Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot

Surgical management of the diabetic foot: The current evidence

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.

A Multidisciplinary Approach to End-Stage Limb Salvage in the Highly Comorbid Atraumatic Population: An Observational Study

Background: The use of free tissue transfer (FTT) is efficacious for chronic, non-healing lower extremity (LE) wounds. The four pillars of managing patient comorbidities, infection control, blood flow status, and biomechanical function are critical in achieving successful limb salvage. The authors present their multidisciplinary institutional experience with a review of 300 FTTs performed for the complex LE limb salvage of chronic LE wounds. Methods: A single-institution, retrospective review of atraumatic LE FTTs performed by a single surgeon from July 2011 to January 2023 was reviewed. Data on patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, postoperative complications, and long-term outcomes were collected. Results: A total of 300 patients who underwent LE FTT were included in our retrospective review. Patients were on average 55.9 ± 13.6 years old with a median Charlson Comorbidity Index of 4 (IQR: 3). The majority of patients were male (70.7%). The overall hospital length of stay (LOS) was 27 days (IQR: 16), with a postoperative LOS of 14 days (IQR: 9.5). The most prevalent comorbidities were diabetes (54.7%), followed by peripheral vascular disease (PVD: 35%) and chronic kidney disease (CKD: 15.7%). The average operative LE FTT time was 416 ± 115 min. The majority of flaps were anterolateral thigh (ALT) flaps (52.7%), followed by vastus lateralis (VL) flaps (25.3%). The immediate flap success rate was 96.3%. The postoperative ipsilateral amputation rate was 12.7%. Conclusions: Successful limb salvage is possible in a highly comorbid patient population with a high prevalence of diabetes mellitus, peripheral vascular disease, and end-stage renal disease. In order to optimize patients prior to their LE FTT, extensive laboratory, arterial, and venous preoperative testing and diabetes management are needed preoperatively. Postoperative monitoring and long-term follow-up with a multidisciplinary team are also crucial for long-term limb salvage success.

Fibular strut graft for primary ankle arthrodesis in diabetic charcot neuroarthropathy patients

INTRODUCTION

Arthrodesis is an expensive procedure that is less applicable in developing countries. In this case report we reported a case of diabetic charcot neuroartropathy (CN) with primary ankle arthrodesis technique with a fibular strut graft which is considered cheaper and has a higher union rate.

CASE DESCRIPTION

A 47 years old female with complaints of pain in her right ankle after falling down the stairs with foot inverted one month before admission. The patient has uncontrolled diabetes mellitus with HbA1C 7.6 % and random blood sugar check >200 mg/dl. The patient's pain score using the visual analog score (VAS) showed a value of 8. While plain film X-ray revealed bony fragmentation in the Ankle joint. Arthrodesis surgery using fibular strut graft was performed. The postoperative X-ray examination revealed two plates attached to the anterior and medial distal tibia. A total of nine wires were attached to the patient. The patient used Ankle Foot Orthosis (AFO) and was able to walk normally 3-weeks post-surgery without pain and ulcer formation.

DISCUSSION

Fibular strut graft has good cost-effectiveness, that is more suitable for use in developing countries. It also requires a simple implant that is easily applied by all orthopedists. Fibular strut graft has the advantage of having osteogenic, osteoinductive, and osteoconductive properties that can potentially improve union.

CONCLUSION

The fibular strut graft technique can be an alternative in obtaining durable ankle fusion and functional salvaged limb with low complications.

Functional outcomes of tibiotalocalcaneal arthrodesis using a hindfoot arthrodesis nail in treating Charcot's arthropathy deformity

Background

Tibiotalocalcaneal arthrodesis or hindfoot fusion is a salvage surgical option used to treat symptomatic or severe deformity as a result of Charcot's arthropathy. It is an internal fixation that utilizes nails to stabilize the hindfoot after surgical correction of the deformity. This study intends to measure the change in functional outcomes of patients with Charcot's arthropathy using this technique and the time taken to achieve fusion.

Method

This study presents a series of 40 cases of Charcot's arthropathy where hindfoot fusion was done using a hindfoot arthrodesis nail. A retrospective analysis was done where these patients' functional scores had been evaluated preoperatively and postoperatively (serially) with the Short-Form Health Survey 36 (SF-36), American Orthopedic Foot and Ankle Society (AOFAS), Foot and Ankle Outcome Score (FAOS), and Foot Function Index (FFI). Along with its complication, the length of time required for the fusion is also reported.

