Introduction. Surgical reconstruction of deformed Charcot feet carries high risk of non-union, metalwork failure and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. Methods. We retrospectively analysed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between 2007 and 2019 in our unit. Patient demographics, co-morbidities, weightbearing status and post-operative complications were noted. Metalwork breakage, non-union, deformity recurrence, concurrent midfoot reconstruction and the measurements related to intramedullary nail were also recorded. Results. There were 70 patients with mean follow up of 50±26 months. Seventy-two percent were fully weightbearing at 1 year post-operatively. The overall union rate was 83%. Age, BMI, HbA1c and peripheral vascular disease did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the non-united group (0.90±0.06 and 0.86±0.09, respectively; p = 0.03). Supplemental compression devices were used for 33% of those in the united compared to 8% in the non-united group (p = 0.04). All patients in the non-union group did not have a miss-a-nail screw. Metalwork failure was seen in 13 patients(19%). There was a significantly greater distal screw metalwork failure in those with supplementary bridging of tibia to midfoot (23% vs. 3%; p = 0.001). An intact medial malleolus was found more frequently in those with intact metalwork (77% vs. 54%, respectively; p = 0.02) and those with union (76% vs. 50%; p = 0.02). Broken metalwork occurred more frequently in patients with non-unions (69% vs. 8%; p < 0.001) and deformity recurrence (69% vs. 9%; p < 0.001). Conclusion. Satisfactory clinical and radiographic outcomes occur in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail, supplementary compression and miss-a-nail screws. An intact medial malleolus is protective against non-union and metalwork failure. Broken metalwork is linked to deformity recurrence and non-union

Introduction. Charcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction. Methods. Between December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients. Results. Mean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion. Surgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot

Background. Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures and instability. Although amputation can be a reasonable cost economic solution, many patients are willing to avoid that if possible. We explored here one of the salvage procedures. Methods. 23 patients with infected ulcerated unstable Charcot neuroarthropathy of the ankle were treated between 2012 and 2017. The mean age was 63.5 ±7.9 years; 16 males and 7 females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, were performed followed by external fixation with an Ilizarov frame. The primary outcome was a stable plantigrade infection free foot and ankle that allows weight bearing in accommodative foot wear. Results. Limb salvage was achieved in 91.3% of cases at the end of a mean follow up time of 25 months (range: 19–32). Fifteen (71.4%) solid bony unions were evident clinically and radiographically, while 6 (28.5%) patients developed stable painless pseudoarthrosis. Two patients had below knee amputations due to uncontrolled infection. Conclusion. Aggressive debridement and arthrodesis with ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection

Introduction. Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal instability, and has an increased risk of ulceration leading to infection and amputation. However, surgical reconstruction may offer limb salvage and restauration of an ulcer-free, plantigrade stable foot for functional weight-bearing. We report on our case series according to a prospective protocol and analyse factors leading to a favourable outcome. Methods. We report a prospective follow-up of 62 patients undergoing Charcot reconstruction, May 2014- Jan 2022, by two surgeons. Peripheral vascular disease was routinely assessed using Duplex scan and major arterial disease was treated before reconstruction. Utilising 3D modelling, pre-operative planning and standardised osteotomies, we performed anatomical correction with radiological evidence. Definitive fixation was undertaken with internal fixation to stabilise the hindfoot. Multivariant analysis was performed to assess risk factors for failure (P>0.05 statistical significance). Results. 59 feet were included, 3 patients did not progress to definitive surgery and 3 patients had bilateral surgery. 62.7% patients were male with an average age of 56, 88.13% had Type 2 diabetes, 56% were hypertensive, 14% were on dialysis. Twenty (54.1%) single stage reconstructions had pre-operative ulceration, 3 pts had ischaemic heart disease and 36 pts had evidence of peripheral arterial disease. 81% of patients achieved normalisation of the 3 out of 4 anatomical angles (P<0.05). Two patients (3.1%) required metalwork removal for infection and limb salvage, 11 (18.6%) had delayed wound healing. Survivorship was 97% at 3yrs, and 94% at 6yrs, however if pre-existing vascular disease was present, it was 94% at 3yrs 85.3% at 6yrs. All patients were mobile at a 3 years mean follow up. Conclusion. Careful patient selection, multidisciplinary team and anatomic reconstruction led to predictable outcomes and functional limb salvage. Pre-operative vascular compromise led to a slight reduction in survivorship, but no major amputation

