1
|
Argyropoulos M, Wynell-Mayow W, Johnson O, Faroug R, Johal KS, Deol RS, Hakmi A, Mordecai S. Charcot neuro-osteoarthropathy: a review of key concepts and an evidence-based surgical management algorithm. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2024; 5:1344359. [PMID: 39219847 PMCID: PMC11362032 DOI: 10.3389/fcdhc.2024.1344359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 07/17/2024] [Indexed: 09/04/2024]
Abstract
Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.
Collapse
Affiliation(s)
| | - William Wynell-Mayow
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
- Imperial College Healthcare NHS Trust, Faculty of Medicine, Imperial College London, Stevenage, United Kingdom
| | - Oscar Johnson
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Radwane Faroug
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | | | | | - Atef Hakmi
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Simon Mordecai
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| |
Collapse
|
2
|
Anciano V, Barcel A, Kaiser P, Habet N, Wang S, Duemmler M, Edwards C, Irwin TA, Jones C. Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model. Foot Ankle Int 2024; 45:888-895. [PMID: 38853769 DOI: 10.1177/10711007241251816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
BACKGROUND Operative management of midfoot Charcot arthropathy often involves an extended midfoot arthrodesis with intramedullary bolts for fixation, a method called "beaming." Recently intramedullary nails have been introduced for the same indication, presumably providing stronger fixation. This study compares midfoot fusion nails to bolts with regard to stiffness and compressive ability. Additionally, we assessed how the addition of a subtalar fusion affects the construct. METHODS Medial column fusions were performed on 10 matched cadaver foot specimens with either a midfoot fusion nail or bolt. Specimens underwent cyclical compression loading, and displacement was measured. Separately, compressive forces produced were compared between the 2 fixation constructs using a synthetic bone block model. Lastly, another 10 matched specimens with midfoot fusion nails were evaluated with or without subtalar fusions. RESULTS No differences in stiffness were found in comparing matched specimens between nail vs bolt or comparing nail only without subtalar fusion (STF) vs nail with STF. The compressive force produced by the nail specimens was significantly and substantially greater than the bolted specimens (751.7 vs 139.0 N, P = .01). The accumulated height drop at the midfoot after cycling was 0.5 mm more in the nail group than in the bolt group (1.72 vs 1.22 mm, P = .008). The nail with STF group had greater initial height drop at the midfoot than the nail-only group (0.68 vs 0.34 mm, P = .035) with similar initial height drop at the ankle. However, there were no differences in strength among the matched pairs of midfoot nail-only vs midfoot nail with STF as measured by displacement after fatigue or maximum force at load to failure. CONCLUSION The overall cadaveric comparisons between matched pairs of nails vs bolts, and nail-only vs nail with STF, did not provide noteworthy differences between the groups with regard to strength or stiffness. However, the compressive force of the midfoot fusion nail was far superior to the bolt in a synthetic bone model. These data provide valuable insight comparing implants used in Charcot midfoot arthrodesis.
Collapse
Affiliation(s)
- Victor Anciano
- University of Louisville Health-Orthopedics, Louisville, KY, USA
| | - Anthony Barcel
- Carolina Orthopaedic and Neurosurgical Associates, Spartanburg, SC, USA
| | - Philip Kaiser
- California Pacific Orthopaedics and Sports Medicine, San Francisco, CA, USA
| | - Nahir Habet
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Marc Duemmler
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Campbell Edwards
- University of Louisville School of Medicine, Louisville, KY, USA
| | - Todd A Irwin
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
| | - Carroll Jones
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
| |
Collapse
|
3
|
Skinner WC, Pattisapu N, Yeoh J, Grear BJ, Richardson DR, Murphy GA, Bettin CC. Surgical Outcomes in Charcot Arthropathy. Orthop Clin North Am 2024; 55:393-401. [PMID: 38782510 DOI: 10.1016/j.ocl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.
Collapse
Affiliation(s)
- William C Skinner
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Naveen Pattisapu
- Beth Israel Lahey Hospital, 41 Mall Road, Burlington, MA 01805, USA
| | - Jane Yeoh
- Nanaimo Orthopaedics, 201-1515 Dufferin Crescent, Nanaimo, British Columbia V9S5H6, Canada
| | - Benjamin J Grear
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - David R Richardson
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Garnett A Murphy
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
| |
Collapse
|
4
|
Boedijono DR, Dilogo IH, Prasetyo M, Antarianto RD, Dewi FNA, Yunir E, Kekalih A, Nugroho A, Aprilya D. A Novel Diabetic Arthritic Model in Rats Induced by Streptozotocin, High-Fat Diet, and Complete Freund's Adjuvant. Orthop Res Rev 2024; 16:163-170. [PMID: 38882468 PMCID: PMC11179661 DOI: 10.2147/orr.s457848] [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] [Received: 01/10/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Ankle arthrodesis is one of the treatments of choice, particularly in late-stage and unstable diabetic Charcot arthropathy. Unfortunately, poor healing capacity might play a role in the high nonunion rate (10-40%). The advancement in regenerative medicine opens a new horizon for enhancing fusion after ankle arthrodesis in patients with poor healing capacity. However, a suitable small animal model is warranted to study the effectivity of these regenerative medicine approaches. Streptozotocin (STZ)-induced diabetes models and adjuvant-induced arthritis models with complete Freund's adjuvant are two established models. However, no study has combined those two models to make a diabetic arthritic model that more closely resembles the condition in Charcot arthropathy. Methods Twenty male Sprague-Dawley rats were assigned into five groups, consisting of one control group, and four diabetic groups which were induced by STZ injection and a high-fat diet. Among these diabetic rats, two groups received complete Freund's adjuvant (CFA) injections to the left ankle of the hind limb. The control group, one of the diabetic-only groups, and one of the arthritic-diabetic-induced groups were euthanized at 4 weeks after STZ induction, and the remainder were euthanized 6 weeks after STZ induction. Clinical, radiological, and histological examinations were then compared in all five groups. Results Diabetic status was successfully achieved in the model, which was maintained until the completion of the study. The CFA-induced ankles were significantly larger than the contralateral ankles in all groups (p<0.05). Histopathological evaluation confirmed arthritic changes in the CFA-induced group with less variability after 4 weeks of arthritis induction. Conclusion This rat model of arthritic diabetic mimics the progressive and chronic nature of Charcot arthropathy in humans. This model can be further use to study treatments that might enhance the fusion rate in ankle arthrodesis in healing-defective patients such as those with diabetes. Level of Clinical Evidence 5.
Collapse
Affiliation(s)
- Dimas Radithya Boedijono
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ismail Hadisoebroto Dilogo
- Department of Orthopaedic and Traumatology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Marcel Prasetyo
- Department of Radiology, Faculty of Medicine Universitas Indonesia - Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | | | - Fitriya Nur Annisa Dewi
- School of Veterinary Medicine and Biomedical Sciences, Bogor Agricultural University (IPB) - Primate Research Center, Bogor Agricultural University (IPB), Bogor, Indonesia
| | - Em Yunir
- Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Aria Kekalih
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ahmad Nugroho
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| | - Dina Aprilya
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| |
Collapse
|
5
|
Roberts RHR, Davies-Jones GR, Brock J, Satheesh V, Robertson GAJ. Surgical management of the diabetic foot: The current evidence. World J Orthop 2024; 15:404-417. [PMID: 38835689 PMCID: PMC11145970 DOI: 10.5312/wjo.v15.i5.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/12/2024] [Accepted: 04/24/2024] [Indexed: 05/15/2024] Open
Abstract
The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.