Results

This study consists of 40 patients (13 men, 27 women; mean age 60.5 years; age range 52-68 years) with a mean follow-up of 64 months (range 24-108 months). The mean time taken for fusion was 5.1 months. All patients showed improvement in functional scoring (SF-36, AOFAS, FFI, and FAOS) postoperatively. We establish that the improvements were gradual over 2 years. Approximately 37.5% of patients had a minor complication and 2.5% had a major complication.

Conclusion

Hindfoot fusion using a hindfoot arthrodesis nail results in improved functional outcome with an acceptable fusion time and acceptable complication rate.

Level of evidence

Level III.

Circular Fixation in Charcot

Static circular fixation is a valuable tool for patients with Charcot foot and ankle deformities. The versatility of circular fixators allows for dynamic adjustments over time and can allow for off-loading of flaps or ulcers. The circular fixator can be used as a primary fixation device in cases of osteomyelitis or to facilitate lengthening when a segmental bone defect exists such as loss of the talus. As a secondary fixation device it can protect the internal fixation or be used when there is a compromised soft tissue envelope.

Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy

Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.

Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes

Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.

Use of the Straight Retrograde Intramedullary Nail for Tibiotalocalcaneal Arthrodesis: A Single-Institution, Single-Surgeon, Single-Implant Retrospective Series

Background:

The hindfoot fusion nail has become a popular implant for tibiotalocalcaneal (TTC) arthrodeses given its rigidity, ease of insertion, and potential for less invasive surgical approaches. The purpose of this study was to evaluate fusion and complication rates following the use of a straight, retrograde intramedullary nail for TTC arthrodeses, and the influence of diabetes and smoking on these results.

Methods:

A review of patient cases performed by a single surgeon at a single institution was performed. Variables included age, comorbidities, smoking history, BMI, hemoglobin A1c, preoperative and postoperative visual analog scale pain scores, assessment of healing, and complications. Relative and absolute risk were assessed for smoking, diabetes, fusion, and surgical complications through risk ratios. Cox proportional hazards survival analyses were performed to assess the effects of smoking and diabetes on fusion rates and complications. Linear regressions were performed to investigate the effects of smoking and diabetes on patient-reported pain levels.

Results:

Of 103 patients, there were 37 cigarette smokers and 30 diabetic patients. Eighty-three patients achieved union of all involved joints and 19 patients achieved union of 1 or 2 joints. Smokers demonstrated a 1.46 (risk ratio) (95% CI 1.03-2.07) times greater risk of nonunion but were not at an increased risk of experiencing surgical complications (0.86, 95% CI 0.56-1.33). Diabetic patients did not demonstrate an increased risk of nonunion (0.86, 95% CI 0.56-1.33) or complications (1.18, 95% CI 0.76-1.83).

Conclusion:

Because of increased nonunion risk, patients undergoing elective tibiotalocalcaneal arthrodesis should be counseled increased nonunion risks associated with smoking. In this series, we did not find a relationship between diabetes and complications or nonunion.

Level of Evidence:

Level III, retrospective cohort study.

Surgical Considerations for the Acute and Chronic Charcot Neuroarthropathy of the Foot and Ankle

Charcot neuroarthropathy (CN) of the foot/ankle is a devastating complication that can occur in neuropathic patients. It is a progressive and destructive process that is characterized by acute fractures, dislocations, and joint destruction that will lead to foot and/or ankle deformities. Early diagnosis is imperative, and early treatment may be advantageous, but the condition is not reversible. There is no cure for CN but only treatment recommendations. Ultimate goals of care should include providing a stable limb for ambulation and no ulcerations.

Charcot Neuroarthropathy: Current Surgical Management and Update. A Systematic Review

Background

Charcot 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.

Methods

All 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.

Results

A 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.

Conclusions

The 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.

Surgical strategies for prevention of amputation of the diabetic foot

Prevention of amputation has become a key objective of clinicians providing care to patients with high-risk diabetic foot problems. In this regard, the multidisciplinary diabetic foot team (MDFT) has been embraced as the most effective way to manage patients with foot ulcers, infections, and Charcot feet. Importantly, such specialized teams have also integrated various surgical specialties to enable more expedient management of these often complex conditions. Experienced diabetic foot surgeons over the last three or four decades have contributed much to this discipline, whereby foot-sparing reconstructive procedures or minor amputations have become fundamental strategies for limb preservation teams. Central to limb salvage, of course, is the recognition of underlying vascular insufficiency and the importance of prompt (endo)vascular intervention. Restoration of adequate perfusion is essential to allow the podiatric, orthopaedic, or plastic surgeon to perform indicated functional reconstructive or minor amputation procedures. This evidence-based overview discusses the various indications and surgical principles inherent in modern concepts aimed at preventing amputation in the high-risk diabetic foot.