Background. Charcot neuropathic osteoarthropathy is a rare, destructive process affecting the bones and joints of feet in patients with diabetic peripheral neuropathy. The aetiology of Charcot remains unknown, although it has been suggested that it is triggered by the occurrence of inflammation in the foot of a susceptible individual, and that the inflammation results in increased osteoclastic activity. Hypothesis. The increased bone turnover in acute Charcot is associated with increased concentrations of pro-inflammatory cytokines, related signalling peptides and bone turnover markers. Methods. 17 patients newly presenting with acute Charcot in diabetes and 16 non-diabetic patients without neuropathy undergoing elective forefoot surgery provided informed consented to participate. Samples of bone were taken by needle biopsy, and were stained with H&E to determine bone architecture and bone remodelling. Serum ALP, CTX, OPG and sRANKL TNF, IL1-beta, IL6 and CRP were measured by immunoassay. Blood was taken from the dorsal foot vein of both the affected and the unaffected foot, as well as an antecubital vein. Results. Classic histopathology features of fracture and bone remodelling were evident in Charcot bone biopsies. Systemic circulating concentrations in the Charcot group antecubital vein for both IL6 and OPG were significantly greater than in controls (p<0.05). There were no significant differences between the dorsal vein concentrations of any analyte when the affected and unaffected feet were compared. However, in patients with an acute Charcot foot the concentration of OPG, ALP and CTX was higher in sera from the dorsal vein of affected foot when compared to controls (p<0.05), this difference was highly significant for IL6 (p<0.001). Conclusion. The elevation in CTX observed in the affected foot in patients with an acute Charcot foot reflects the bone breakdown and remodelling which is present. The higher circulating concentration of IL-6 in the Charcot patient group, reflects the inflammation which is present and which is thought to be central to the development of the condition. Although OPG values were significantly greater in Charcot than control group, circulating concentrations of OPG are known to be higher in diabetes

Background: Simultaneous pancreas-kidney transplantation is performed in type 1 diabetic patients with long standing diabetes and end stage renal disease. Morbidity and mortality rates early after transplantation are high, with lower limb amputations being an important event. However, no data are available on the exact rate of Charcot foot presentation after simultaneous pancreas-kidney transplantation. The aim of the present study was to examine the prevalence of Charcot foot in the population of simultaneous pancreas-kidney transplanted patients at our institution. Methods: We retrospectively examined the medical files and radiographic documents of 66 consecutive patients transplanted in our institution. Demographic and historical data collected included gender, date of diagnosis of DM and nephropathy, mean HbA1c and mean C-peptide, retinopathy and data on renal replacement therapy. Data on immunosuppressive therapy and transplant outcome were also collected. Results: None of the patients was found to have Charcot foot before transplantation. 8 patients (12%) developed a Charcot foot afterwards (mean 1.8 ± 1.9 years post-transplantation) and four of them developed bilateral involvement in time (6%). No new Charcot foot attacks in the previously affected foot were recorded. Considering the pre-transplant demographic characteristics, all 66 patients were at high risk to develop Charcot foot. Comparing patients who developed Charcot foot to those who did not, a significant difference was only found for pre-transplant glycemic control (mean HbA1c 9.2 ± 1.0 vs. 8.0 ± 1.4, p = 0.01). In patients developing Charcot foot, acute rejection, graft failure and mortality show a trend to be more frequent (HR = 3.57, p = 0.164, HR = 4.56, p = 0.165 and HR = 2.46, p = 0.236, respectively). Conclusions: Charcot foot proves to be a frequent complication early after simultaneous pancreas-kidney transplantation. Considering the important morbidity and mortality of this complication, awareness of all healthcare providers treating transplanted patients is mandatory to detect a presentation early after onset. Prompt referral to a multidisciplinary diabetic foot clinic for further diagnosis and specialised treatment must always be considered

