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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.
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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
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Tiruveedhula M, Kavarthapu V. Managing Cavovarus Feet in Diabetic Patients. Foot Ankle Clin 2023; 28:873-887. [PMID: 37863541 DOI: 10.1016/j.fcl.2023.05.006] [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: 10/22/2023]
Abstract
A cavovarus foot is characterized by exacerbated medial longitudinal arch (cavus), hindfoot varus, plantar flexed first ray, forefoot pronation (apparent supination), forefoot adduction, and claw toe deformities. It can be broadly divided as flexible and rigid and further classified based on the neurological and non-neurological causes. Diabetes associated peripheral neuropathy complicates individual bony deformities associated with cavovarus foot with early callus which can breakdown to ulceration rapidly. Based on the disease progression in neurological and non-neurological causes of cavovarus feet in patients with diabetic neuropathy, 3 stages of the disease and its management is described.
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Affiliation(s)
- Madhu Tiruveedhula
- Mid & South Essex Foundation NHS Trust, Basildon Hospital, Nethermayne, Basildon SS16 5NL, UK.
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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.
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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
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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.
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Wukich DK, Liu GT, Johnson MJ, Van Pelt MD, Raspovic KM, Lalli T, Nakonezny P. A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy. J Foot Ankle Surg 2022; 61:1334-1340. [PMID: 35701302 DOI: 10.1053/j.jfas.2022.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/09/2020] [Accepted: 04/20/2022] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used.
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Affiliation(s)
- Dane K Wukich
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - George T Liu
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew J Johnson
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael D Van Pelt
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Trapper Lalli
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul Nakonezny
- Department of Clinical Sciences (Biostatistics), University of Texas Southwestern Medical Center, Dallas, TX
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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.
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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
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Miller R. NEMISIS: Neuropathic Minimally Invasive Surgeries. Charcot Midfoot Reconstruction, Surgical Technique, Pearls and Pitfalls. Foot Ankle Clin 2022; 27:567-581. [PMID: 36096552 DOI: 10.1016/j.fcl.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The last decade has seen a significant development in early surgical intervention for patients with or at risk of ulceration owing to deformity resulting from the sequalae of diabetic foot disease. Midfoot Charcot neuroarthropathy is the most common deformity; its correction is enabled by specialized surgical implants designed to maintain surgical corrections. There has also been an increasing number of orthopedic foot and ankle surgeons, with a specific interest in diabetic foot disease who provide early surgical correction in patients identified as high risk. Minimally invasive surgery using percutaneous incisions completes the triumvirate, facilitating earlier surgical intervention to decrease reulcerations.
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Affiliation(s)
- Roslyn Miller
- NHS Lanarkshire Universities Hospitals, Lanarkshire, Scotland, UK; Glasgow Caledonian University, Glasgow, Scotland, UK; Department of Orthopaedics, Foot and Ankle Service Lead, Hairmyres University Hospital, 218 Eaglesham Road, East Kilbride, Glasgow G75 8RG, UK.
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Najefi AA, Zaidi R, Chan O, Hester T, Kavarthapu V. Predictors of metalwork failure and nonunion after hindfoot Charcot reconstruction. Bone Joint J 2022; 104-B:703-708. [PMID: 35638210 DOI: 10.1302/0301-620x.104b6.bjj-2022-0127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. METHODS We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded. RESULTS There were 70 patients with mean follow-up of 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). CONCLUSION Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703-708.
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Affiliation(s)
- Ali-Asgar Najefi
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Razi Zaidi
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Oliver Chan
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Thomas Hester
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
| | - Venu Kavarthapu
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, UK
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Kavarthapu V, Budair B. Two-stage reconstruction of infected Charcot foot using internal fixation : a promising functional limb salvage technique. Bone Joint J 2021; 103-B:1611-1618. [PMID: 34587806 DOI: 10.1302/0301-620x.103b10.bjj-2021-0339.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. METHODS We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months' follow-up. RESULTS We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. CONCLUSION Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of 'long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion' is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611-1618.
