Reconstructive Charcot surgery

NewsBot · Oct 25, 2023

Functional evaluation and quality of life in the follow-up of patients with Charcot arthropathy treated by ankle arthrodesis with a locked retrograde nail
E G López-Gavito et al
Acta Ortop Mex. 2023 Jan-Feb;37(1):25-29.

Introduction: Charcot's arthropathy is a disabling non-infectious, progressive condition characterized by bony and articular destruction in patients with sensory neuropathy. In advanced cases with deformities and ankle instability, it requires a more invasive treatment as an ankle fusion with a retrograde locked intramedullary nail. It is unknown if, in these patients, the functional results of AOFAS (American Orthopaedic Foot and Ankle Society) correlate with the quality of life ones from the EuroQol-5D test and the possible postoperative complications.

Material and methods: the design is experimental, longitudinal prospective with ambispective data analysis (retrospective and prospective) to evaluate the functional results and life quality with a year of following patients with Charcot's arthropathy diagnosis treated with a retrograde locked nail from January 1, 2010, to November 1, 2018.

Results: this study resulted in complete consolidation from nine out of 11 cases, with a success rate of 81.2%, and only two cases (18.2%) developed nonunion. AOFAS and EuroQol-5D tests correlate positively in agreement with the Pearson correlation.

Conclusions: AOFAS and EuroQol-5D correlate positively, having a 45 and 63% of acceptable and satisfactory results, respectively, for both tests.
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NewsBot · Jan 11, 2024

Intraoperative Radiation Exposure During Midfoot Charcot Reconstruction
Dominick J Casciato et al
J Foot Ankle Surg. 2024 Jan 6:S1067-2516(24)00005-X

While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ 0.05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5±5.39 mGy and 256.64±130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p=0.32) or fluoroscopy times (p=0.71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p=0.01) and body mass index (p=0.03) and number of stages (p=0.04). Similarly, a relationship existed between fluoroscopy time with weight (p=0.02), body mass index (p=0.03), and number of beams/screws (p=0.003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.
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NewsBot · Jan 18, 2024

Surgical management of Charcot foot - The advancements over the past decade
Omeair Khan et al
J Clin Orthop Trauma. 2023 Dec 14

Charcot neuroarthropathy is a progressive, destructive condition leading to deformity, dysfunction and, in some cases, amputation. Much evolution has occurred over the last couple of decades in the management of Charcot foot with a focus on developing limb salvage and reconstructive techniques. The aim has been to achieve a stable plantigrade foot that remains pain and ulcer-free whilst reducing amputation rates. Soft tissue and bony reconstructions have been explored, and various modalities of fixation, including internal, external, and combined techniques, have been described and their outcomes published. Currently, no strong evidence exists which supports a particular modality of treatment, nor have there been any randomised studies to this effect, but the results are nevertheless promising. Recent studies have reported on minimally invasive techniques, the use of super construct fixation, computer-navigated deformity correction, the efficacy of techniques such as subtalar arthrodesis or tendon balancing procedures and staged deformity corrections. There is a need for more controlled and comparative studies with consistent reporting of intended outcomes to create a stronger portfolio of evidence on the surgical management of Charcot foot.
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NewsBot · May 24, 2024

Surgical Outcomes in Charcot Arthropathy
William C Skinner et al
Orthop Clin North Am. 2024 Jul;55(3):393-401

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.
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NewsBot · May 28, 2024

CHARCOT NEUROARTHROPATHY: SURGICAL OUTCOMES FOLLOWING HIND- AND MIDFOOT RECONSTRUCTION. A MINIMUM 12-MONTH FOLLOW-UP FROM A TERTIARY HOSPITAL
The British Orthopaedic Foot & Ankle Society (BOFAS) Annual Congress 2019, Nottingham, England, 13–15 November 2019.
J. Giddie et al

Background
Corrective fusion of a deformed / unstable Charcot neuroarthropathy (CN)of the midfoot and hindfoot is performed with the aim to prevent ulcers and maintain patient mobility.

Methods
Between October 2007 and July 2018, 103 CN mid and hind foot corrections in 95 patients were performed. There were 34 hind-foot, 38 mid-foot and 31 combined hind and mid-foot surgeries. 83 feet had single stage corrections, whereas 20 required a staged operation.