Introduction:. Charcot arthropathy is a complex condition affecting diabetic patients with neuropathy. Diagnosis of acute Charcot arthropathy particularly in absence of any perceptible trauma is very challenging as clinically it can mimic osteomyelitis and cellulitis. Delay in recognition of Charcot arthropathy can result in gross instability of foot and ankle. Early diagnosis can provide an opportunity to halt the progression of disease. We report the role of SPECT /CT in the early diagnosis and elucidation of the natural progression of the disease. Methods:. Our multidisciplinary team analysed the scans of neuropathic patients presented with acute red, hot, swollen foot with normal radiological findings (Eichenholtz stage 0), attending the diabetic foot clinic from 2009–2013. The patients were selected from our database, clinic and nuclear medicine records. Initial workup included the assessment of peripheral neuropathy, temperature difference, between the feet, serum inflammatory markers and weight bearing dorsoplantar, lateral and oblique x-rays. All patients had three dimensional triple Phase Bone Scan using 800Mbq . 99m. Tc HDP followed by CT scan. Those patients with obvious radiological findings and signs of infection were excluded. Results:. We evaluated 193 scans in 189 patients. One hundred and forty nine patients showed increase in focal radionuclide uptake at ligament insertion or subchondral bone with a positive predictive value of 77 percent. Forty four out of 193 were negative for Charcot changes and they were not treated as Charcot. These patients did not develop any Charcot changes in the mean follow up of 8 months, indicating a clinically false positive rate of 23%. Conclusion:. SPECT/CT scan is a highly sensitive and specific tool for early diagnosis and accurate localisation of Charcot neuroarthropathy as clinical examination results in high false positive rate. SPECT/CT also helps to understand the natural progression of this disease

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

Introduction. Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique. Methods. This is a prospective observational case series of all patients who underwent surgical reconstruction of Charcot foot deformity in a single centre between June 2017 and June 2023. Patient demographics, smoking status, diabetic control and BMI were recorded. Outcomes were determined from case notes and included clinical outcomes (complications, return to theatre, amputation and mortality) radiological outcomes and patient reported outcomes. The follow up period was 1–7 years post operatively. Results. 42 reconstructions were included. At the time of surgery the mean age was 59.1 years (29 – 91 years), average HbA1c was 65.2 (33–103); this did not correlate with return to theatre rate. 4 procedures were internal fixation alone (9.5%), 3 external fixation alone (7.1%) and 35 were combined fixation (83.3%). At most recent follow up 7 patients were deceased (16.7%), 2 patients had ipsilateral amputations, 2 had contralateral amputations. 11 patients had issues with recurrent ulcerations. Excluding refreshing of frames and operations on the contralateral side, 17 patients (40%) returned to theatre. We aim to present a detailed analysis of the rate of post-operative complications, return to theatre, radiographic outcomes and patient reported outcomes. Conclusion. This is the largest UK based case series of hybrid type Charcot joint reconstructions and shows that hybrid fixation is a viable option for patients undergoing Charcot joint reconstruction. To best confirm findings and determine which patients have the best post-operative prognosis a larger multi-centre study is required