Long-term outcome of persons with diabetic and non-diabetic neuro-osteoarthropathy after foot correction using external fixation

AIM

Diabetic neuro-osteoarthropathy (Charcot foot) is a serious form of diabetic foot syndrome, often leading to severe deformity of the foot and subsequently to ulcers and osteomyelitis. The aim of this retrospective study was to determine the success rate and long-term outcomes for a Charcot foot operation using external fixation in 115 individuals who underwent surgery between July 2008 and December 2012.

METHODS

Some 115 consecutive persons, 78 (68%) men and 37 (32%) women, were enrolled in this study. The eligibility criterion for this retrospective study was reconstructive foot surgery using a Hoffmann II external fixator in diabetic and non-diabetic neuro-osteoarthropathy. The main examination parameters in the follow-up were walking ability, amputation and mortality. Average follow-up was 5.7 (± 3.2) years.

RESULTS

Ninety-seven per cent of people were able to walk after the operation with bespoke shoes or an orthosis. At follow-up, 77% were able to walk and 51% were fully mobile even outside the home. Subsequent amputations were performed in 29 individuals (26%), with 17 (15%) minor and 12 (11%) major amputations. Forty-seven individuals died before follow-up, the majority (53%) from cardiovascular events. Average survival time post surgery was 4.5 (± 2.9) years.

CONCLUSION

Reconstruction surgery using external fixation is a very useful method for maintaining walking ability in the case of conservatively non-treatable diabetic and non-diabetic neuro-osteoarthropathy. Individuals with severe Charcot foot disease had a low rate of major amputations. Osteomyelitis was the main reason for major amputations.

Two Cases of Periprosthetic Fracture After Surgery for Acute Midfoot Charcot

Charcot neuroarthropathy is a rare condition that often results in deformity of the foot and ankle, with a high incidence of ulceration and a high risk of amputation. Traditionally, treatment of the acute stages of Charcot foot has been nonoperative until consolidation. Still, a large number of patients develop deformities, and early operative treatment of unstable Charcot feet has been suggested. To overcome some of the inherent challenges when operating on acute-stage Charcot feet, the superconstruct technique has been proposed. Early surgery for dislocated Charcot foot is sparingly described in the literature. To investigate the utility of the superconstruct technique for acute midfoot Charcot, we planned a prospective cohort study including patients with midfoot manifestation (Brodsky 1) in the active stages of the disease. Patients eligible for the study were treated with open surgery and midfoot arthrodesis using the superconstruct technique. In this report, we present the development of periprosthetic fractures related to early surgery using the superconstruct technique, possibly causing a more proximal Charcot manifestation in 2 patients with >24 months of follow-up. To our knowledge, such complications have been sparsely noted in the literature.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

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.

Diabetic Foot. Part 2: Charcot Neuroarthropathy

Charcot neuroarthropathy (CN) is an unfortunate and common complication of patients with diabetes, most likely resulting from a lack of proper understanding of the disease, which leads to late diagnosis. It is commonly misdiagnosed as infection and treated with antibiotics and a frustrated attempt of surgical drainage, which will reveal only debris of the osteoarticular destruction. Proper education of diabetic patients and of the health care professionals involved in their treatment is essential for the recognition of the initial signs of CN. The general orthopedic surgeon is usually the first to treat these patients in the early stages of the disease and must be aware of the signs of CN in order to establish an accurate diagnosis and ensure proper treatment. In theory, this would make it possible to decrease the morbidity of this condition, as long as proper treatment is instituted early.

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.

An Approach to Managing Midfoot Charcot Deformities

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.

Charcot Reconstruction: Understanding and Treating the Deformed Charcot Neuropathic Arthropathic Foot

With worsening diet and increasing prevalence of diabetes, patient encounters with Charcot neuropathic arthropathy (CNA) are expected to increase. Without intervention, the pathology progresses with further subluxation/dislocation and fracture, placing soft tissues at risk of preulceration or formal ulceration, infection, and potentially major amputation. The need to avoid amputation is of paramount importance. Although a formal single eradicating tool for CNA is lacking, there is capacity to intervene in ways that may curtail the pace of destruction. This article reviews understanding of the disease process and provides guidance to surgical reconstruction of the deformity.