Results
Ninety-five patients were prospectively followed up. The mean patient age in our study was 57 years (21 – 85). Twenty-seven patients had type1 diabetes, 64 patients had type 2 and 4 patients had a neuropathy secondary to other conditions. Forty patients (42%) were offered a below knee amputation prior to attending our foot clinic. At a mean follow up of 56 months (12 – 140) we achieved 100% limb salvage with a 75% full bone fusion rate. There were 17 mortalities within our cohort at a mean period of 3 years. Ninety-seven percent (n=92) patients were mobilizing post-operatively in orthotic footwear. Fifty-two feet had pre-operative ulcers. Post-operatively 17 feet (16 patients) had persistent ulceration. Eight patients had ulcer resolution following further surgery and alteration of footwear, one patient has been listed for a below knee amputation for unstable non-union, whilst the remaining 7 patients have stable ulcers which are managed with dressings. Of the 26 feet (25 patients) with non-unions, 6 patients had revision fixation procedures whilst 8 patients required minor surgical procedures. The remaining 11 patients are stable non-unions who are asymptomatic and weight bearing. Other complications included a deep infection rate of 8% (n=7).

Conclusion
We demonstrated a 100% limb salvage rate and an 83% success rate in ulcer resolution. We recommend this be done with the support of the multi-disciplinary team.
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NewsBot · Jun 6, 2024

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint
Shirvan Rastegar et al
J Orthop Surg Res. 2024 Jun 3;19(1):332

Introduction: Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge.

Methods: This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score.

Results: Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002).

Conclusion: This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.
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NewsBot · Jun 12, 2024

Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model
Victor Anciano et al
Foot Ankle Int. 2024 Jun 10

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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NewsBot · Jun 12, 2024

Painful Nonunion in Patients With Clinically Plantigrade Diabetes-Associated Charcot Foot Arthropathy
Michael S Pinzur et al
Foot Ankle Int. 2024 Jun 10

Background: It has been assumed that diabetic patients with peripheral neuropathy should not have pain associated with Charcot foot arthropathy.

Methods: During a 19-year period, 14 diabetic patients (15 feet) presented for treatment with pain following resolution of the acute phases of midfoot Charcot foot arthropathy. All were clinically plantigrade with plain radiographic evidence of bony union without deformity. Pain did not resolve with the use of appropriate therapeutic footwear. When used, CT scans uniformly demonstrated nonunion.

Results: All 14 patients had resolution of their presenting pain following successful arthrodesis. Nonunion was confirmed at surgery in all of the patients. One patient developed a fatal pulmonary embolus following removal of the external fixator. Two required late exostectomy for bony overgrowth at the surgical site of fusion for nonunion.

Conclusion: This small series of patients would suggest that nonunion of the Charcot neuroarthropathy process was responsible for complaints of pain not able to be managed with therapeutic footwear. Successful arthrodesis resolved the pain. CT imaging may help identify a treatable source of pain in this population.
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NewsBot · Jun 30, 2024

Comparing Clinical Characteristics and Short-Term Outcomes Between Adult and Geriatric Patients Undergoing Charcot Reconstruction
Dominick J Casciato, DPM AACFAS et al
June 11, 2024

Maintaining an acceptable quality of life following a lifetime of chronic diseases and resulting physiologic effects poses a challenge when treating an aging population. In those with Charcot neuroarthropathy, wounds and infection complicate decision making when considering limb preservation versus amputation. The purpose of this investigation is to describe the clinical characteristics and short-term outcomes of geriatric patients undergoing Charcot reconstruction. A retrospective chart review of patients who underwent Charcot reconstruction from 2016-2022 was conducted. Demographics, medical history, deformity type, surgical intervention, discharge planning and short-term complications were collected. Descriptive statistics were calculated, and clinical characteristics and short-term outcomes were compared between the non-geriatric, adult, (A) and geriatric (G) cohorts using Student's t-test or Chi-squared test. Overall, 125 patients were reviewed for final analysis. Charcot deformity type, prevalence of wounds, osteomyelitis, and fixation construct did not significantly differ between groups. While the proportion of those experiencing a prolonged admission did not significantly differ between cohorts, the geriatric group showed age-related pathology including delirium and urinary tract infections. While discharge to nursing facilities did differ between groups (G 43% versus A 19%), baseline function did not. The 30-day unplanned readmission and mortality rates did differ between groups, though this difference was not statistically significant. Prior to geriatric Charcot reconstruction, consideration should be given to age-related comorbidities. Specifically, with a greater incidence of age-related complications unrelated to the surgery as well as mortality in the geriatric group, complications should be discussed at length.
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NewsBot · Sep 10, 2024

Charcot neuro-osteoarthropathy: a review of key concepts and an evidence-based surgical management algorithm
Miltiadis Argyropoulos et al
Front Clin Diabetes Healthc. 2024 Aug 16

Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.
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NewsBot · Sep 28, 2024

Operative Management of Charcot Neuropathy of the Foot and Ankle: A Retrospective Cohort Study of Long-Term Outcomes
Naveen Pattisapu,et al
Source