Collapse
Affiliation(s)
| | - Gareth Rhys Davies-Jones
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
| | - James Brock
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Vaishnav Satheesh
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Greg AJ Robertson
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
| |
Collapse
|
6
|
Raspovic KM, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Wukich DK. Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3653. [PMID: 37179484 DOI: 10.1002/dmrr.3653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin. METHODS We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted. RESULTS We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission. CONCLUSIONS There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease.
Collapse
Affiliation(s)
- Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
7
|
Khan O, Kavarthapu M, Edmonds M, Kavarthapu V. Surgical management of Charcot foot - The advancements over the past decade. J Clin Orthop Trauma 2023; 47:102317. [PMID: 38196500 PMCID: PMC10772398 DOI: 10.1016/j.jcot.2023.102317] [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: 09/30/2023] [Revised: 11/13/2023] [Accepted: 12/13/2023] [Indexed: 01/11/2024] Open
Abstract
Charcot neuroarthropathy is a progressive, destructive condition leading to deformity, dysfunction and, in some cases, amputation. Much evolution has occurred over the last couple of decades in the management of Charcot foot with a focus on developing limb salvage and reconstructive techniques. The aim has been to achieve a stable plantigrade foot that remains pain and ulcer-free whilst reducing amputation rates. Soft tissue and bony reconstructions have been explored, and various modalities of fixation, including internal, external, and combined techniques, have been described and their outcomes published. Currently, no strong evidence exists which supports a particular modality of treatment, nor have there been any randomised studies to this effect, but the results are nevertheless promising. Recent studies have reported on minimally invasive techniques, the use of super construct fixation, computer-navigated deformity correction, the efficacy of techniques such as subtalar arthrodesis or tendon balancing procedures and staged deformity corrections. There is a need for more controlled and comparative studies with consistent reporting of intended outcomes to create a stronger portfolio of evidence on the surgical management of Charcot foot.
Collapse
Affiliation(s)
- Omeair Khan
- Specialty Orthopaedic Registrar, Department of Trauma and Orthopaedics, King's College Hospital, London, UK
| | | | - Michael Edmonds
- Diabetic Foot Physician, Diabetic Foot Clinic and Diabetic Department, King's College Hospital, London, SE5 9RS, UK
- Department of Diabetes, Faculty of Life Sciences and Medicine, King's College, Strand, London, WC2R 2LS, UK
| | - Venu Kavarthapu
- Consultant Orthopaedic Surgeon, Department of Trauma and Orthopaedics, King's College Hospital, London, UK
- University of Southern Denmark, Denmark
| |
Collapse
|
8
|
Zhang B, Li W, Li Y, Du H, Wu Y. Case Report: Supramalleolar osteotomy to preserve joint function and delay the development of Charcot neuroarthropathy of the ankle. Front Surg 2023; 10:1292120. [PMID: 38053720 PMCID: PMC10694268 DOI: 10.3389/fsurg.2023.1292120] [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: 09/11/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023] Open
Abstract
Background Charcot neuroarthropathy (CN) is a severe disease that primarily affects the foot and ankle. Conservative treatment with total contact casts is suitable for early stages, but surgery is necessary for complications such as ulceration, malalignment, infection, or severe pain. The ankle instability caused by excessive axial load may require arthrodesis. However, preserving joint function in young patient can significantly enhance the quality of life. Case report A 33-year-old woman underwent open reduction and internal fixation after the right tibia and fibula fractures following a fall while walking. She developed severe pain and deformity in her right ankle after full weightbearing. After further evaluation, she was diagnosed with Charcot neuroarthropathy (CN) of the right ankle. The patient declined arthrodesis and opted for a supramalleolar osteotomy (SMO) instead 18 months after the initial surgery. The SMO procedure involved correcting the hindfoot malalignment through osteotomy and fixation. Although she experienced skin necrosis, the patient eventually achieved satisfactory outcomes with improvements in pain, deformity, and functionality of the ankle. Radiographic measurements showed positive realignment, and the patient reported a significant improvement in her quality of life at the final follow-up. Conclusions The SMO procedure could potentially be considered as an option to preserve ankle function and delay the disease development of CN for young patients. The restored foot stability and hindfoot alignment can help improve patients' quality of life.
Collapse
Affiliation(s)
- Baozhou Zhang
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, The Fourth Clinical College of Peking University, Beijing, China
| | - Wenjing Li
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, The Fourth Clinical College of Peking University, Beijing, China
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, Capital Medical University, Beijing, China
| | - Ying Li
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, The Fourth Clinical College of Peking University, Beijing, China
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, Capital Medical University, Beijing, China
| | - Hui Du
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, The Fourth Clinical College of Peking University, Beijing, China
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, Capital Medical University, Beijing, China
| | - Yong Wu
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, The Fourth Clinical College of Peking University, Beijing, China
- Department of Foot and Ankle Surgery, Beijing JiShuiTan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
Mehlhorn AT, Illgner U, Lemperle S, Hoerterer H, Krenn V, Walther M. Histopathological assessment of a two-stage reconstructive procedure of the infected Charcot foot. Arch Orthop Trauma Surg 2023; 143:1223-1230. [PMID: 34743216 DOI: 10.1007/s00402-021-04238-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Charcot neuropathic osteoarthropathy (CN) can be complicated by osteomyelitis (OM). Surgery is a standard procedure to treat OM including debridement and interposition of antibiotic-loaded cement (ABLC) spacer. The course of CN and OM was investigated on a histopathological level. MATERIALS AND METHODS Diabetic patients (n = 15) suffering from CN and midfoot OM underwent surgical debridement and interposition of ABLC was interposed. 6 weeks later, ABLC was removed and bone samples were taken again. Histopathological Charcot Score (HCS), Histopathological Osteomyelitis Evaluation Score (HOES) and microbiological assessment were used to evaluate osteomyelitic and neuroosteoarthropathic activity at both time points. RESULTS Interposition of ABLC leads to microbiological/histopathological eradication of OM in 73%/87% of patients. CN activity-measured by HCS-could be reduced from moderate to low activity by ABLC spacer and correlated with HOES. CONCLUSIONS CN activity could be reduced by surgery. It can be suggested that neuroosteoarthropathic activity measured by HCS is triggered by OM.
Collapse
Affiliation(s)
- Alexander T Mehlhorn
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany.