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Affiliation(s)
- Venu Kavarthapu
- Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, UK.,University of Southern Denmark, Odense, Denmark
| | - Basil Budair
- Trauma & Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Aston University School of Engineering and Applied Science, Birmingham, UK
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Wukich DK, Liu GT, Raspovic K, Vicenzi F. Biomechanical Performance of Charcot-Specific Implants. J Foot Ankle Surg 2021; 60:440-447. [PMID: 33612405 DOI: 10.1053/j.jfas.2020.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/30/2020] [Indexed: 02/03/2023]
Abstract
Over the past 2 decades, an increased number of diabetic Charcot neuroarthropathy reconstructions have been performed. Despite advances in implant technology, arthrodesis complication rates remain high. This study examined the biomechanical properties (4-point bending, cantilever bending, and thread pullout resistance) of intramedullary implants designed for midfoot reconstruction. Large implants included A1 (7.4 mm cannulated stainless steel beam), B1 (6.5 mm solid titanium bolt), and C1 (7.0 mm cannulated titanium beam). Smaller implants included A2 (5.4 mm cannulated stainless steel beam) and C2 (5.0 mm solid titanium bolt). Four-point bending testing compared flexural properties of the body of the implants. Cantilever-bending testing was performed with the maximum bending moment being applied off the main thread of the implant to assess the thread portion. Thread pullout strength was tested by fixing the implants to a Sawbone block on a platform, and the distal portion of the implant in a clamp connected to loading actuator. Implant A1 demonstrated higher stiffness, force to failure, and fatigue compared to implants B1 and C1 (p < .05). Pullout strength of implant A1 was higher than implant B1 (p < .05). Thread fatigue strength of implant A1 was higher than implant C1 (p < .05). Implant A2 demonstrated higher stiffness, force to failure, tip fatigue strength, and thread pullout strength compared to implant C2 (p < .05), while implant C2 demonstrated higher body fatigue failure than implant A2 (p < .05). Alteration of beam/bolt parameters influences the biomechanical performance of implants used in Charcot reconstruction. Greater stiffness resists deformation, providing improved stability. Greater static failure load and fatigue limit improves the implant's ability to withstand higher and repetitive loads before failing This study should stimulate further clinical research to determine if these biomechanical properties translate into reduced implant failure rates and improved clinical outcomes in patients with diabetic Charcot neuroarthropathy.
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Affiliation(s)
- Dane K Wukich
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - George T Liu
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine Raspovic
- Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Federico Vicenzi
- Engineer, Department of Research, Development and Innovation, Orthofix Srl, Bussolengo, Italy
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Ahluwalia R, Maffulli N, Lázaro-Martínez JL, Kirketerp-Møller K, Reichert I. Diabetic foot off loading and ulcer remission: Exploring surgical off-loading. Surgeon 2021; 19:e526-e535. [PMID: 33642205 DOI: 10.1016/j.surge.2021.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/26/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration. METHODS We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations. RESULTS Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements. CONCLUSIONS AND IMPLICATIONS Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.
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Affiliation(s)
- Raju Ahluwalia
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England, E1 4DG, UK.
| | - José L Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Del Hospital, Clínico San Carlos (IdISSC), 28040, Madrid, Spain.
| | - Klaus Kirketerp-Møller
- Copenhagen Wound Healing Center, Department of Dermatology and Wounds, Bispebjerg Hospital, Copenhagen, Denmark; Steno Diabetes Center Copenhagen, Denmark.
| | - Ines Reichert
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
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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.
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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
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Kavarthapu V, Hester T. Charcot hindfoot deformity reconstruction using a hindfoot nail- surgical technique. J Clin Orthop Trauma 2021; 16:277-284. [PMID: 33738236 PMCID: PMC7937564 DOI: 10.1016/j.jcot.2021.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/29/2022] Open
Abstract
Various techniques of reconstruction of deformed Charcot hindfoot using different internal fixation devices have been described in the literature. We present our surgical technique using specific principles that has resulted in improved outcomes to allow correction of deformity, obtain stability and allow progression to weightbearing in orthotic shoes. We describe our preoperative evaluation, planning and surgical timing. We also hope to share some technical pearls and details on the finer points to achieve a satisfactory correction and reduce the learning curve.
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Affiliation(s)
- Venu Kavarthapu
- Consultant Orthopaedic Surgeon, Department of Trauma & Orthopaedics, King’s College Hospital Denmark Hill, London, SE5 9RS, UK,Associate Professor, University of Southern Denmark, King’s College Hospital Denmark Hill, London, SE5 9RS, UK,Corresponding author.
