[The Charcot joint]

[Hindfoot fusion for Charcot osteoarthropathy with a curved retrograde nail]

BACKGROUND

Charcot osteoarthropathy of the hindfoot with considerable dislocation and instability represents a therapeutic dilemma. The treatment goal is a plantigrade, stable foot that is free of infection and ulceration with the ability to ambulate in special footwear.

MATERIALS AND METHODS

Over a period of 6 years, we performed 23 hindfoot fusions in 21 patients with manifest Charcot arthropathy with the help of a curved retrograde nail (HAN). All patients suffered from insulin-dependent diabetes mellitus with polyneuropathy; 12 patients had additional peripheral vasculopathy. An average of 3.5 previous surgeries had been performed prior to hindfoot fusion.

RESULTS

Complete tibiotalocalcaneal fusion was obtained in 16 of 21 patients (76 %). Of these 21 patients, 18 (86 %) were followed clinically and radiologically for an average of 2 years. Overall, 16 patients (89 %) reported a substantial subjective improvement compared to the preoperative state. Hardware failure occurred in 7 cases (30 %) that could be brought to consolidation with exchange of the locking bolts or the complete nail. In 5 cases (22 %), a postoperative hematoma had to be removed and in 8 cases (35 %) wound edge necrosis was treated with local wound care. In 2 cases (9 %), a secondary or reactivated osteitis occurred that finally required below knee amputation.

CONCLUSION

Tibiotalocalcaneal fusion with a curved retrograde intramedullary nail (HAN) is an effective treatment option in highly unstable and deforming Charcot osteoarthropathy of the hindfoot. It is an alternative to external or other internal fixation methods and helps to avoid below knee amputation in more than 90 % of cases.

[Complex reconstruction with internal locking plate fixation for Charcot arthropathy]

BACKGROUND

Osteosynthesis and reposition of the Charcot foot is challenging with respect to choice of a proper implant. There is currently no international consensus regarding the optimal implant.

OBJECTIVES

Locking plates seem to be an innovative and stable method for reconstruction. The aim of this work is to analyze bone fusion, complications, pseudoarthrosis, and patient satisfaction.

METHODS

This paper presents a retrospective analysis of 63 consecutive Charcot feet treated between 2004 and 2014. The mean follow-up time was 2.4 years.

RESULTS

All Charcot feet treated between 2004 and 2014 were Sanders type II or III. A bony fusion was achieved in 50 % of the cases, 26 % had a functional pseudoarthrosis with intact implants and pain-free mobility, and 22 % showed no healing with broken implants. Conclusion Internal fixation with locking plates is superior to screw fixation only with regard to biomechanics. We prefer internal fixation plates to external fixation because of stability even in the case of pseudoathrosis and because of the learning curve.

[Why do osteosyntheses fail? The problem with biomechanics and biology]

Avoidance of complications in the course of fracture treatment is of essential importance not only for patients but increasingly from an economic point of view. In the past 15 years emphasis has been placed on the development and fine-tuning of minimally invasive reduction techniques with suitable implants. The main objectives were avoidance of surgical site infection and uneventful fracture healing. This facilitated the solving of long-standing problems but created new sources of error. Minimally invasive, dynamic forms of osteosynthesis were found to fail with extensive open reduction or neglect of biomechanics. Additionally, it appeared that some traditional techniques and basic rules of operative fracture treatment fell into oblivion. The majority of complications are determined already preoperatively by the choice of treatment or implant. After exact analysis of the biomechanics and biological etiology, nonunion is dealt with by an imperative increase in mechanical stability. Additional procedures, i.e., bone graft or debridement, are incorporated into the therapeutic regime. Increasing mechanical stability should be attempted with a minimum of added trauma to avoid local biological impairment. Further improvement of outcome depends on innovative and adapted teaching concepts. Training exclusively with one implant, even under the guidance of the producing company, is insufficient to grasp the various fundamentals of operative fracture treatment indispensable for a successful day-to-day routine.