- Department of Orthopedics and Trauma Surgery, Medical Center, Albert-Ludwigs University of Freiburg, Freiburg, Germany.
| | - Ulrich Illgner
- Orthopädische Privatpraxis Seintsch Illgner, Koblenz, Germany
| | - Stefan Lemperle
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
| | - Hubert Hoerterer
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Veith Krenn
- MVZ-Zentrum Für Histologie, Zytologie Und Molekulare Diagnostik GmbH, Max-Planck-Str. 5, Trier, Germany
| | - Markus Walther
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
| |
Collapse
|
10
|
High rate of complications after corrective midfoot/subtalar arthrodesis and Achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3. INTERNATIONAL ORTHOPAEDICS 2023; 47:141-150. [PMID: 36136106 PMCID: PMC9810683 DOI: 10.1007/s00264-022-05567-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Corrective midfoot resection arthrodesis is the standard treatment of Charcot arthropathy type Sanders 2 and 3 with severe dislocation. In order to critically evaluate the effect of surgical correction, a retrospective analysis of our patient cohort was performed. Hereby, special emphasis was set on the analysis of the pre- and post-operative equinus position of the hindfoot. METHODS Retrospectively, all patients (n = 82) after midfoot resection arthrodesis in Charcot type Sanders 2 or 3 were included. Complications were recorded, and the mean complication-free interval was calculated. Additionally, the calcaneal pitch as well as Meary's angle were measured pre- and post-operatively and in case of complications. RESULTS Overall complication rate was 89%. Revision surgery was necessary in 46% of all patients. The mean complication-free interval was 285 days (0-1560 days). Calcaneal pitch and Meary's angle significantly improved after operation but returned to pre-operative values after onset of complications. Achilles tendon lengthening showed no significant effects on the mean complication-free interval. CONCLUSION Operative treatment of Charcot arthropathy remains a surgical challenge with high complication rates. Surgical correction of equinus position has been highlighted for successful treatment but was not able to prevent complications in this study, which is demonstrated by the recurrent decrease of the calcaneal pitch in cases of reoperation. Therefore, as a conclusion of our results, our treatment algorithm changed towards primarily addressing the equinus malpositioning of the hindfoot by corrective arthrodesis of the hindfoot.
Collapse
|
11
|
Abstract
The Charcot diabetic foot presents unique challenges to the podiatric surgeon in the quest to salvage the limb. This disorder is an intersection of prototypical metabolic diseases and neurodegenerative disorder. Furthermore, it can be considered a disease of bone and ligaments that is often complicated by peripheral vascular disease and serious deep infection. Presently, simplistic ablative surgical procedures and the brace-makers art, still have a valid place in treating this disorder. Newer methods of surgical reconstruction are rapidly evolving to address distorted and nonfunctional limb. This article seeks to evidence the principles and practice of beaming the Charcot midfoot. As will be presented, the beam is a load-sharing device, which can be surgically introduced in an intramedullary method to restore architecture and strength to the Charcot foot. Problems with beam failure and migration have resulted in unsatisfactory outcomes as will be discussed. New Charcot-specific beams are currently reaching the podiatric surgeon with hopes of improving durability. In this article, we aim to address the surgical art of the beam, the engineering principles of beaming, and the novel introduction of a truss/tie rod configuration of beaming.
Collapse
Affiliation(s)
- William Grant
- Tidewater Foot and Ankle, 760 Independence Boulevard, Virginia Beach, VA 23455, USA.
| | - Lisa Grant-McDonald
- Tidewater Foot and Ankle, 760 Independence Boulevard, Virginia Beach, VA 23455, USA
| |
Collapse
|
12
|
Spingola HD, Martucci J, DiDomenico LA. Plate Fixation in Midfoot and Ankle Charcot Neuroarthropathy. Clin Podiatr Med Surg 2022; 39:675-693. [PMID: 36180196 DOI: 10.1016/j.cpm.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Surgical reconstruction of Charcot arthropathy in the foot and ankle is extremely difficult. The fundamentals of reconstruction are necessary to provide adequate outcome. Removing and resecting the diseased bone is needed along with good anatomic alignment and rigid fixation. This reconstructive surgery is not only difficult from medical management point of view but also involves patient compliance and good technical components of the surgery from the surgeon. The surgeon must have skills with internal and external fixation, a good understanding of lower extremity vascular disease, and a good understanding of infectious disease and plastic surgical techniques of the lower extremity.
Collapse
Affiliation(s)
- Henry D Spingola
- NOMS Ankle and Foot Care Centers, 8175 Market Street, Youngstown, Ohio 44512, USA
| | - John Martucci
- NOMS Ankle and Foot Care Centers, 8175 Market Street, Youngstown, Ohio 44512, USA
| | - Lawrence A DiDomenico
- NOMS Ankle and Foot Care Centers, 8175 Market Street, Youngstown, Ohio 44512, USA; NOMS Ankle and Foot Care Centers, 16844 Street, Clair Avenue, East Liverpool, Ohio 43920, USA.
| |
Collapse
|
13
|
Evidence-based conservative limb preserving surgery for the diabetic foot complications: A systematic review of systematic reviews. Foot Ankle Surg 2022; 28:670-679. [PMID: 34479784 DOI: 10.1016/j.fas.2021.08.006] [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: 06/25/2021] [Revised: 08/17/2021] [Accepted: 08/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC. METHODS PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies' quality. RESULTS 22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82. CONCLUSIONS There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.
Collapse
|
14
|
Simonik MM, Pitarresi J, Willing R. Analysis of Intramedullary Beam Designs Using Customized Finite Element Models for Medial Column Arthrodesis of the Foot. J Foot Ankle Surg 2022; 61:508-519. [PMID: 34776331 DOI: 10.1053/j.jfas.2021.10.002] [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: 02/26/2021] [Revised: 09/29/2021] [Accepted: 10/02/2021] [Indexed: 02/03/2023]
Abstract
Intramedullary beaming is a surgical option for medial column arthrodesis; however, disagreement exists about which beam design should be used. This computational study aimed to analyze the effects that common beam parameters have on medial column arthrodesis using a set of 5 subject-specific finite element models. A full-factorial design of experiments was conducted with 3 factors: implant stiffness (114 GPa Titanium vs 193 GPa Stainless Steel), threaded portion (25 mm Partially Threaded vs 130 mm Fully Threaded) and cannulation (Cannulated vs Solid). Increasing implant stiffness, threaded portion and using a solid beam all significantly increased medial column stiffness from 13.9 to 20.0 N/mm (p < .001), 15.2 to 18.8 N/mm (p = .001) and 13.6 to 20.4 N/mm (p < .001), respectively. Moreover, simultaneously increasing all 3 factors resulted in a 172% increase in medial column stiffness, as well as a 33% decrease in maximum von-Mises stress, 70% decrease in strain energy and 44% decrease in the average normal force in the implant during bending; all of which were significant. There was no significant increase in contact area in any of the joints, but there was a significant decrease in micromotion in each joint, ranging from 63% to 66%. Based on the parameters tested, a stainless steel, fully threaded (design that can apply compression), solid intramedullary device would produce the most stable construct for medial column arthrodesis under ideal conditions. Future studies simulating neuropathic conditions are needed before clinical use; however, this study shows the potential benefits of altering the implant design.
