Edmonds M. The benefits of working together in diabetic foot care for the vulnerable patient. PRACTICAL DIABETES 2016. [DOI: 10.1002/pdi.1995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wukich DK, Raspovic KM, Hobizal KB, Sadoskas D. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:292-6. [PMID: 26452590 DOI: 10.1002/dmrr.2748] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality. SURGICAL MANAGEMENT The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality. CONCLUSION Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use.
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MESH Headings
- Ankle/pathology
- Ankle/surgery
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/pathology
- Arthropathy, Neurogenic/rehabilitation
- Arthropathy, Neurogenic/surgery
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Decision Trees
- Diabetic Foot/complications
- Diabetic Foot/pathology
- Diabetic Foot/rehabilitation
- Diabetic Foot/surgery
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/pathology
- Diabetic Neuropathies/rehabilitation
- Diabetic Neuropathies/surgery
- Evidence-Based Medicine
- External Fixators/adverse effects
- External Fixators/trends
- Foot Deformities, Acquired/complications
- Foot Deformities, Acquired/pathology
- Foot Deformities, Acquired/rehabilitation
- Foot Deformities, Acquired/surgery
- Heel/pathology
- Heel/surgery
- Humans
- Internal Fixators/adverse effects
- Internal Fixators/trends
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Precision Medicine
- Preoperative Care/adverse effects
- Preoperative Care/trends
- Quality of Life
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - David Sadoskas
- Fellow Reconstruction and Limb Salvage Surgery UPMC Mercy Hospital, Pittsburgh, PA, USA
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49
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Petrova NL, Edmonds ME. Acute Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2016; 32 Suppl 1:281-6. [PMID: 26451965 DOI: 10.1002/dmrr.2734] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 01/29/2023]
Abstract
Charcot neuro-osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Charcot foot when the X ray is still negative (stage 0 or incipient Charcot foot). Recent advances in imaging modalities have enabled the detection of initial signs of inflammation and underlying bone damage before overt bone and joint destruction has occurred. Casting therapy remains the mainstay of medical therapy of acute CN. If timely instituted, offloading can arrest disease activity and prevent foot deformity. In cases with severe deformity, modern surgical techniques can correct the unstable deformity for improved functional outcome and limb survival. Emerging new studies into the cellular mechanisms of severe bone destruction have furthered our understanding of the mechanisms of pathological bone and joint destruction in CN. It is hoped that these studies may provide a scientific basis for new interventions with biological agents.
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MESH Headings
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/diagnosis
- Arthropathy, Neurogenic/physiopathology
- Arthropathy, Neurogenic/therapy
- Bone Density Conservation Agents/adverse effects
- Bone Density Conservation Agents/therapeutic use
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Diabetic Foot/complications
- Diabetic Foot/diagnosis
- Diabetic Foot/physiopathology
- Diabetic Foot/therapy
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/diagnosis
- Diabetic Neuropathies/physiopathology
- Diabetic Neuropathies/therapy
- Early Diagnosis
- Evidence-Based Medicine
- Fractures, Bone/complications
- Fractures, Bone/epidemiology
- Fractures, Bone/etiology
- Fractures, Bone/therapy
- Humans
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Postoperative Complications/prevention & control
- Precision Medicine
- Protective Devices/trends
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Risk Factors
- Severity of Illness Index
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | - M E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
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50
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Hegewald KW, Wilder ML, Chappell TM, Hutchinson BL. Combined Internal and External Fixation for Diabetic Charcot Reconstruction: A Retrospective Case Series. J Foot Ankle Surg 2015; 55:619-27. [PMID: 26188625 DOI: 10.1053/j.jfas.2015.04.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Indexed: 02/03/2023]
Abstract
Diabetic Charcot neuroarthropathy is a complex, limb-threatening disease process with major lifestyle-altering repercussions for patients. When Charcot neuroarthropathy leads to unstable deformity, ulceration, and potential infection despite conservative therapies, foot and ankle surgeons often consider reconstructive limb salvage procedures to restore function. The purpose of the present study was to evaluate the clinical and radiographic outcomes of diabetic Charcot reconstruction using combined internal and external fixation. A total of 22 patients were reviewed; 16 (72.73%) midfoot and 6 (27.27%) tibiotalocalcaneal arthrodesis procedures were consecutively performed from March 2009 to May 2013. All surgical procedures were performed in nonacute phases of the Charcot process in patients with diagnosed diabetes mellitus and documented peripheral neuropathy. Patients were excluded from the study if they were not diabetic despite having undergone Charcot reconstruction, regardless of the fixation method, or if they did not complete radiographic imaging. During a mean follow-up period of 58.60 ± 42.37 (range 16 to 164) weeks, limb salvage was achieved in 20 patients (90.91%), and 2 (9.09%) required below-the-knee amputation at a mean of 42 ± 14.14 weeks. Wound dehiscence occurred in 8 (36.36%), pin tract infection in 10 (45.45%), and superficial wound infection in 9 (40.91%) and peaked in bimodal fashion at 4 and 8 weeks postoperatively. Radiographic analysis of the pre- versus postoperative alignment showed statistically significant changes in the lateral talo-first metatarsal angle (p = .02) and lateral talar declination angle (p = .01). The limb salvage rates with diabetic Charcot reconstruction are improving in part because of the continued development of increasingly superior modalities for both internal and external fixation.
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Affiliation(s)
- Kenneth W Hegewald
- Fellow, Silicon Valley Reconstructive Foot and Ankle Fellowship, Palo Alto Medical Foundation, Mountain View, CA.
| | - Megan L Wilder
- Resident, Franciscan Foot and Ankle Institute, CHI Franciscan Health, Federal Way, WA
| | - Todd M Chappell
- Resident, Franciscan Foot and Ankle Institute, CHI Franciscan Health, Federal Way, WA
| | - Byron L Hutchinson
- Director, Franciscan Foot and Ankle Institute, and Medical Director, Foot and Ankle Service, CHI Franciscan Health, Federal Way, WA
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