Ankle fusion following failed initial treatment of complex ankle fractures in neuropathic diabetics

BACKGROUND

Unstable ankle fractures in diabetics with peripheral neuropathy have an increased risk of postoperative complications, often leading to amputation. Primary ankle arthrodesis has been suggested as an alternative when acceptable reduction and mechanical stabilization cannot be obtained.

METHODS

Over a fourteen year period, thirteen diabetic patients with peripheral neuropathy underwent an attempt at primary ankle arthrodesis following the early post-fracture development of acute neuropathic (Charcot) deformity of the ankle after sustaining a low energy unstable ankle fracture. Eight patients with open wounds and osteomyelitis underwent single stage debridement of the osteomyelitis and primary ankle fusion with an ankle fusion construct circular external fixator. Five patients without evidence of infection underwent primary arthrodesis with a retrograde locked intramedullary nail used for fixation. A successful clinical outcome was achieved with either successful radiographic arthrodesis or stable pseudarthrosis, when community ambulation was achieved with commercially-available therapeutic footwear and a short ankle orthosis.

RESULTS

Eight of the thirteen patients achieved a successful clinical outcome at a mean follow-up of 48 (range 12-136) months following the initial surgery. Three achieved clinical stability following a second surgery and one following a third. One patient with radiographic nonunion expired due to unrelated causes. One patient underwent transtibial amputation due to persistent infection. Of the five patients with failure of radiographic union, three successfully ambulated in the community with a short ankle orthosis. Postoperative complications included wound and pin-site infection, infected nonunion, chronic wounds, and tibial stress fracture.

CONCLUSION

In spite of the high risk for complications and initial failure, primary ankle fusion is a reasonable option for diabetic neuropathic patients who develop acute neuropathic arthropathy following ankle fracture.

LEVEL OF EVIDENCE

Level IV retrospective case series.

Charcot foot reconstruction outcomes: A systematic review

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.

Results of Simple Conservative Treatment of Midfoot Charcot Arthropathy

Background

Traditionally, conservative management with an offloading orthosis, such as total contact cast (TCC), has been the standard of care for midfoot Charcot arthropathy. Considering complications of TCC and surgery, we treated midfoot Charcot arthropathy without TCC in our patients. The purpose of this study was to report clinical and radiological outcomes of conservative management of midfoot Charcot arthropathy.

Methods

A total of 34 patients (38 feet) who were diagnosed as having midfoot Charcot arthropathy between 2006 and 2014 were included. Patients started full weight bearing ambulation in a hard-soled shoe immediately after diagnosis. Outcomes such as progression of arch collapse, bony prominence, ulcer occurrence, limb amputation, and changes in Charcot stage were evaluated.

Results

Of 38 feet, arch collapse was observed in four while progression of bottom bump of the midfoot was observed in five feet. Foot ulcers related to bony bumps were found in two feet.

Conclusions

Conservative treatment without restriction of ambulation is recommended for midfoot Charcot arthropathy because it is rarely progressive, unlike hindfoot-ankle arthropathy. In some cases, simple bumpectomy can be required to prevent catastrophic infection.

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.

Optimizing Results in Diabetic Charcot Reconstruction

Reconstruction of the diabetic Charcot foot can be a challenge even for the most experienced foot and ankle surgeon. The first portion of this article discusses the preoperative evaluation with an emphasis on factors that can be modified before surgical reconstruction to help optimize surgical results. The second portion of the article focuses on intraoperative methods and techniques to help improve postoperative outcomes. Surgeons should strive to provide high-quality, cost-effective care by optimizing patient selection and perioperative care. Objective measures of patient outcomes will become increasingly important with the transition from volume-based to value-based care.

Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for charcot osteoneuropathy of the foot: A case series

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Retrograde IM Nailing is a promising therapy for Charcot osteoneuroarthopathy.

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Assessment using VAS, AOFAS Scale, and SF-36 showed good result.

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No complication were recorded with this procedure using Expert Tibia Nail.

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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.