Charcot spondyloarthropathy is one of the late complications of traumatic spinal cord injury that produces further disability. Purpose of this paper is to introduce 5 patients who developed Charcot spine after traumatic spinal cord injury treated surgically in our hospital (SIC) and discuss the result. Methods: 1) We experienced 7 pts who presented characteristic clinical and radiographic findings of Charcot spine treated in SIC for 20 years (an incidence < 1%). 2) 5 out of 7 pts underwent surgical fusion. They were 4 males, 1 female, aged: 39~66, previous injury comprises of: C6 Fracture-dislocation(Fx/Dx) in 1, T11 Fx/Dx in 2, T12 Fx/Dx in 2. respectively, 3) 4 pts had complete paraplegia, 0ne incomplete(Frankel B) and the Charcot spine occurred below fusion mass under the injured level. 4) Posterior spinal fusions combined with kyphosis correction were performed in 3, the same with posterior shortening osteotomy using TSRH instruments in 2. Fusions were extended to L4 in 1, L5 in 2, S1 in 2 respectively. Results: 1) 4 pts who had been followed-up over one year showed ultimate osseous union. Another one showed loosening of screws resulted in non-union at 5 months postoperatively. 2) Cobb angle of kyphosis were improved from 67.7 degrs. in av.(58~82) to 13.7 degrs in av. (15~36) by the operation. 3) All pts could have restored a good sitting balance tolerated a long time wheelchair sitting without any localized back pain. Conclusion: It is important for physicians who treat spinal cord injury patients to be aware of posttraumatic Charcot spine. As longevity of the people with paralysis is increasing, this phenomenon may occur more apparently. Special attention should be given to the spinal segments just below the fused level in patients with previous spinal fusion. For the unstable and symptomatic Charcot spine, a surgical correction and fusion should be considered. The correction of kyphosis is essential, but too much correction should be avoided, because it may worsen a sitting balance of the patient. We now recommend a posterior shortening osteotomy and rigid fusion using a solid pedicle screw instrumentation like TSRH

Charcot neuroarthropathy is a progressive, destructive process occurring in the presence of neuropathy. We report the outcome of neuropathic foot joints presenting to our clinic over a 12 year period. Methods. Cases were identified from the Diabetic Foot Clinic Register, 1989–2001. We studied patient demographics, clinical presentation, distribution, treatment and outcome. Results. Twenty-eight episodes of arthropathy occurred in 23 patients. Age at onset ranged from 40 to 79 years. Presentation was acute in 14 and subacute in the others. Sites affected included 23 mid foot, 4 ankle and 1 MTP. Nine feet were ulcerated at presentation, eight had a history of ulcer, nine have no ulcer history. Infection complicated the Charcot process in 15. Mean Hba1c at presentation was 9.3%. Treatments. Total contact casting 23, 4 “scotch cast” boots and 1 Air-cast walker. Pamidronate was given to 10 patients. Outcomes. Three patients died. Two had below knee amputations. Casts were required for up to 12 months. Three required orthopaedic foot reconstructions. All ulcers present initially healed. Conclusion. Charcot arthropathy remains uncommon. In our series treatment was successful in all but two patients in terms of preserved limbs, mobility and freedom from ulceration

Aim: To evaluate the results of management of Char-cot foot and ankle deformities by the use of the Ilizarov apparatus. Material-Method: This is a retrospective study of 11 cases (9 patients) aged from 39 to 60 years old (mean 44 years), all suffering from Charcot foot neuroarthropathy. All cases showed established midfoot breakdown. In four cases hindfoot deformity coexisted. Three feet were ulcerated. In six cases the Iizarov frame was applied using complex hinges and closed compression fusions were performed, utilizing the bent wire technique. In five cases the correction of the deformities was performed acutely with the use of percutaneous cannulated screws. In the later cases the Ilizarov frame neutralized the former osteosynthesis method. The Ilizarov device remained attached for 8 weeks, regardless the presence of other osteosynthesis hardware. The Maryland Foot score (MFS) was utilized for objective assessment by the physician and the SF-36 questionaire for subjective assessment by the patient. Results: A statistically significant improvement in MFS and SF-36 score was recorded. In all cases the aim for a stable and painless extremity was achieved. All patients returned to their previous activities and kept using normal shoe wear. Conclusions: A lot of references are found in the literature describing failure in the treatment of Charcot foot deformity with the use of internal fixation. This is justified by the poor bone quality and decreased bone density of the diabetic and alcoholic patients. The use of tensioned wires in multiple levels provides adequate fixation in cases where a frame is used solely and safe neutralization where a frame is combined with internal fixation

