Nerve palsy occurring after elective primary total hip arthroplasty (THA) is a devastating complication because of its effect on motor strength, walking ability, potential for pain, and unexpected nature. In general, the nerve distribution involved is the peroneal branch of the sciatic nerve, and the level of involvement is usually mixed motor and sensory. Prior publications have associated limb lengthening, dysplasia and use of the posterior approach to be associated with a higher incidence of nerve palsy. In the literature, the incidence of sciatic nerve palsy is estimated to be 0.2 to 1.9%. We examined the rate of sciatic nerve palsy after THA performed by the joint replacement service at Hospital for Special Surgery between the years 1998–2013. Each case was matched with 2 controls that underwent THA and did not develop postoperative neuropathy. Controls were matched by surgical date having been within 7 days of their matched case's surgery date. Patient and surgical variables were reviewed using data from patient charts and the institution's total joint replacement registry. A multivariable logistic regression model was created to identify potential risk factors for neuropathy following THA while adjusting for potential confounders. We found that, of 39,056 primary THA cases, there were 81 cases of sciatic nerve palsy, giving an incidence of 0.21%. The factors with the greatest odds ratios for nerve palsy were: history of smoking (OR=3.45); history of spinal stenosis (OR=4.45), and time of day of 1PM or later (OR=3.98). We did not find limb lengthening, dysplasia, or type of fixation to be associated with nerve palsy. In conclusion, post-surgical neuropathy has a low incidence after primary THA, but at our institution, was associated with several factors. Spine-related comorbidities, such as spinal stenosis and lumbar spine disease, and smoking history should be closely monitored to inform the patient and surgeon for the potential increased risk of postoperative neuropathy following THA

Nerve palsy occurring after elective primary total hip arthroplasty is a devastating complication because of its effect on motor strength, walking ability, potential for pain, and unexpected nature. In general, the nerve distribution involved is the peroneal branch of the sciatic nerve, and the level of involvement is usually mixed motor and sensory. Prior publications have associated limb lengthening, dysplasia and use of the posterior approach to be associated with a higher incidence of nerve palsy. In the literature, the incidence of sciatic nerve palsy is estimated to be 0.2–1.9%. We examined the rate of sciatic nerve palsy after THA performed by the joint replacement service at Hospital for Special Surgery between the years 1998 and 2013. Each case was matched with 2 controls that underwent THA and did not develop post-operative neuropathy. Controls were matched by surgical date having been within 7 days of their matched case's surgery date. Patient and surgical variables were reviewed using data from patient charts and the institution's total joint replacement registry. A multivariable logistic regression model was created to identify potential risk factors for neuropathy following THA while adjusting for potential confounders. We found that, of 39,056 primary THA cases, there were 81 cases of sciatic nerve palsy, giving an incidence of 0.21%. The factors with the greatest odds ratios for nerve palsy were: history of smoking (OR=3.45); history of spinal stenosis (OR=4.45), and time of day of 1PM or later (OR=3.98). We did not find limb lengthening, dysplasia, or type of fixation to be associated with nerve palsy. In conclusion, post-surgical neuropathy has a low incidence after primary THA, but at our institution, was associated with several factors. Spine-related comorbidities, such as spinal stenosis and lumbar spine disease, and smoking history should be closely monitored to inform the patient and surgeon for the potential increased risk of post-operative neuropathy following THA