Prognostic Scoring System for Patients Undergoing Reconstructive Foot and Ankle Surgery for Charcot Neuroarthropathy: The Charcot Reconstruction Preoperative Prognostic Score

Charcot neuroarthropathy is a destructive process that occurs in patients with peripheral neuropathy, often due to poorly controlled diabetes mellitus. Surgical reconstruction can be necessary to provide a plantigrade foot that is wound free. A risk of major amputation exists after a Charcot event and after attempted reconstruction. We retrospectively reviewed the data from 34 patients (36 reconstructions) who had undergone reconstructive surgery for Charcot neuroarthropathy. The mean patient age was 56.44 years. The mean follow-up period was 56 months. We collected patient age, body mass index, presence of wound or osteomyelitis, anatomic location, activity of disease, and hemoglobin A1c. Using these data, each patient was given a score using our novel prognostic scoring system, the Charcot Reconstruction Preoperative Prognostic Score (CRPPS). Our primary outcome measure was no wound and no major amputation at the final follow-up visit. The limb salvage rate was 89% (32 of 36), and 78% (28 of 36) had no wound at the final follow-up examination. For patients without a wound or major amputation at the final follow-up visit, the mean CRPPS was 2.96 ± 1.23. The mean CRPPS for those with a wound or major amputation at the final follow-up visit was 4.33 ± 1.07 (p = .0024). Univariate logistic regression revealed 2 statistically significant predictors of wound and/or amputation: anatomic location (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.051 to 23.789; p = .043) and CRPPS (OR 2.724, 95% CI 1.274 to 5.823, p = .01). A CRPPS of ≥4 was also predictive of a negative outcome (OR 7.286, 95% CI 1.508 to 35.211; p = .013). This scoring system, with a sensitivity of 75%, specificity of 71%, and negative predictive value of 85%, is a potential starting point when educating patients and making treatment decisions in this exceptionally challenging group.

Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail-The Kings' Experience

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.

High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot

Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.

Hybrid Fixation for Ankle Fusion in Diabetic Charcot Arthropathy

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.

Ilizarov External Fixator Versus Retrograde Intramedullary Nailing for Ankle Joint Arthrodesis in Diabetic Charcot Neuroarthropathy

Charcot neuroarthropathy of the ankle joint is a destructive process that leads to instability and significant morbidity that can end with amputation. Surgical arthrodesis in Charcot neuroarthropathy has a high failure rate. The aim of the present prospective study was to compare the outcomes of an Ilizarov external fixator and retrograde intramedullary nailing (IMN) for tibiotalar arthrodesis in Charcot neuroarthropathy. From February 2010 to October 2013, 27 patients (16 males and 11 females) with Charcot neuropathy of the ankle joint were treated in our department. Their ages ranged from 32 to 75 (average 54) years. Of the 27 patients, 14 received an Ilizarov external fixator and 13 underwent IMN. A preoperative clinical and radiologic assessment of all patients was performed. The outcomes were measured for bone union, development of complications, and clinical follow-up. The mean score of modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale was 80 ± 2.7 points in the Ilizarov group and 75 ± 1.9 points in the IMN group. In the Ilizarov group, 12 of 14 patients achieved union, and in the IMN group, 10 of 13 patients achieved union. The complication rate was significantly greater in the external fixator group than in the IMN group. The complications in the Ilizarov group included nonunion in 2 patients (14%), pin tract infection in 8 (57%), pin tract loosening in 3 (21%), surgical wound infection in 3 (21%), and wound breakdown in 1 patient (7%). In the IMN group, nonunion occurred in 3 patients (23.1%), back-out of a distal locking bolt in 2 (15.4 %), and a superficial wound infection that resolved with antibiotics in 1 patient (7.7%). In conclusion, retrograde IMN and the Ilizarov external fixator both yielded better union for tibiotalar arthrodesis in Charcot neuroarthropathy. The Ilizarov external fixator resulted in a greater union rate than IMN but the complications with external fixation were significantly greater than those with IMN.

Intramedullary Nailing and External Ring Fixation for Tibiotalocalcaneal Arthrodesis in Charcot Arthropathy

BACKGROUND

Surgical strategies to address deformities of the ankle and hindfoot in patients with Charcot arthropathy include the use of retrograde intramedullary nails and ring fixators. The literature has not shown superiority of one technique over the other. This study presents a single surgeon's case series of Charcot arthropathy patients treated with either a ring fixator or retrograde intramedullary nail to achieve tibiotalocalcaneal arthrodesis.

METHODS

We performed a retrospective analysis of 27 consecutive patients with Charcot arthropathy who underwent a tibiotalocalcaneal arthrodesis using either a retrograde intramedullary (IM) nail (n = 16 patients) or a ring fixator (RF) (n = 11 patients) by a single surgeon. We report the rates of limb salvage complications requiring secondary surgery and fusion in both groups. The patient demographics and presence of medical comorbidities known to increase the risk of surgical complications were similar between groups. The mean duration of follow-up for the retrograde nail group was 3.6 years and 2.2 years for the ring fixator group.