Collapse
Affiliation(s)
| | - James Pitarresi
- Binghamton University, Mechanical Engineering, Binghamton, NY
| | - Ryan Willing
- Western University, Mechanical and Materials Engineering, London, Canada
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Superconstructs in reconstruction surgery of Charcot foot Brodsky 1: A case report. Int J Surg Case Rep 2021; 90:106670. [PMID: 34896775 PMCID: PMC8666559 DOI: 10.1016/j.ijscr.2021.106670] [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] [Received: 11/04/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive condition of joints, soft tissues, and bones. CN causes considerable high mortality and morbidity. A common issue is early diagnosis and appropriate treatment. Thus, the operative treatment is indicated when patients have progressive deformities, infection and ulceration. The superconstructs method for Charcot foot (CF) is considered giving better clinical outcome than other methods. Presentation of case A 61-year-old male admitted to an outpatient clinic with chief complaint of swelling and pain on a left foot with history of diabetes mellitus type 2. From the physical examination, left foot revealed a swelling with rocker bottom deformity and limited range of motion. The radiological examination showed sclerotic appearance of bone deformity metatarsal joint of midfoot of toe. The patients were diagnosed with left Charcot foot Brodsky Type 1, Eichenholtz grade III with diabetes mellitus type 2. Discussion We made superconstructs rather than standard fixation which is frequently inadequate due to changes accompanying the Charcot process. Thus, we performed an adequate reduction of deformity, reduce soft tissue tension, fixation extension beyond a zone of injury, then use of strongest fixation devices that are applied to maximize mechanical function. Conclusion This study showed that superconstructs provide satisfactory clinical and outcomes. This method is useful for achieving construct and stable fixation especially for Charcot foot. Limited studies reported the outcome of the method of “superconstruct” surgery for Charcot's foot. Anatomical position and stable fixation are achieved with superconstruct surgery. Satisfactory clinical outcome was concluded after superconstruct surgery.
Collapse
|
17
|
Wang BK, Wukich DK, Sambandam S. Complications from ankle arthrodesis in diabetes-related Charcot foot syndrome. J Diabetes Complications 2021; 35:108071. [PMID: 34674895 DOI: 10.1016/j.jdiacomp.2021.108071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/13/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes. METHODS The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared. RESULTS Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001). CONCLUSION Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN. LEVEL OF EVIDENCE Cohort study; Level of evidence, 3.
Collapse
Affiliation(s)
- Benjamin K Wang
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Division of Orthopaedic Surgery, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Senthil Sambandam
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Division of Orthopaedic Surgery, Veterans Affairs North Texas Health Care System, Dallas, TX, USA.
| |
Collapse
|
18
|
Wang G, Lin J, Zhang H, Pei Y, Zhu L, Xu Q. Three-dimension correction of Charcot ankle deformity with a titanium implant. Comput Assist Surg (Abingdon) 2021; 26:15-21. [PMID: 33625935 DOI: 10.1080/24699322.2021.1887356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy of the ankle is an extremely challenging clinical dilemma, and its surgical management can be highly complicated. The goal of Charcot ankle treatment is to to restore a plantigrade and stable foot, and thus to avoid ulceration with subsequent infection. This report aims to introduce a method of correcting ankle deformity using a novel 3D printing technique. PATIENT AND METHODS One patient with Charcot ankle deformity was operated in this study. The ankle deformity of this patient was quantified in three dimensions through computed tomography. On the basis of the computed tomography scans, a new titanium implant was designed and manufactured using 3D printing. The implant was applied in the surgery of tibio-talo-calcaneal arthrodesis to restore local anatomy of the affected ankle of the patient with Charcot neuroarthropathy. RESULTS Evaluation of the post-operative radiography indicated union in the affected ankle. After surgery, the planar foot in this patient was restored. The patient was satisfied with the post-operative course, and joint fusion was successful as indicated by 2-year post-operative evaluation. The results of post-operative follow-up showed that the lower limb length of the patient with Charcot neuroarthropathy was salvaged, and the patient retained the plantigrade foot. CONCLUSION Three-dimensional printing technique combined with tibio-talo-calcaneal arthrodesis may help to correct ankle deformity in patients with Charcot neuroarthropathy.
Collapse
Affiliation(s)
- Gang Wang
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Junhao Lin
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Hong Zhang
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Yantao Pei
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Lei Zhu
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Qingjia Xu
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| |
Collapse
|
19
|
Simonik MM, Pitarresi JM, Willing R. Development of customized finite element models of medial column fixation using an intramedullary beam: A computational sensitivity analysis. Med Eng Phys 2021; 88:32-40. [PMID: 33485511 DOI: 10.1016/j.medengphy.2020.12.003] [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] [Received: 03/29/2020] [Revised: 11/11/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022]
Abstract
Intramedullary beaming is commonly used for medial column arthrodesis to prevent or correct rocker-bottom deformities; however, the biomechanics of these reconstructions have not been rigorously studied. Customized FE models of intramedullary beaming of the medial column were developed and compared to a previous cadaveric study, which resulted in a strong correlation in medial column stiffness (ρ = 0.83, p = .079) and implant failure locations. A design of experiments was performed to quantify the models' sensitivities to varying cortical shell and cartilage thicknesses, cancellous bone and cartilage elastic moduli, and surgical medial column compression distance. Cartilage thickness and cartilage elastic modulus had the largest impact on medial column stiffness and compression distance had the greatest effect on cartilage contact area. Cortical shell thickness and cancellous bone properties did not have a significant effect on the measured parameters for the values tested. Overall, the FE models exhibited behavior that is consistent with known mechanical principles related to bending and composite structures as well as the experimental results. This study elucidates the effects of varying commonly assumed model parameters that can aid future studies aimed at screening implant designs.
Collapse
Affiliation(s)
- Melissa M Simonik
- Mechanical Engineering Department, Binghamton University, Vestal, NY, USA.
| | - J M Pitarresi
- Mechanical Engineering Department, Binghamton University, Vestal, NY, USA
| | - R Willing
- Mechanical Engineering Department, Binghamton University, Vestal, NY, USA; Department of Mechanical and Materials Engineering, Western University, London, Canada
| |
Collapse
|
20
|
Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
Collapse
Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
| |
Collapse
|
21
|
Abstract
Charcot neuropathic arthropathy (CN) is a devastating condition resulting in non-reducible foot deformity that places patients with distal peripheral neuropathy at risk for the development of chronic neuropathic foot ulcers, major lower extremity amputation, and even death. The condition is often misdiagnosed early in its presentation because of a lack of knowledge among members of the medical community. Consequently, initial therapies for the condition are fewer and patients who present in more advanced stages of the condition are more difficult to manage. We now understand that CN is a multifactorial process resulting in unregulated osteoclastogenesis and bony destruction. Classically, the patient will present with an edematous, erythematous foot with increased temperature. These non-specific findings lead to a multitude of differential diagnoses. However, there are no diagnostic biomarkers or pathognomonic clinical signs to distinguish this condition from other common foot ailments seen in the context of peripheral neuropathy. Advancing our understanding of this condition, while educating the medical community about its devastating impact, is needed to advance and improve outcomes for patients affected by CN.
Collapse
Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48106, USA.
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Abstract
We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.