Traditional risk factors for post-operative neuropathy include learning curve of surgical approach, DDH, and significant leg lengthening (>1 inch). Despite these risk factors, the most common scenario of a neuropathy is in a routine THA, by an experienced surgeon, for osteoarthritis, with no leg lengthening. Post-operative hematoma can lead to nerve compression, albeit rarely. The usual clinical presentation is of an acute event, with a previously intact nerve, sometime within the first days of surgery. Once diagnosed, immediate surgical decompression should be performed. Sciatic neuropathy is the most common, regardless of surgical approach, but the posterior approach poses the highest risk. Routine gluteus maximus tendon release may help to reduce the risk. When seen in the PACU, our approach is to immediately perform CT imaging to evaluate nerve integrity or to check on acetabular screw position. If no underlying cause is identified, the patient will be managed conservatively with foot orthotics and monitored for recovery. Femoral nerve palsy (FNP) can result in significant initial disability. Fortunately most patients recover function (although it can take over 18 months). In the early post-operative period it is often diagnosed after a patient complains of the leg giving away while attempting to walk. A knee brace will assist the patient with mobilization while the nerve recovers. The highest incidence of FNP is described for the direct lateral approach. Superior gluteal nerve (SGN) palsy is related to the direct lateral approach and may be avoided if the gluteus medius split is made within the safe zone (<5 centimeters from the tip of the greater trochanter). While early post-operative limp is common after the direct lateral approach, the true reported incidence of SGN palsy is low. Few studies showed that the persistent positive Trendelenburg test and limp is not exclusively related to the SGN damage and therefore the clinical effect of the SGN damage remains controversial. Lateral femoral cutaneous nerve can be affected during the direct anterior hip approach. One study suggests the presence of peri-incisional numbness in over 80% of patients. This is akin to numbness seen lateral to the incision after TKA. The incidence of meralgia paresthetica is extremely low (<1%)

We performed a new operation for ulnar neuropathy caused by recurrent dislocation at the medial epicondyle. There were eleven patients, eight men and three women, with an average age of 52 years (24–74 years) at the time of surgery. The mean duration of symptoms was 23 months. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in five patients, and grade 3 in one patient. The operation consisted of ulnar groove plasty proximal to the cubital tunnel. The ulnar nerve was replaced into this reconstructed groove. The nerve was confirmed to be stable throughout the full range of elbow motion. The cubital tunnel retinaculum of all patients was hypoplastic and the dislocated portion of the ulnar nerves was hard. One nerve showed severe adhesion around the dislocation site. One patient had a pseudo-neuroma. All patients were relieved of discomfort, and motor and sensory function were recovered. The ulnar nerve in the groove showed neither irritation nor adhesion. In patients with grade 1, symptoms or numbness of the fingers was relieved within three months of the operation. Sensory disturbances in patients with grade 2 symptoms also improved within six months. Grade 2 patients with intrinsic muscle weakness regained normal muscular power, and these with patients with intrinsic muscle atrophy had showed increasing muscular power. The patient with grade 3 symptomes recovered normal sensation after 1 year; clawing of the ring and little fin-gers recovered, and the muscle volume was increased. Friction ulnar neuropathy has been treated traditionally by anterior transpositon or medial epicondylectomy. The ulnar nerve may become entrapped in scar tissue after these operations. We believe that this anatomical position is optimum for the nerve and that this procedure is essential for treatment of friction neuropathy

The aim of the present investigation is to study the status of the blood-nerve barrier in the carpal tunnel syndrome and cubital tunnel syndrome using gadolinium enhanced MRI. The subjects were 68 patients (92 hands) with idiopathic carpal tunnel syndrome and 21 patients (23 elbows) with cubital tunnel syndrome. The MRI equipment used was a 0.3-T permanent magnet. Using the SE method, T1-weighted axial images were obtained. Then, we intravenously injected gadolinium for enhanced images. We studied the relationship between nerve enhancement and the symptoms of the patients. Out of 92 hands with carpal tunnel syndrome, 74 hands (80%) showed enhancement of the median nerve. The patients had 58 hands classified as Grade I (sensory disturbance only) out of which 44 hands (76%) showed nerve enhancement , as did 25 out of 29 hands (86%) classified as Grade II (I + thenar muscle atrophy) and all 5 hands (100%) classified as Grade III (II + disturbance of opposition). Enhancement was more prominent in the patients with thenar muscle atrophy. All 23 elbows with cubital tunnel syndrome revealed enhancement of the ulnar nerve. Two elbows were categorized as grade I (sensory disturbance only), 12 as grade II (I + 1’st inter-osseus muscle atrophy), and 9 as grade III (II + claw finger deformity). In general, capillaries exist inside the endoneurial spaces of peripheral nerves. Intraneural homeostasis is maintained by the perineurium as a diffusion barrier and by the blood-nerve barrier existing in the endothelium. MRI could demonstrate intraneural enhancement at the site of nerve entrapment where intraneural edema resulted from an increase in the vascular permeability of the endoneurium. We conclude that gadolinium-enhanced MR imaging can detect morphological and functional changes of peripheral nerve in patients with entrapment neuropathy