RESULTS

The mean time to discharge from the hospital after the index surgical procedure was 2.7 days for the IM group and 4.6 days for the RF group. For the patients treated with a ring fixator, the mean time to removal of the frame after the initial application was 13.3 ± 1.8 weeks. The limb salvage rate for the RF group was 9 of 11 patients whereas it was 15 of 16 in the IM group. Complications including deep infection, hardware failure, and symptomatic nonunion requiring revision surgery were common in the IM group, with 11 of 16 patients requiring further surgery. Seven patients in the IM group required removal of the implant at a mean of 117.2 weeks after the index procedure because of the development of deep infection or nail cutout. In the RF group, only 1 patient required revision surgery. Fusion rates were similar between both groups, with 10 of 16 patients fusing in the IM group and 7 of 11 in the RF group.

CONCLUSION

Use of a retrograde intramedullary rod or ring fixator resulted in high rates of successful limb salvage when used for tibiotalocalcaneal arthrodesis in patients with Charcot arthropathy. However, in this study, the need for revision surgery was more frequent in the retrograde nail group compared to the ring fixator group.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Comparison of Diabetic Charcot Patients With and Without Foot Wounds

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.

Effectiveness of Hindfoot Arthrodesis by Stable Internal Fixation in Various Eichenholtz Stages of Neuropathic Ankle Arthropathy

The optimal time to treat neuropathic (Charcot) arthropathy of the ankle and peritalar joint is controversial because of the various treatment options available and the variable results reported in published studies. We sought to determine the outcome of hind foot arthrodesis with stable internal fixation in patients with different Eichenholtz stages of arthropathy. We prospectively studied patients with substantial disabilities caused by neuropathic arthropathy in deformed, unstable ankle and peritalar joints, with or without ulcerations, who had undergone treatment from July 2007 to December 2012. All patients underwent ankle arthrodesis, autologous iliac crest bone grafting, and subtalar joint arthrodesis, with or without talonavicular joint arthrodesis, fixed internally with an intramedullary hindfoot nail, with or without an additional plate or cancellous screws. Of the 33 enrolled patients, 9 (27.3%) had stage I, 13 (39.4%) had stage II, and 11 (33.3%) had stage III Charcot arthropathy. The cause of arthropathy was diabetes mellitus in 25 (75.8%) patients. The duration of symptoms ranged from 1 to 120 (median 7) months. The mean follow-up period was 40 (range 12 to 76) months and did not differ markedly among the groups. The hindfoot scores, rate of salvage or amputation, or complication rates did not differ significantly across Eichenholtz stage. For the patients with stage I, II, and III, the preoperative hindfoot score was 50, 49, and 48, respectively (p = .9). The corresponding postoperative scores were 68, 68, and 70 (p = .5). We found no evidence that the effectiveness of hindfoot arthrodesis by stable fixation varied across the Eichenholtz stage of Charcot arthropathy involving ankle and peritalar joint. Furthermore, we found that stable internal fixation and bone grafting using a hindfoot nail results in an 84.84% union rate and salvages the unstable and disabled foot in 90.9% of patients with ankle and peritalar Charcot arthropathy.

Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients

Background

Charcot neuropathic arthropathy (CN) is a chronic, progressive, destructive, non-infectious process that most frequently affects the bone architecture of the foot in patients with sensory neuropathy. We evaluated the outcome of protected weightbearing treatment of CN in unilaterally and bilaterally affected patients and secondarily compared outcomes in protected versus unprotected weightbearing treatment.

Methods

Patient records and radiographs from 2002 to 2012 were retrospectively analyzed. Patients with Type 1 or Type 2 diabetes with peripheral neuropathy were included. Exclusion criteria included immunosuppressive or osteoactive medication and the presence of bone tumors. Ninety patients (101 ft), mean age 60.7 ± 10.6 years at first diagnosis of CN, were identified. Protected weightbearing treatment was achieved by total contact cast or custom-made orthosis. Ulcer, infection, CN recurrence, and amputation rates were recorded. Mean follow-up was 48 (range 1–208) months.