Collapse
Affiliation(s)
- Ashtin Doorgakant
- Foot and Ankle Unit, Northern General Hospital, Foot and Ankle Offices, Selby Wing, Herries Road, Sheffield S5 7AU, UK.
| | - Mark B Davies
- Northern General Hospital, Foot and Ankle Unit, Herries Road, Sheffield, S5 7AU, UK
| |
Collapse
|
24
|
Pradana AS, Phatama KY, Utomo AS, Bimadi MH, Putera MA, Sukmajaya WP, Mustamsir E, Hidayat M. Union of Brodsky type 1/Eichenholtz stage III Charcot neuroarthropathy after forefoot arthrodesis. Int J Surg Case Rep 2020; 71:139-143. [PMID: 32446994 PMCID: PMC7256205 DOI: 10.1016/j.ijscr.2020.04.040] [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] [Received: 01/09/2020] [Revised: 04/10/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION One of the surgical intervention options for Charcot neuroarthropathy (CN) is arthrodesis. The arthrodesis procedure for the foot and ankle joint have been widely used in previous studies. This study aimed to evaluate the functional and radiological outcomes after arthrodesis procedure for the CN patient with Brodsky type 1/Eichenholtz stage III. PRESENTATION OF CASE A 49-years-old diabetic woman presented with alteration of her right foot's shape and a cracking sensation while walking in the last six months. Rocker-bottom deformity and a decreased sensation on the right foot were found, and the initial American Orthopaedic Foot & Ankle Society (AOFAS) score was 45. Subsequently, forefoot arthrodesis of the right foot was performed. DISCUSSION Several studies state that arthrodesis procedure is often used for CN management in order to achieve a plantigrade and stable foot. This study presents an improvement of the foot arch, AOFAS score, and union of the talus six months after surgery. CONCLUSION The arthrodesis procedure by using screws and Kirschner wire (K-wire) fixation is an effective method in CN management if the patient is compliant. This study showed a good result, anatomically restored the foot arch, and excellent radiological union, but different tools to analyze foot functional status and longer follow up period are needed for a better analysis.
Collapse
Affiliation(s)
- Ananto Satya Pradana
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia.
| | - Krisna Yuarno Phatama
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Adhi Satrio Utomo
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Muhammad Hilman Bimadi
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia.
| | - Marvin Anthony Putera
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - William Putera Sukmajaya
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Edi Mustamsir
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Mohamad Hidayat
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Yammine K, Assi C. Intramedullary nail versus external fixator for ankle arthrodesis in Charcot neuroarthropathy: A meta-analysis of comparative studies. J Orthop Surg (Hong Kong) 2020; 27:2309499019836012. [PMID: 30894064 DOI: 10.1177/2309499019836012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Ankle Charcot neuroarthropathy presents a great challenge for treatment. While conservative treatments yield poor results, arthrodesis is considered the treatment of choice for unstable Charcot ankles. There are two methods used for ankle fusion: retrograde intramedullary nail (IMN) and external fixator (EF). Literature reports inconclusive results on which method is better for arthrodesis. METHODS The aim of this meta-analysis is to look for significant difference between the two techniques in terms of fusion rate and complications. Four comparative studies including 117 patients (117 interventions) were located and analyzed. RESULTS IMN was found to yield double fusion rate than EF ( p = 0.2) with 5 weeks less time to heal ( p = 0.4). While no significance was noted for revision surgery and amputation rates, EF yielded higher rates of hardware infection ( p = 0.01) and wound infection ( p = 0.01). The IMN method seems to offer quicker and better fusion rate when compared to EF with significantly lower postoperative infection rates. CONCLUSION In the clinical context of high-risk patients such as the diabetic population, IMN technique could be a better option in the case of ulcer-free ankles/feet or in the presence of medial/lateral ulcers. In case of presence of plantar ulcers, EF might be a better choice to avoid the plantar approach for nail insertion. Future research with bigger sample sized and randomized studies are warranted for validation.
Collapse
Affiliation(s)
- Kaissar Yammine
- 1 Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon.,2 School of Medicine, Lebanese American University, Byblos, Lebanon.,3 Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,4 Diabeti Foot Clinic, Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon
| | - Chahine Assi
- 1 Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon.,2 School of Medicine, Lebanese American University, Byblos, Lebanon.,3 Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| |
Collapse
|
27
|
Abstract
This article discusses rearfoot fusions for foot and ankle surgeons. It establishes normal foot and ankle function primarily in the stance phase of gait. The foot is greatly affected by external and internal forces, which contribute to normal function or the need for compensatory mechanisms. As a result of compensation, many symptoms develop, often leading to debilitating disorders such as degenerative joint disease. The interaction of the ankle, subtalar, and midtarsal joints are outlined. Congenital deformities, trauma and abnormal compensation are reviewed along with corresponding sequelae. Surgery is often indicated to reduce symptoms, improve position, and help stabilize the foot.
Collapse
Affiliation(s)
- Harold D Schoenhaus
- Penn Presbyterian Medical Center, Philadelphia, PA, USA; Temple University School of Podiatric Medicine, Philadelphia, PA, USA.
| |
Collapse
|
28
|
New Concepts in the Management of Charcot Neuroarthropathy in Diabetes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:391-415. [PMID: 32124412 DOI: 10.1007/5584_2020_498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Charcot Neuroarthropathy (CN) is an uncommon, debilitating and often underdiagnosed complication of chronic diabetes mellitus though, it can also occur in other medical conditions resulting from nerve injury. Till date, the etiology of CN remains unknown, but enhanced osteoclastogenesis is believed to play a central role in the pathogenesis of CN, in the presence of neuropathy. CN compromises the overall health and quality of life. Delayed diagnosis can result in a severe deformity that can act as a gateway to ulceration, infection and in the worst case, can lead to limb loss. In an early stage of CN, immobilization with offloading plays a key role to a successful treatment. Medical therapies seem to have limited role in the treatment of CN.In case of severe deformity, proper footwear or bracing may help prevent further deterioration and development of an ulcer. In individuals with a concomitant ulcer with osteomyelitis, soft tissue infection and severe deformity, where conservative measures fall short, surgical intervention becomes the only choice of treatment. Early diagnosis and proper management at an early stage can help prevent the occurrence of CN and amputation.
Collapse
|
29
|
Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management. Clin Podiatr Med Surg 2019; 36:663-684. [PMID: 31466574 DOI: 10.1016/j.cpm.2019.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.
Collapse
|
30
|
Sabapathy SR, Periasamy M. Healing ulcers and preventing their recurrences in the diabetic foot. Indian J Plast Surg 2019; 49:302-313. [PMID: 28216809 PMCID: PMC5288904 DOI: 10.4103/0970-0358.197238] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 – the foot at risk, Class 2 – superficial ulcers without infection, Class 3 – the crippled foot and Class 4 – the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot.
Collapse
Affiliation(s)
- S Raja Sabapathy
- Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Madhu Periasamy
- Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| |
Collapse
|
31
|
Wanzou JPV, Sekimpi P, Komagum JO, Nakwagala F, Mwaka ES. Charcot arthropathy of the diabetic foot in a sub-Saharan tertiary hospital: a cross-sectional study. J Foot Ankle Res 2019; 12:33. [PMID: 31210786 PMCID: PMC6567465 DOI: 10.1186/s13047-019-0343-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/29/2019] [Indexed: 01/14/2023] Open
Abstract
Background Charcot foot arthropathy is a potentially limb-threatening condition that leads to progressive destruction of the bones and joints in the neuropathic foot. One of its main causes is diabetes mellitus whose prevalence is steadily increasing. The acute phase is often misdiagnosed thus leading to foot deformity, ulceration and increased risk of amputation. There is a paucity of literature on this condition from sub-Saharan Africa. This study aimed at determining the extent of Charcot foot arthropathy, the radiological patterns of Charcot foot arthropathy and patient’s factors associated with Charcot foot arthropathy among adult patients with longstanding diabetes in an African setting. Methods This was a cross-sectional study that was carried at a national referral and university teaching hospital in Kampala, Uganda. One hundred patients with longstanding diabetes mellitus were consecutively recruited. Patients with a history of having diabetes mellitus for at least seven years since diagnosis were considered to have a longstanding disease. Clinical assessment of both feet was done. Weight-bearing radiographs of the selected foot were taken and evaluated using the Sanders and Frykberg and modified Eichenholtz classifications. A blood sample was taken for glycosylated haemoglobin (HbA1c). Data were summarized using descriptive statistics and student t-test. Results The proportion of Charcot foot arthropathy among patients with longstanding diabetes was 12% of which one-third (4 out of 12) were acute cases. Fifty percent of the lesions were in the forefoot and 50% in the midfoot. Seventeen percent of lesions were at the inflammatory stage of the modified Eichenholtz classification, 50% at the developmental stage, 25% at the healing stage, and 8% at the remodelling stage. An abnormal foot radiograph was significantly associated with Charcot foot arthropathy among patients with longstanding diabetes. Conclusion Charcot foot arthropathy is fairly common in patients with longstanding diabetes mellitus in these settings with one third of patients presenting in the early acute phase. An abnormal weight-bearing radiograph was an associated factor of Charcot foot arthropathy among this specific group of patients. To reduce on the morbidity and limb threatening sequelae of this condition, clinicians are therefore advised to routinely examine the feet of patients with diabetes and send those with suspicious signs and symptoms for radiographic assessment.