Aim: Evaluation of multifactorial treatment of Charcot foot disease in diabetic patients. Materials and Method: We followed 25 diabetic patients with Charcot foot in acute phase (Eichenholtz Stage I) from 2001 to 2003 (mean follow-up 22 months) admitted to the Day Hospital of Diabetology of the Catholic University of Rome. All patients presented a good vascularization (ABI > 0.9) and osteomielytis was excluded by means of 111Indium labelled leukocyte scintigraphy. Six patients presented a structural derangement localized to the forefoot (Pattern I according to Sanders and Frykberg Classification), one to the ankle (Pattern IV) and 18 to the mid-foot region (Pattern II and III). At first clinical evaluation, 13 patients presented a plantar monolateral ulcer. Their treatment was multifactorial. An offloading regimen was adopted, with the use of a total contact cast and crutches, in order to avoid weight-bearing on the affected foot for the first two months. Patients responsive to the treatment were successively treated with a pneumatic cast (Air cast) and partial weight-bearing for another four months. Four unresponsive patients underwent surgical treatment. 10 patients were also treated with alendronate (70 mg per os once a week). Three patients died during treatment and one during the follow-up, three of them for cardiovascular disease, one for bronchopneumopathy. Results: All patients reached the quiescent or chronic phase (Eichenholtz Stage III) at an average of six months from the onset of the treatment (range 3 to 9 months). No major or minor amputation was performed. Multifactorial treatment prevented the development ulcers in all patients that started the treatment without this complication (12 patients). 7 out of 13 ulcerated patients developed a recalcitrant ulcer (unresponsive to medical and orthotic treatment). 4 patients underwent surgical treatment: midfoot arthrodesis with Ilizarov external fixation (2 patients), rockerbottom deformity resection (one patient), Lelievre realignment (one patient). 3 patients healed after surgical treatment. Thus an overall amount of 9 out of 13 ulcerated patients healed after multifactorial treatment. Conclusions: Multifactorial treatment demonstrated effective in the management of Charcot foot in diabetic patients. Medical and orthotic treatment alone is effective in preventing complication throughout the natural history of the disease. Medical and orthotic treatment alone is frequently unsuccessful in treating plantar ulcers when major deformities has already developed. Medical and orthotic treatment combined with surgical treatment demonstrated an increased percentage of success

Introduction Charcot arthropathy is a well recognised complication in denervated synovial joints. This is a late complication of traumatic spinal cord injury that is rarely reported in the literature. Early recognition is important and can be difficult as the clinical presentation can vary from pain, deformity, autonomic dysreflexia and audible noises with motion. Methods We present 5 cases of Charcot’s arthropathy of the spine in patients with in patients with traumatic paraplegia. All patients had spinal surgery to stabilise the spine shortly after the acute injury. Results The average time from initial injury to presentation with Charcot’s arthropathy was 27 years (range 10–41). A combination of localised and neuropathic pain was the dominant symptom (4 patients) causing re-presentation, but other symptoms included deformity (1 patient). The level of the initial spinal cord injury was at the thoracolumbar junction patients. The Charcot joint level was usually 1 to 2 segments caudal to the spinal fusion. The features noted on plain radiology were destructive changes of the endplate in 4 patients and deformity in 1. With one exception, all patients went on to have MRI to exclude infection and subsequently all were surgically stabilised. All patients were treated surgically. One had an anterior approach, one had posterior approach and one had staged anterior and posterior approaches. The remaining two had anterior and posterior stabilisation through a lateral extra-cavitary approach. At an average follow-up of 36 months all patients reported good relief of their symptoms, and had returned to their best function post-injury. Discussion Surgical stabilisation in this series yielded very good results. We observed a wide variation in presenting symptoms and therefore would indicate that a high index of suspicion is required. We believe that MRI is mandatory to exclude infection and would advocate early stabilisation. The lateral extra-cavitary approach allows posterior and anterior stabilisation in a single procedure and in now the preferred method in our institution. As patients with spinal cord injuries live increasingly active lives, this problem will be seen more frequently

Introduction. Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and major amputation. The treatment of these patients is controversial. Internal stabilization and/or external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective major amputation. However, we report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases. Methods. We treated 9 diabetic patients attending a multidisciplinary diabetic/orthopaedic foot clinic with progressive severe Charcot hind foot deformity despite treatment with total contact casting, 5 with predominant varus deformity and 2 with valgus deformity and 2 with unstable ankle joints. Five patients had developed secondary ulceration. All patients underwent corrective hind foot fusion with tibiotalo-calcaneal arthrodesis using a retrograde intra-medullary nail fixation and screws and bone grafting. One patient also with fixed plano-valgus deformity of the foot underwent a corrective mid-foot reconstruction. Results. Patients were followed up closely in the diabetic /orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5casesand limb salvage was achieved in all cases. Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. In another patient with previously existing heel ulceration, the fixation device was removed due to progressive ulceration. However, by then, the patient had achieved fibrous union and stability of the hind foot. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy. Conclusion. In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration

Introduction Fracture dislocation of the midtarsus with subsequent collapse of the longitudinal arch, dislocation of the forefoot and development of the rocker-bottom deformity is a significant complication of the neuropathic foot. Bony deformity and lack of protective sensation may lead to plantar ulceration, infection and amputation. Surgical reconstruction entails reduction of the dislocation and restoration of the alignment of the foot. Fixation of the arthrodesis may be challenging due to bony dissolution, fragmentation and osteoporosis which accompany the Charcot process. The purpose of the the current study is to describe the technique and review the clincial results of midtarsal arthrodesis with intamedullary axial screw fixation used to treat Charcot midfoot collapse. Methods A retrospective study of 12 patients undergoing surgical reconstruction and arthrodesis of Charot midfoot deformity was done. Long intramedullary screws were applied antegrade or retrograde to bridge the apex of the deformity after the area had been prepared for arthrodesis through bony resection or osteotomy. Axial screws are applied such that the head or shaft of the screw gained purchase in the intramedullary canal of two or more metatarsal bones. Compression of the arthrodesis bed was achieved by tightening the screws. Radiographic measurements were taken pre-operatively, immediately post-operatively and at the last follow-up to assess the amount of durability of the correction achieved. Results Patients were evaluated clincally and radiographically at an average of 35 month follow-up (5 to 144 months). Bony union was achieved in 83% of patients, at an average of 5.3 months. All patients returned to functional ambulatory status within seven months. The talar-first metatarsal angles in the anterior and lateral planes, talar declination angle and calcaneal-fifth metatarsal angle were all corrected to near normal values following the surgery and showed no significant collapse between immediate post-op and final follow-up. The amount of dorsal displacement of the medial column was reduced to normal values and showed no significant recurrence at final follow-up. There were no recurrent plantar ulcerations. Hardware failure occurred in one patient who was unable to comply with weight bearing restrictions and significant soft tissue complications were encountered. Conclusions Surgical correction of Charcot midfoot collapse with midfoot osteotomy and arthrodesis utilizing multiple large-diameter intramedullary axial screws which span the area of dissolution provides an adequate construct to achieve arthrodesis and maintain alignment and reduction of the deformity. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Aim. Our study aimed to analyze 1) the prevalence of peripheral arterial disease (PAD) and infection in diabetic patients with and without Charcot foot (CF), 2) the characteristics of PAD in these 2 groups, 3) the prognosis of patients with CF and PAD and/or infection. Method. We retrospectively reviewed the medical and radiological records of 172 hospitalized patients in our diabetic foot unit between 2010 and 2014. These patients were identified using the ICD-9-CM. The CF group and the diabetic foot (DF) group included 56 and 116 patients, respectively. All statistical analyses were performed using SPSS 25.0.01. A p <0.05 was considered as statistically significant. Results. In the CF group, the prevalence of PAD and infection reached 66.1% and 67.9%, respectively. Diabetic foot ulcers (DFUs) were neuroischemic, infected or both in 69.5%, 80% and 57.7% of cases, respectively. No significant difference was found with the DF group. PAD in the CF group affected the infrapopliteal arteries alone more often (59.4% vs 26.7%, p 0.005) and neuroischemic DFUs needed less often revascularization (34.4% vs 78.7%, p <0.001). Endovascular revascularization was feasible in 77.8% of cases in the CF group, without significant difference with the DF group. Independent predictors of PAD in CF were DFUs (OR 24.5, CI 1.8–334.4, p 0.016) and coronary artery disease (OR 17.1, CI 1.7–167.4, p 0.016). Both patients' survival and limb salvage were not affected by PAD, neuroischemic DFUs and infected neuroischemic DFUs in the CF group. Conclusions. In agreement with current literature, our study showed that infection is often associated with DFUs, both in DF and CF. However, our study demonstrated that beside infection, PAD is associated with CF more often than previously thought. As a consequence, DFUs in CF are most often neuroischemic. However, our study did not show worse outcomes in patients with CF and PAD or neuroischemic DFUs. This probably results from a less severe PAD in CF, a high rate of successful revascularization as well as a low rate of deaths and major amputations in our study. In conclusion, clinicians should no longer consider the CF as a purely neuropathic foot, especially in the presence of a DFU. Moreover, PAD in CF should be evaluated systematically before any surgical procedure as recommended in DF