Results

Per the Eichenholtz classification, 9 ft were prodromal, 61 in stage 1 (development), 21 in stage 2 (coalescence) and 10 in stage 3 (reconstruction). Duration of protected weightbearing was 20 ± 21 weeks and 22 ± 29 weeks in patients with unilateral and bilateral CN, respectively. In bilaterally affected patients, new ulcers developed in 9/22 (41%) feet. In unilaterally affected patients, new ulcers developed in 5/66 (8%) protected weightbearing feet and 4/13 (31%) unprotected, full weightbearing feet (p = 0.036). The ulceration rate was significantly higher in bilaterally versus unilaterally affected patients with a protected weightbearing regimen (p = 0.004). Soft tissue infection occurred in 1/13 (8%) unprotected weightbearing feet and 1/66 (2%) protected weightbearing feet in unilaterally affected patients, and in 1/22 (4%) protected weightbearing feet of bilaterally affected patients. Recurrence and amputation rates were similar across treatment modalities.

Conclusions

Bilateral CN results in significantly more ulcers than unilateral CN and leads to slightly higher soft tissue infections. Protected weightbearing in an orthopedic device can reduce the risk for complications in acute CN of the foot and ankle.

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.

Staged Reconstruction for Acute Charcot's Subtalar Joint DislocationA Case Report

Charcot's neuroarthropathy can have devastating consequences if left untreated or misdiagnosed. With progression of the disease from the acute to the chronic phase, substantial deformity and instability may result, leading to ulceration and a nonfunctional limb. The purpose of this case report is to present a staged reconstruction for active Charcot's neuroarthropathy involving the subtalar joint with complete dislocation that resulted in limb salvage and maintenance of limb function at 1-year follow-up. Although for many patients the mainstay of treatment for early Charcot's neuroarthropathy is conservative care with off-loading, early surgical correction that includes external fixation followed by definitive arthrodesis for select patients may be warranted.

Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction

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.

Internal Versus External Fixation of Charcot Midfoot Deformity Realignment

Internal and external fixation techniques have been described for realignment and arthrodesis of Charcot midfoot deformity. There currently is no consensus on the optimal method of surgical reconstruction. This systematic review compared the clinical results of surgical realignment with internal and external fixation, specifically in regard to return to functional ambulation, ulcer occurrence, nonunion, extremity amputation, unplanned further surgery, deep infection, wound healing problems, peri- or intraoperative fractures, and total cases with any complication. A search of multiple databases for all relevant articles published from January 1, 1990, to March 22, 2014, was performed. A logistic regression model evaluated each of the outcomes and its association with the type of fixation method. The odds of returning to functional ambulation were 25% higher for internal fixation (odds ratio [OR], 1.259). Internal fixation had a 42% reduced rate of ulcer occurrence (OR, 0.578). External fixation was 8 times more likely to develop radiographic nonunion than internal fixation (OR, 8.2). Internal fixation resulted in a 1.5-fold increase in extremity amputation (OR, 1.488), a 2-fold increase in deep infection (OR, 2.068), a 3.4-fold increase in wound healing complications (OR, 3.405), and a 1.5-fold increase in the total number of cases experiencing any complication (OR, 1.525). This was associated with a 20% increase in the need for unplanned further surgery with internal fixation (OR, 1.221). Although internal fixation may decrease the risk of nonunion and increase return to functional ambulation, it had a higher rate of overall complications than external fixation for realignment and arthrodesis of Charcot midfoot deformity. [Orthopedics. 2016; 39(4):e595-e601.].

The Charcot Foot: A Clinical Challenge

The Charcot foot (CF) is a clinical challenge. The CF occurs in the presence of sensory neuropathy; its etiology and pathogenesis are constantly debated. The aim of this short article is to examine therapeutic options from the perspective of experienced podiatrists.

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Charcot Neuroarthropathy in Patients With Diabetes: An Updated Systematic Review of Surgical Management

Charcot neuroarthropathy (CN) of the foot and ankle is a demanding clinical dilemma, and surgical management can be very complicated. Historically, the evidence guiding surgical management of CN has been small retrospective case series and expert opinions. The purpose of the present report was to provide a systematic review of studies published from 2009 to 2014 and to review the indications for surgery. A Medline search was performed, and a systematic review of studies discussing the surgical management of CN was undertaken. Thirty reports fit the inclusion criteria for our study, including 860 patients who had undergone a surgical procedure for the treatment of CN. The surgical procedures included amputation, arthrodesis, debridement of ulcers, drainage of infections, and exostectomy. The midfoot was addressed in 26.9% of cases, the hindfoot in 41.6%, and the ankle in 38.4%. Of the 30 studies, 24 were retrospective case series (level 4), 4 were controlled retrospective studies (level 3), and 2 were level II studies. The overall amputation rate was 8.9%. The quality of the published data on the surgical management of CN has improved during the past several years. Evidence concerning the timing of treatment and the use of different fixation methods remains inconclusive.