| | - Thomas Hester
- Consultant Orthopaedic Surgeon, Department of Trauma & Orthopaedics, King’s College Hospital Denmark Hill, London, SE5 9RS, UK
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Mehlhorn AT, Ugland KI, Hörterer H, Gottschalk O, Südkamp N, Walther M. A high-profile thread with grit-blasted and acid-etched surface reduces loosening of medial column fusion bolt in instable Charcot foot. Foot Ankle Surg 2020; 26:637-643. [PMID: 31521519 DOI: 10.1016/j.fas.2019.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/30/2019] [Accepted: 08/08/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intramedullary fusion bolts (FB) were introduced to stabilize the medial column of the instable Charcot foot (ICF), but complications as bolt loosening or breakage are frequent. We compared the use of a standard FB and a high-profile threaded FB with a grit-blasted surface. We hypothesized that implant related complications occurred less often and osseous consolidation of fusion sites was more distinctive using the latter type of FB. METHODS Consecutive patients suffering from an ICF were stabilized with a high-profile threaded and surface-modified FB (HTFB) (n=20) or with a standard FB (n=20) which was placed into the first ray. Additional bolts and dorsal low-profile plates were applied in every patient. In a retrospective assessment osseous consolidation of the fusion sites was analyzed at 3 month and quantified by CT scan. At 3 and 12 month longitudinal foot arch collapse and rate of bolt loosening were assessed. RESULTS Compared to the control group, the HTFB group reached significant higher consolidation after 3 month. No dislocation and a single bolt breakage was observed in the HTFB group after the fourth month, while the control group included 3 patients with bolt dislocation at 3±1 month and 5 patients with bolt breakage at 6±1.8 month. Compared to preoperative values, the improvement of Meary's angle after one-year was significant higher in the HTFB group (23.4°±14) than in controls (11.7°±13). CONCLUSIONS Modification of bolt design improves the stability of the medial column: A higher rate of osseous consolidation of the medial column leads to lower rate of bolt dislocation/breakage and finally to permanently erected longitudinal foot arch. Initially disappointing results following medial column stabilization with fusion bolts can be rejected by modifications of bolt design and its technical application.
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Affiliation(s)
- Alexander T Mehlhorn
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University of Freiburg, Medical Center, Freiburg, Germany.
| | - Karl I Ugland
- Department of Biosciences, University of Oslo, PB 1066 Blindern, 0316 Oslo, Norway
| | - Hubert Hörterer
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
| | - Oliver Gottschalk
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
| | - Norbert Südkamp
- Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University of Freiburg, Medical Center, Freiburg, Germany
| | - Markus Walther
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
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Ramanujam CL, Stuto AC, Zgonis T. Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review. J Wound Care 2020; 29:S19-S28. [PMID: 32530758 DOI: 10.12968/jowc.2020.29.sup6.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes. METHOD A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded. RESULTS A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction. CONCLUSION Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C Stuto
- LVPG Orthopedics and Sports Medicine, Lehigh Valley Health Network, Bethlehem, PA, US
| | - Thomas Zgonis
- Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
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Trieb K. The Charcot foot: pathophysiology, diagnosis and classification. Bone Joint J 2017; 98-B:1155-9. [PMID: 27587513 DOI: 10.1302/0301-620x.98b9.37038] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 04/12/2016] [Indexed: 12/15/2022]
Abstract
Neuropathic changes in the foot are common with a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy is often delayed in diabetic patients with harmful consequences including amputation. The appropriate diagnosis and treatment can avoid an extensive programme of treatment with significant morbidity for the patient, high costs and delayed surgery. The pathogenesis of a Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels. In most cases, changes are due to a combination of both pathophysiological factors. The Charcot foot is triggered by a combination of mechanical, vascular and biological factors which can lead to late diagnosis and incorrect treatment and eventually to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. The clinical diagnostic pathways based on different classifications are presented. Cite this article: Bone Joint J 2016;98-B:1155-9.
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Affiliation(s)
- K Trieb
- Klinikum Wels-Grieskirchen, Grieskirchnerstr. 42, Wels, 4600, Austria
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An Overview of Internal and External Fixation Methods for the Diabetic Charcot Foot and Ankle. Clin Podiatr Med Surg 2017; 34:25-31. [PMID: 27865312 DOI: 10.1016/j.cpm.2016.07.004] [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: 11/22/2022]
Abstract
Diabetic Charcot neuroarthropathy (DCN) of the foot and ankle is a challenging disease with regard to clinical presentation, pathogenesis, and prognosis. Its surgical management is equally difficult to interpret based on the wide array of options available. In the presence of an ulceration or concomitant osteomyelitis, internal fixation by means of screws, plates, or intramedullary nailing needs to be avoided when feasible. External fixation becomes a great surgical tool when managing DCN with concomitant osteomyelitis. This article describes internal and external fixation methods along with available literature to enlighten surgeons faced with treating this complex condition.
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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.
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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.
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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.
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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
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Affiliation(s)
- Patrick K Strotman
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Taylor J Reif
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Kucera T, Shaikh HH, Sponer P. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. J Diabetes Res 2016; 2016:3207043. [PMID: 27656656 PMCID: PMC5021483 DOI: 10.1155/2016/3207043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022] Open
Abstract
Charcot neuropathic osteoarthropathy of the foot is a relatively common complication of diabetic neuropathy. Incorrect diagnosis and improper treatment often result in the extremity having to be amputated. This paper summarises the current view on the etiology, diagnostics, and treatment of diabetic Charcot neuropathic osteoarthropathy, with particular focus on preserving the extremity through surgical intervention from our own experiences.
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Affiliation(s)
- Tomas Kucera
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
| | - Haroun Hassan Shaikh
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Pavel Sponer
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
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22
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Surgical procedures and complications in midfoot Charcot neuroarthropathy. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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