The mid foot joints are usually the first to be affected in Charcot neuroarthropathy(CN). Reconstruction is technically demanding and fraught with complications. Fixation methods have evolved over time from cancellous screws, plates, bolts and a combination of these. We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. In this series we undertook mid foot corrective fusion in 27 feet (25patients) and are presenting the results of those with a minimumof six months follow up. Twelve of these had concurrent hindfoot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy. Average patient age was 59 (43 to 80) and our mean follow up was 35 months (7 to 67). One patient was lost to follow up and 2 patients died. 18 patients had plates, 3 had bolts and 6 had a combination. Complete follow up data was available for 26 feet in 24 patients. Satisfactory correction of deformity was achieved in all patients. The mean correction of calcaneal pitch was from 0.6 preoperatively to 10.6 degrees postoperatively, mean Meary angle from 22 to 9 degrees, talo- metatarsal angle on AP view from 33 to 13 degree. Bony union was achieved in 21 out of 26 feet and atleast one joint failed to fuse in 5. 19 out of 24 patients were able to mobilize fully or partially weight bearing. We had 6 patients with persisting and 3 withrecurrent ulceration. Seven repeat procedures were carried out which included 2 revision fixations. 4 out of 5 non-unions were seen where bolts were used alone or supplemented with plates. With our technique and a strict protocol 100% limb salvage and 81% union was achieved. 80% patients were mobile and ulcer healing was achieved in 72%. Corrective mid foot fusion is an effective procedure in these complex casesbut require the input of a multidisciplinary team for perioperative care

Introduction. The mid foot joints are usually the first to be affected in Charcot neuroarthropathy (CN). Reconstruction is technically demanding and fraught with complications. Patients and methods. We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. We undertook mid foot corrective fusion in 27 feet (25 patients). Twelve of these had concurrent hind foot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade 3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy. Results. Average patient age was 59 (43 to 80) and our mean follow up was 35 months (7 to 67). One patient was lost to follow up and 2 patients died. Complete follow up data was available for 26 feet in 24 patients. Satisfactory correction of deformity was achieved in all patients. The mean correction of calcaneal pitch was from 0.6 preoperatively to 10.6 degrees postoperatively, mean Meary angle from 22 to 9 degrees, talo-metatarsal angle on AP view from 33 to 13 degree. Bony union was achieved in 21 out of 26 feet and at least one joint failed to fuse in 5. 19 out of 24 patients were able to mobilize fully or partially weight bearing. We had 6 patients with persisting and 3 with recurrent ulceration. Seven repeat procedures were carried out which included 2 revision fixations. Conclusion. With our technique and a strict protocol 100% limb salvage and 81% union was achieved. 80% patients were mobile and ulcer healing was achieved in 72%. Corrective mid foot fusion is an effective procedure in these complex cases but require the input of a multidisciplinary team for perioperative care

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and amputation. The treatment of these patients is controversial. Internal stabilisation and external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective amputation. We report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases. Conservative measures such as total contact casting were tried in 5 patients had predominant varus deformity, 2 with valgus deformity and 2 with unstable ankle joints. 5 patients had developed secondary ulceration. All patients underwent corrective hind foot fusion with tibio-talo-calcaneal arthrodesis using a retrograde intramedullary nail fixation and screws and bone grafting. One patient also with fixed planovalgus deformity of the foot underwent a corrective midfoot reconstruction. Patients were followed up in a diabetic/orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5 cases and limb salvage was achieved in all cases. Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy. In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration