Combined midfoot arthrodesis, muscle flap coverage, and circular external fixation for the chronic ulcerated Charcot deformity

Management of the Charcot Foot and Ankle: Nonreconstructive Surgery

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management

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

The Biology of Bone and Ligament Healing

This review describes the normal healing process for bone, ligaments, and tendons, including primary and secondary healing as well as bone-to-bone fusion. It depicts the important mediators and cell types involved in the inflammatory, reparative, and remodeling stages of each healing process. It also describes the main challenges for clinicians when trying to repair bone, ligaments, and tendons with a specific emphasis on Charcot neuropathy, fifth metatarsal fractures, arthrodesis, and tendon sheath and adhesions. Current treatment options and research areas are also reviewed.

Lower Extremity Amputation and Mortality Rates in the Reconstructed Diabetic Charcot Foot and Ankle With External Fixation: Data Analysis of 116 Patients

The aim of this study was to determine the lower extremity amputation and mortality rates of a group of patients who underwent reconstructive surgery using circular external fixation for treatment of diabetic Charcot neuroarthropathy (CN) of the foot and/or ankle. Existing studies regarding lower extremity amputation or mortality rates for diabetic CN of the foot and/or ankle have been performed on mostly conservatively treated patients. The objective of the statistical analysis in this studied population was to understand the difference in overall amputation and mortality rates between the 2 main groups: one with foot and/or ankle ulceration (group 1), and the other without ulceration or osteomyelitis (group 2, control group). Within group 1, 2 subgroups were established: one with osteomyelitis (group 1A) and the other without osteomyelitis (group 1B). Initially, a retrospective analysis of 150 consecutive surgically reconstructed diabetic foot and ankle cases using circular external fixation from January 2005 through December 2012 was conducted. Those which were not supported with the diagnosis of diabetic CN were excluded and the 2 other charts without proper follow-up duration (6 months) for analysis were removed, resulting in the final sample size of N = 116. There were a total of n = 7 (6.0%) below the knee amputations (group 1A = 1, group 1B = 4, and group 2 = 2) with a total of n = 5 mortalities (4.3%) (group 1A = 2, group 1B = 2, and group 2 = 1). The total amount of time for a lower extremity amputation event (n = 7) since the time of surgical reconstruction was 729.43 ± 519.73 days (range 230-1777 days) while for a mortality event (n = 5), it was 1302.00 ± 765.48 days (range 633-2499 days).

LEVELS OF EVIDENCE

Prognostic, Level III: Retrospective study.

Versatility of intrinsic muscle flaps for the diabetic Charcot foot

Bone, joint, and/or tendon exposure following surgical debridement of diabetic foot infections requires careful consideration when choosing appropriate closure methods. The unique architecture of the foot, coupled with the functional demands of mobilization, makes soft tissue reconstruction for plantar defects especially challenging. Muscle flaps incorporate the muscle, associated nerve, and vascular pedicles during transposition. This article covers their unique properties for soft tissue coverage in the diabetic Charcot foot.

[Diabetic osteoarthropathy: problems and complications in foot surgery]

Charcot neuroarthropathy is one of the most serious manifestations of the diabetic foot syndrome and the multifaceted disease pattern requires interdisciplinary cooperation. Problems may arise even if the diagnosis is made early and lack of pain may mislead to the assumption of an infectious or traumatic event. With respect to operative therapy the characteristics of polyneuropathy and altered bone metabolism have to be taken into account. Rehabilitation, in particular, differs from the guidelines for trauma patients. In the face of high complication risks substantial improvement of function must be the goal for operative treatment.

Primary arthrodesis and sural artery flap coverage for subtalar joint osteomyelitis in a diabetic patient

Diabetic chronic wounds with joint sepsis and osteomyelitis of the hindfoot can be difficult pathologic entities to treat. Limb salvage approaches are based on careful preoperative evaluation, surgical technique, and postoperative care. This article reviews the overall management of subtalar joint osteomyelitis with a case report showing primary arthrodesis with external fixation and soft tissue coverage with a reverse sural artery neurofasciocutaneous flap.

Antibiotic-loaded cement beads for Charcot ankle osteomyelitis

The concomitant presence of osteomyelitis and diabetic Charcot neuroarthropathy of the foot and ankle places those patients affected at increased risk for limb loss. Antibiotic-loaded cement has been reported to be useful in the treatment of deep soft tissue and joint infections. The authors present an overview of this adjunctive treatment modality and present a case report using antibiotic-loaded cement beads in staged reconstruction for Charcot ankle osteomyelitis.

Abductor hallucis muscle flap and staged medial column arthrodesis for the chronic ulcerated charcot foot with concomitant osteomyelitis

Midfoot ulceration is a common sequela of the diabetic Charcot rocker-bottom deformity. Because redundant soft tissue from a non- weight-bearing area is often scarce in this area of the foot, soft-tissue coverage may be challenging. Wound closure may be difficult to achieve with local wound care and off-loading techniques if the predisposing deformity that caused the ulceration is not addressed. In the same setting, surgical reconstruction is often feared when open wounds are present, given the potential for infection. Approaching these wounds with a rational stepwise and staged approach is prudent to eradicate the underlying infection and also to achieve durable wound closure and long-term deformity correction. The authors present the use of a local muscle flap and circular external fixation for closure of a recalcitrant Charcot plantar-medial midfoot ulceration and also discuss different adjunctive modalities to facilitate soft-tissue reconstruction in the diabetic foot.

The role of an extended medial column arthrodesis for Charcot midfoot neuroarthropathy

The etiology of diabetic Charcot neuroarthropathy involving the midfoot often includes an inciting traumatic event or repetitive micro-trauma from an uncompensated biomechanical imbalance that potentiates an incompletely understood pathway leading to a rocker-bottom foot deformity and ulceration. In the setting of a severe Charcot foot fracture and/or dislocation with obvious osseous instability, diagnostic delay can potentiate the limb-threatening sequelae of infected midfoot ulcerations in this patient population. In this article, the authors discuss the thought process as well as the advantages of performing an extended medial column arthrodesis for selected Charcot midfoot deformities.