Collapse
Affiliation(s)
- Jean Paul Vwakya Wanzou
- 1Department of Orthopaedics, College of Health Sciences, Makerere University, P.O BOX 7072, Kampala, Uganda
| | - Patrick Sekimpi
- 1Department of Orthopaedics, College of Health Sciences, Makerere University, P.O BOX 7072, Kampala, Uganda
| | | | - Frederick Nakwagala
- 3Department of Internal medicine, Endocrinology Unit, Mulago Hospital, P.O BOX 7051, Kampala, Uganda
| | - Erisa Sabakaki Mwaka
- 4Department of Anatomy, College of Health Sciences, Makerere University, P.O BOX 7072, Kampala, Uganda
| |
Collapse
|
32
|
Oesman I, Asdi ARB. Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for charcot osteoneuropathy of the foot: A case series. Int J Surg Case Rep 2019; 57:9-14. [PMID: 30875627 PMCID: PMC6416671 DOI: 10.1016/j.ijscr.2019.02.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/29/2019] [Accepted: 02/18/2019] [Indexed: 11/28/2022] Open
Abstract
Retrograde IM Nailing is a promising therapy for Charcot osteoneuroarthopathy. Assessment using VAS, AOFAS Scale, and SF-36 showed good result. No complication were recorded with this procedure using Expert Tibia Nail. Overall patients satisfaction for this procedure was 9/10.
Introduction Charcot osteoneuroarthopathy (CN) is a progressive degenerative arthropathy determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines. The aim of treatment is to maintain the foot on plantigrade position, recover foot deformity, osseous stability, and prevent ulceration. Intramedullary fixation in calcaneotalotibial arthrodesis has been described in promotion of rigid internal fixation with minimal soft tissue violation producing deformity correction, minimal periosteal aggression, vascular damaged and good functional outcome, with less postoperative fusion time and able to achieve fusion of the ankle and the subtalar joint after failed fusion. Presentation of case Two patients with charcot foot underwent tibiocalcaneal arthrodesis with retrograde intramedullary technique by Expert Tibial Nail (ETN). The patients are both male 59 years with right ankle deformity 9 months prior to admission and history of trauma and 40 years old with history of Type 2 Diabetes Mellitus. Visual analog scale (VAS), AOFAS and SF score were assessed pre and post operative. Discussion A good stability, plantigrade ankle and painless foot on both patients were achieved with a mean score 9 for satisfaction. Pre and 3 months post operative VAS were 4 and 1, AOFAS Scale were 58 and 83, mean of SF-36 were 28.4 and 48.6 for physical condition, 37.3 and 67.2. for mental condition consecutively. No severe postoperative complication were recorded Conclusion Tibiotalocalcaneal arthrodesis with retrograde intramedullary technique using ETN system was proven to have a good option for ankle joint salvage with improvement of clinical and functional score. Hence, its application in the charcot joint is promising.
Collapse
Affiliation(s)
- I Oesman
- Consultant of Foot and Ankle Division, Staff of Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangunkusumo Hospital, Jl. Diponegoro No. 71, Jakarta, 10430, Indonesia.
| | - A R B Asdi
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangunkusumo Hospital, Jl. Diponegoro No. 71, Jakarta, 10430, Indonesia.
| |
Collapse
|
33
|
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.
Collapse
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
| |
Collapse
|
34
|
Bernasconi A, Sadile F, Smeraglia F, Mehdi N, Laborde J, Lintz F. Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update. Foot Ankle Surg 2018; 24:374-382. [PMID: 29409273 DOI: 10.1016/j.fas.2017.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/05/2017] [Accepted: 06/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy. METHODS Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated. RESULTS Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous. CONCLUSIONS The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.
Collapse
Affiliation(s)
- Alessio Bernasconi
- Department of Public Health, "Federico II" Naples University School of Medicine and Surgery, Orthopaedic and Traumatology Unit, Via S. Pansini 5, Napoli 80131, Italy.
| | - Francesco Sadile
- Department of Public Health, "Federico II" Naples University School of Medicine and Surgery, Orthopaedic and Traumatology Unit, Via S. Pansini 5, Napoli 80131, Italy.
| | - Francesco Smeraglia
- Department of Public Health, "Federico II" Naples University School of Medicine and Surgery, Orthopaedic and Traumatology Unit, Via S. Pansini 5, Napoli 80131, Italy.
| | - Nazim Mehdi
- Clinique de l'Union, Ankle and Foot Surgery Center, Boulevard de Ratalens, 31240 Saint-Jean, France.
| | - Julien Laborde
- Clinique de l'Union, Ankle and Foot Surgery Center, Boulevard de Ratalens, 31240 Saint-Jean, France.
| | - François Lintz
- Clinique de l'Union, Ankle and Foot Surgery Center, Boulevard de Ratalens, 31240 Saint-Jean, France.