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the main treatment, but surgical intervention has gained interest to improve poor long-term outcomes. Few long-term outcome studies exist on operative management of CN. A retrospective chart review was performed to analyze demographics, comorbidities, complications, and outcomes of operative management of CN. Patients were divided into two cohorts for analysis: limited surgical intervention (LSI) and reconstructive surgery (RS). Fifty-eight patients with CN treated surgically over 11 years were identified. Average follow-up was 46 months (range, 1 to 173 months). The mean age was 60.2 (range, 29 to 81) years, and the average body mass index was 34.3. Diabetes caused CN in 72.4% (42/58) of patients. The LSI cohort (n = 32) had significantly higher rates of presenting infection (59.4%; 19/32) and ulceration (87.5%; 28/32) compared with the RS cohort (n = 26; 23.1% [6/26] and 50% [13/26], respectively). Rates of postoperative infection and ulceration were lower in the LSI group (25% [8/32] and 34.4% [11/32], respectively) than the RS group (42.3% [11/26] and 42.3% [11/26], respectively). The amputation rate for the LSI cohort was 21.9% (7/32) compared with 23.1% (6/26) for RS. This large, single-center study of operatively treated CN patients showed no significant difference between LSI and RS. This study provides data to help surgeons counsel patients on expected outcomes.
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NewsBot · Nov 4, 2024

MIDFOOT CHARCOT ARTHROPATHY: BUTT FRAME CORRECTION FOLLOWED BY BEAMING FOR SEVERE DEFORMITY
A Duguid et al
The British Limb Reconstruction Society (BLRS) Annual Meeting 2024, Glasgow, Scotland, 14–15 March 2024.

Introduction
Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction.

Materials and Methods
Nine patients underwent this treatment between 2020–2023. Initial deformity correction by Ilizarov or hexapod butt frame was followed by internal beaming with a mean follow up of 11 months. A retrospective analysis of radiographs and electronic records was performed. Meary's angle, calcaneal pitch, cuboid height, hindfoot midfoot angle and AP Meary's angle were compared throughout treatment. Complications, length of stay and the number of operations are also described.

Results
Mean age was 53 years (range:40–59). Mean frame duration was 3.3 months before conversion to beaming. Prior frame-assisted deformity correction resulted in consistently improved radiological parameters. Varying degrees of subsequent collapse were universal, but 5 patients still regained mobility and a stable, plantargrade, ulcer-free foot. Complications were common, including hardware migration (N=6,66%), breakage (N=2,22%), loosening (N=3,33%), infection (N=4,44%), 1 amputation and an unscheduled reoperation rate of 55%. Mean cumulative length of stay was 42 days.

Conclusions
Aggressive deformity correction and internal fixation for Charcot arthropathy requires strategic and individualised care plans. Complications are expected for each patient. Patients must understand this is a limb salvage scenario. This management strategy is resource heavy and requires timely interventions at each stage with a well-structured MDT delivering care. The departmental learning points are to be discussed.
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NewsBot · Nov 8, 2024

Difficulty in bone union after arthrodesis to treat Charcot arthropathy of the foot and ankle
Mitsuru Hanada et al
J Orthop. 2024 Oct 10:62:13-16

Introduction: A major complication of arthrodesis is non-union in patients with Charcot arthropathy. This study examined the bone union in joints affected arthrodesis for Charcot arthropathy of the foot and ankle.

Methods: The current retrospective study enrolled 15 patients (20 feet) who underwent arthrodesis (performed in 47 joints) for Charcot arthropathy from 2014 to 2020. Post-operative radiographs were classified based on the Brodsky anatomical classification system at 6 months, 1 year, and 2 years post-operatively. The association with pre-operative and intra-operative data was determined.

Results: Bone union was achieved in 28 % of patients at 6 months, 57 % at 1 year, and 66 % at 2 years post-operatively. The bone union rates according to the Brodsky anatomic classification at 6 months, 1 year, and 2 years were 50 %, 67 %, and 67 % for type 1; 20 %, 44 %, and 56 % for type 2; and 36 %, 86 %, and 86 % for type 3A, respectively. At 1 year after arthrodesis surgery, the odds ratio for non-union in Brodsky type 2 compared to that in type 3A joints was 8.727 (95 % CI: 1.623-46.935, p = 0.006).

Conclusion: Arthrodesis procedures in joints affected by Charcot arthropathy, especially in Brodsky type 2 joints, should ensure perfect bone-to-bone fitting, good adaptation, sufficient bone grafting, and strong fixation.
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Reconstructive Charcot surgery

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USA trained podiatrist Rearfoot Reconstructive Surgery

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Reconstructive Charcot surgery

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USA trained podiatrist Rearfoot Reconstructive Surgery

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