Orthopedic complications in diabetes

Diabetes is associated with a number of lower extremity orthopedic conditions and complications including fractures, Charcot neuroarthropathy, plantar ulcers, and infection. These complications are of significant clinical concern in terms of morbidity, mortality, and socioeconomic costs. A review of each condition is discussed, with particular emphasis on the clinical importance, diagnostic considerations, and orthopedic treatment recommendations. The goal of the article is to provide a clinical picture of the challenges that orthopedic surgeons confront, and highlight the need for specific clinical guidelines in diabetic patients.

Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction - Results from a multi-centre study

BACKGROUND

Charcot osteo-neuroarthropathy (CN) of the foot can induce severe instability and deformity. Results of a consecutive clinical multi-centre study with Midfoot Fusion Bolt (MFB, Synthes GmbH, Oberdorf, Switzerland) are reported.

METHODS

All patients (aged 18 years and older) treated between 2009 and 2013 with surgical reconstruction of the midfoot with MFB for CN were included. Demographics, pre-surgical health status, details of foot pathology, details of surgery, postoperative treatment, treatment failure, and adverse events were registered. The following radiographic angles were measured on pre-op, post-op and last follow-up radiographs: talo-1st metatarsal (TMT) angle dorsoplantar and lateral view, and calcaneo-5th metatarsal angle.

RESULTS

Forty-seven patients (48 feet) were included in three centres. In 38 patients (80.1%) diabetes was diagnosed. Wound healing problems occurred in 21% of patients and recurrent ulceration in 13%. Revision surgery for loss of correction was performed in three cases (6%). Union rate at final follow-up was 98%. Major amputation for deep infection was performed in two patients (4%), minor amputation at the foot level in three cases (6%). Failure was more frequent when only one MFB (instead of 2 or 3) was used and no Gastrocnemius lengthening was performed. Radiographic alignment significantly improved pre- versus postoperatively and preoperatively versus follow-up.

CONCLUSIONS

Realignment and fixation with MFB in severe CN result in adequate correction with minimal loss of correction in the observed clinical course. The non-union rate was lower than previously reported. Stable fixation with MFB is a valuable treatment option for CN with minimal loss of correction and high union rates. The use of a minimum of two bolts is recommended to avoid recurrent deformity. Clinical Trials.gov: NCT01770639.

Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature

BACKGROUND

While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior.

METHODS

A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material.

RESULTS

This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables.

CONCLUSION

Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft.

LEVEL OF EVIDENCE

Level IV.

Charcot neuroarthropathy: realignment of diabetic foot by means of osteosynthesis using intramedullary screws - case report

Diabetes mellitus is a serious disease that affects a large portion of the population. Charcot neuroarthropathy is one of its major complications and can lead to osteoarticular deformities, functional incapacity, ulcers and ankle and foot infections. Realignment of the foot by means of arthrodesis presents a high rate of implant failure due to weight-bearing on an insensitive foot. The aim of this report was to describe successful use of intramedullary osteosynthesis with compression screws to stabilize the deformed foot, in a diabetic patient with neuroarthropathy.

Comparison of Complications for Internal and External Fixation for Charcot Reconstruction: A Systematic Review

The surgical reconstruction of Charcot deformity can be a challenge for foot and ankle surgeons. Consensus is lacking among surgeons regarding the best method of surgical fixation to be used in reconstruction, and clear strong evidence is also lacking in published studies. We undertook a systematic review of electronic databases and other relevant sources in an attempt to better understand the complications and outcomes associated with internal and external fixation for Charcot foot and ankle reconstruction. A total of 23 level 4 studies with 616 procedures were identified. Of these, 12 studies with 275 procedures used internal fixation, and 11 studies with 341 procedures used external fixation. The odds of a successful outcome with internal fixation was 6.86. The odds of a successful outcome with external fixation was 13.20 (odds ratio 0.52, 95% confidence interval 0.30 to 0.90). The odds of success for internal fixation was 0.52 times as likely as the odds of success with external fixation. Because the odds ratio did not include 1, this difference was statistically significant at the p < .05 level. An identified trend was that external fixation was used more often in cases deemed to be difficult by the surgeon preoperatively. These findings could prove helpful to foot and ankle surgeons when making decisions regarding fixation for Charcot reconstruction.