| |
Collapse
|
35
|
Bullen B, Young M, McArdle C, Ellis M. Charcot neuroarthropathy patient education among podiatrists in Scotland: a modified Delphi approach. J Foot Ankle Res 2018; 11:54. [PMID: 30258497 PMCID: PMC6154915 DOI: 10.1186/s13047-018-0296-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 09/12/2018] [Indexed: 11/10/2022] Open
Abstract
Background This evaluation sought to determine current Charcot neuroarthropathy (CN) diabetes patient education practices among Scottish National Health Service (NHS) and academic podiatrists and evaluate novel visual tools and develop expert consensus for future practice. Methods Questionnaires collected mixed qualitative and quantitative responses, analysed concurrently within a convergence coding matrix. Delphi methodology permitted member-checking and agreement of consensus over two rounds. Results Fourteen participants (16.28%) completed a Round One questionnaire, leading to the generation of four themes; Experience; Person-Centred Care and the Content and Context of CN patient education. Seven consensus statements were subsequently developed and six achieved over 80% agreement among 16 participants (18.60%) with a Round Two questionnaire. Respondents agreed CN patient education should be considered for all ‘At-risk’ individuals with diabetic peripheral neuropathy (DPN). Verbal metaphors, including the ‘rocker-bottom’ foot, soft or brittle bones, collapsing, walking on honeycomb and a shattering lightbulb were frequently employed. Visual tools, including visual metaphors and The Charcot Foot Thermometer, were positively evaluated and made available online. Conclusions Key findings included respondent’s belief that CN education should be considered for all individuals with DPN and the frequent use of simile, analogy and metaphor in CN education. The concept of ‘remission’ proved controversial due to its potential for misinterpretation. Electronic supplementary material The online version of this article (10.1186/s13047-018-0296-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Benjamin Bullen
- 1NHS Lothian Diabetes Foot Service, New Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew Young
- 1NHS Lothian Diabetes Foot Service, New Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Carla McArdle
- 2Podiatry Department, School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Mairghread Ellis
- 2Podiatry Department, School of Health Sciences, Queen Margaret University, Edinburgh, UK
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Klos K, Gueorguiev B, Carow JB, Modabber A, Nebelung S, Kim BS, Horst K, Weber CD, Knobe M. Soft tissue microcirculation around the healthy Achilles tendon: a cross-sectional study focusing on the Achilles tendon and dorsal surgical approaches to the hindfoot. J Orthop Surg Res 2018; 13:142. [PMID: 29880004 PMCID: PMC5992692 DOI: 10.1186/s13018-018-0850-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023] Open
Abstract
Background Dorsal approaches to the hindfoot are frequently used. Furthermore, the vascular supply is discussed as a possible cause for ruptures and degeneration of the Achilles tendon. The aim of this study was to evaluate the microperfusion of three possible posterior approaches to the hindfoot and different areas of the Achilles tendon. Methods In 111 subjects, a laser Doppler/white light spectroscopy was used to measure microperfusion in terms of blood flow (Flow) and capillary venous oxygen saturation (SO2) in the hindfoot and Achilles tendon. Measurements were performed at two measurement points (MP, proximal and distal) of three dorsal approaches (medial, lateral and central) and inside the Achilles tendon. Results Microperfusion differed partially between the surgical approaches. The medial and the lateral approaches were significantly superior to the central approach with regard to Flow in both MP (p < 0.001), while SO2 was significantly higher at the proximal measurement point (MP 1; p < 0.001). In this area, the lateral approach was significantly superior to the medial approach regarding Flow (MP 1; p = 0.012). The Achilles tendon exhibited a significantly reduced microperfusion 5 cm proximal to the calcaneal tubercle (SO2 p = 0.001; Flow p = 0.048). Demographic factors, such as body mass index and age, had different effects. Microcirculation was partially superior in men and negatively affected by smoking. Conclusions Soft tissue microcirculation on the lateral and medial side of the healthy Achilles tendon was better than centrally on the tendon. Proximally, the lateral approach was better than the medial approach. These circumstances could provide advantages regarding the surgical approach. The Achilles tendon exhibited significantly reduced microperfusion at the typical side of degeneration and rupture. This circumstance could be a possible cause of degenerative processes.
Collapse
Affiliation(s)
- Kajetan Klos
- Department of Foot and Ankle Surgery, Catholic Hospital Mainz, Mainz, Germany
| | | | - John Bennet Carow
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University of Aachen Medical Center, Aachen, Germany
| | - Sven Nebelung
- Department of Radiology, University of Aachen Medical Center, Aachen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery, Reconstructive and Hand Surgery, University of Aachen Medical Center, Aachen, Germany
| | - Klemens Horst
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | - Christian David Weber
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany.
| |
Collapse
|
38
|
Abstract
Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.
Collapse
Affiliation(s)
- Önder İ. Kılıçoğlu
- Department of Orthopaedics and Traumatology, İstanbul University, Istanbul Faculty of Medicine, Turkey
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, İstanbul University, Istanbul Faculty of Medicine, Turkey
| | - Şamil Aktaş
- Department of Underwater and Hyperbaric Medicine, İstanbul University, Istanbul Faculty of Medicine, Turkey
| |
Collapse
|
39
|
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
| |
Collapse
|
40
|
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.
Collapse
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
| |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
DiDomenico L, Flynn Z, Reed M. Treating Charcot Arthropathy Is a Challenge: Explaining Why My Treatment Algorithm Has Changed. Clin Podiatr Med Surg 2018; 35:105-121. [PMID: 29156160 DOI: 10.1016/j.cpm.2017.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Charcot deformity is a challenge that foot and ankle surgeons struggle to manage successfully. Despite the advances in knowledge, technology, and treatment modalities, limb loss is still greater than 10%. This article discusses the efficacy of conservative measures and traditional surgical approaches. It proposes a multidisciplinary team approach, medical optimization, and lifestyle modification to put the patient in the best position to heal. Also discussed is the authors' staged surgical treatment protocol to enhance outcomes and decrease the rate of limb loss.
Collapse
Affiliation(s)
- Lawrence DiDomenico
- St. Elizabeth Medical Center, 8175 Market Street, Youngstown, OH 44512, USA.
| | - Zachary Flynn
- St. Elizabeth Medical Center, 8175 Market Street, Youngstown, OH 44512, USA
| | - Michael Reed
- Northside Medical Center, 500 Gypsy Lane, Youngstown, OH 44512, USA
| |
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Capobianco CM. Surgical Equinus Correction for the Diabetic Charcot Foot: What the Evidence Reveals. Clin Podiatr Med Surg 2017; 34:33-41. [PMID: 27865313 DOI: 10.1016/j.cpm.2016.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Triceps surae contracture, or equinus, is a known deforming force in the foot and ankle. Biomechanical studies have shown that ankle equinus significantly alters gait and plantar pressures, and in the diabetic neuropathic patient population, this can propagate plantar ulceration and/or Charcot neuroarthropathy (CN). Surgical correction of equinus is globally and frequently used to aid in plantar wound healing in the neuropathic diabetic patient, with and without CN. Treatment guidelines for equinus correction in this medically complex population are undefined and lack evidence from high-quality published peer-reviewed studies.
Collapse
Affiliation(s)
- Claire M Capobianco
- Orthopaedic Associates of Southern Delaware, 1539 Savannah Road, Suite 203, Lewes, DE 19958, USA.
| |
Collapse
|
45
|
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.
Collapse
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
| |
Collapse
|
46
|
Alrashidi Y, Hügle T, Wiewiorski M, Herrera-Perez M, Valderrabano V. Surgical Treatment Options for the Diabetic Charcot Midfoot Deformity. Clin Podiatr Med Surg 2017; 34:43-51. [PMID: 27865314 DOI: 10.1016/j.cpm.2016.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Management of diabetic Charcot midfoot deformity is one of the most demanding aspects of foot and ankle surgery. Its treatment should aim at reducing the rate of complications, including foot and ankle amputations or limb loss. Attempting reconstruction at Eichenholtz stages I and II carries the risk of infection and loss of fixation. It is advisable to limit surgical reconstruction to Eichenholtz stage III in the absence of any evidence of infection or vascular insufficiency. Achilles lengthening or gastrocnemius-soleus release is an essential initial step in surgery. Addressing the medial foot column first is a key to a successful reconstruction.
Collapse
Affiliation(s)
- Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, PO Box 30001, Prince Naif Road, Almadinah Almunawwarah, Kingdom of Saudi Arabia; Orthopaedic Department, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 11-15, Basel 4010, Switzerland
| | - Thomas Hügle
- Rheumatology Department, Osteoarthritis Research Center Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 11-15, Basel 4010, Switzerland
| | - Martin Wiewiorski
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Winterthur, Brauerstrasse 15, Winterthur 8401, Switzerland
| | - Mario Herrera-Perez
- Universidad de La Laguna, University Hospital of Canary Islands, Calle El Pilar 50 4 piso, Tenerife 38002, Spain
| | - Victor Valderrabano
- Orthopaedic Department, Osteoarthritis Research Center Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 11-15, Basel 4010, Switzerland.
| |
Collapse
|
47
|
Mehlhorn AT, Walther M, Iblher N, Südkamp NP, Schmal H. Complication assessment and prevention strategies using midfoot fusion bolt for medial column stabilization in Charcot's osteoarthropathy. Foot (Edinb) 2016; 29:36-41. [PMID: 27888790 DOI: 10.1016/j.foot.2016.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/21/2016] [Accepted: 10/24/2016] [Indexed: 02/04/2023]
Abstract
In Charcot's osteoarthropathy stabilization of the medial column of the foot was introduced in order to establish a stable foot and reduce the risk for amputation. This study was performed to analyze postoperative complications, define risk factors for those and develop strategies for prevention. Since bolt dislocation takes place frequently, it was aimed to predict an appropriate time point for bolt removal under the condition that osseous healing has occurred. Fourteen consecutive patients with neuroosteoarthropathy of the foot and arch collapse were treated with open reduction and stabilization using midfoot fusion bolt and lateral lag screws. Age, gender, presence of preoperative osteomyelitis or ulcer, number of complications and operative revisions, Hba1c value, consolidation of arthrodesis, presence of a load-bearing foot and period to bolt dislocation was assessed. The mean follow-up was 21.4±14.6 (mean±SDM) months, 64% of patients suffered from diabetes with a preoperative Hba1c of 8.5±2.4. The mean number of revisions per foot was 3.6±4.1. Bolt dislocation was seen in 57% of the patients following 11.3±8.5 months; in 75% of these patients bony healing occurred before dislocation. There was a significant association between preoperative increased Hba1c value, presence of preoperative ulcer and wound infection. Healing of arthrodesis was demonstrated in 57% and a permanent weight-bearing foot without recurrent ulcer was achieved in 79%. The early and late postoperative complications could be controlled in general. A fully load-bearing and stable foot was obtained, despite osseous consolidation was not detected in all of these cases. Once a stable foot has established early removal of fusion bolt should be considered. To decrease the risk of infection Hba1c should be adjusted and ulcers should be treated before the operation.
Collapse
Affiliation(s)
- Alexander T Mehlhorn
- Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrasse 55, Germany; Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106 Freiburg, Germany; Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Harlachingerstraße 51, 81547 Munich, Germany.
| | - Markus Walther
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106 Freiburg, Germany; Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Harlachingerstraße 51, 81547 Munich, Germany
| | - Niklas Iblher
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106 Freiburg, Germany; Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Harlachingerstraße 51, 81547 Munich, Germany
| | - Norbert P Südkamp
- Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrasse 55, Germany
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrasse 55, Germany; Department of Orthopedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, 500 Odense C, Denmark
| |
Collapse
|
48
|
Miller RJ. Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction. Foot Ankle Clin 2016; 21:595-627. [PMID: 27524708 DOI: 10.1016/j.fcl.2016.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group.
Collapse
Affiliation(s)
- Roslyn J Miller
- Department of Orthopaedics, Hairmyres Hospital, East Kilbride, Lanarkshire, UK; The London Orthopaedic Clinic, London, UK.
| |
Collapse
|
49
|
Laborde JM, Philbin TM, Chandler PJ, Daigre J. Preliminary Results of Primary Gastrocnemius-Soleus Recession for Midfoot Charcot Arthropathy. Foot Ankle Spec 2016; 9:140-4. [PMID: 26395022 DOI: 10.1177/1938640015607051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED Background Treatment of Charcot arthopathy of the foot can be challenging. The goal of this investigation was to determine whether primary gastrocnemius-soleus recession could decrease rate of new ulcers, progression of deformity, and amputation in patients with Charcot arthropathy of the midfoot.Methods A retrospective chart review revealed 28 feet in 24 diabetic patients with radiographic evidence of Charcot arthropathy of the midfoot. They were treated with primary gastrocnemius-soleus recession. Eleven feet in 11 patients had concurrent plantar midfoot ulcers. Three feet in 3 patients were lost to follow-up. Twenty-five feet in 21 patients were followed for an average of 37 months postoperatively (range = 18-79).Results A favorable outcome was defined as healing of existing ulcers, no new ulcers, no obvious progression of deformity, and no amputation. Favorable outcomes were obtained in 22 of 25 feet (18 of 21 patients). Only one patient had a persistent ulcer after gastrocnemius-soleus recession. The other 10 patients with preexisting ulcers healed. Deformity of midfoot progressed in one patient, leading ultimately to transtibial amputation. Another patient developed a knee joint infection and had a transfemoral amputation at another institution.Discussion These preliminary data suggest that primary gastrocnemius-soleus recession is followed by a much lower rate of persistent, recurrent, and new ulceration than previously reported studies. Gastrocnemius-soleus recession seems to aid in the treatment of Charcot arthropathy of the midfoot. LEVELS OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- J Monroe Laborde
- Touro Infirmary, New Orleans, Louisiana (JML)Westerville Medical Campus, Westerville, Ohio (TMP, JD)Beaumont Army Medical Center, El Paso, Texas (PJC)
| | - Terrence M Philbin
- Touro Infirmary, New Orleans, Louisiana (JML)Westerville Medical Campus, Westerville, Ohio (TMP, JD)Beaumont Army Medical Center, El Paso, Texas (PJC)
| | - Philip J Chandler
- Touro Infirmary, New Orleans, Louisiana (JML)Westerville Medical Campus, Westerville, Ohio (TMP, JD)Beaumont Army Medical Center, El Paso, Texas (PJC)
| | - Justin Daigre
- Touro Infirmary, New Orleans, Louisiana (JML)Westerville Medical Campus, Westerville, Ohio (TMP, JD)Beaumont Army Medical Center, El Paso, Texas (PJC)
| |
Collapse
|
50
|
La Fontaine J, Lavery L, Jude E. Current concepts of Charcot foot in diabetic patients. Foot (Edinb) 2016; 26:7-14. [PMID: 26802944 DOI: 10.1016/j.foot.2015.11.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/20/2014] [Accepted: 11/12/2015] [Indexed: 02/04/2023]
Abstract
The Charcot foot is an uncommon complication of neuropathy in diabetes. It is a disabling and devastating condition. The etiology of the Charcot foot is unknown, but it is characterized by acute inflammation with collapse of the foot and/or the ankle. Although the cause of this potentially debilitating condition is not known, it is generally accepted that the components of neuropathy that lead to foot complications must exist. When it is not detected early, a severe deformity will result in a secondary ulceration, infection, and amputation. Immobilization in the early stages is the key for success, but severe deformity may still develop. When severe deformity is present, bracing may be attempted but often patients will need surgical intervention. Good success has been shown with internal and external fixation. In patients with concomitant osteomyelitis, severe deformity, and/or soft tissue infection, a high amputation may be the best treatment of choice.
Collapse
Affiliation(s)
- Javier La Fontaine
- UT Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, USA.
| | - Lawrence Lavery
- UT Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, USA
| | - Edward Jude
- Tameside Hospital NHS Foundation Trust, Lancashire, UK
| |
Collapse
|