Introduction The role of tendon transfer in progressive hereditary motor sensory neuropathy (CMT) is controversial. This paper examines a large single surgeon cohort and reviews the surgical outcome of tendon transfers against a large group of CMT patients represented by the Australian CMT Health Survey 2001. Methods A retrospective review was carried out in 29 patients (57 feet) with CMT, managed surgically by a single author (GW). Functional outcomes were measured using standard tools such as SF-36, AOFAS ankle hindfoot clinical rating scale, and a clinical review including a specially designed questionairre. Quality of life and functional outcome has been compared with the Australian CMT Health Survey 2001 in 324 patients. Twenty-nine patients were managed with tendon transfers, typically by flexor to extensor transfer of toes, combined with peroneus longus release and transfer, and tibialis posterior transfer. Results The Levitt classification rated 80% of patients as having good-excellent outcomes. Ninety-two percent of patients reported an improvement overall with surgery, specifically 52% reported improvement in pain, 85% felt their gait had benefited, and 74% reported an improvement in the appearance of their foot deformity, as a direct result of their surgery. All patients reviewed would recommend similar surgery to others, and 92% of those surveyed wished they had their surgery much earlier (months to years). The AOFAS clinical rating system for ankle-hindfoot showed an average improvement of 36 points out of 100. In general, patients treated by this method were improved when considered against a larger cohort both in quality of life measures and functional outcome. This combination was not always successful, and a small number of disappointed patients were identified. Conclusions Tendon transfers in the younger patient has a role in the treatment of flexible deformities in CMT, and improving quality of life. This paper shows that patients benefit at an earlier stage of their disease by tendon transfers. Indications for tendon transfers have been refined by this study and lessons learned recognised

Aims: Better understanding of the influence of body mass to plantar peak pressure as a main biomechanical risk factor for ulcerations in the diabetic foot. To predict the effect of weight change on peak pressure. Methods: In-shoe peak pressure measurement (PEDAR, Novel) are performed in 5 patients with diabetic neuropathy and 5 controls: all wearing the same kind of ready made shoes with ready made standard fitting insoles of cork. Each subject is measured in 3 modes of weight simulation: normal weight, 20 kg weight increase (waistcoat with weight pieces) and 20 kg weight release by a movable overhead suspension covering a 6m walkway. Pace is selected individually after some pre-test walking to be comfortable in all 3 weight modes. For data analysis the plantar area of the foot is divided into 6 regions, particularly metatarsal region and heel. Results: No significant difference between diabetics and controls is found. In the most threatened regions (metatarsals and heel) peak pressure increases and decreases linearly with weight: A simulated weight change ± 20 kg increases/ decreases metatarsal peak pressure by ± 6.4 N/cm2. The corresponding figure for the heel region is ± 2.6 N/cm2. Conclusions: Weight increase or weight loss in the individual patient has at least in the metatarsal and heel region a significant effect to the plantar peak pressure. The linear relationship allows for a simple method of predicting the effect of weight change to peak pressure

Purpose: The vast majority of forefoot infectious in neuropathy patients are plantar ulcers in diabetics. When conservative treatment is unsuccessful, radical treatment may be indicated, but correct choice of the amputation level is essential. The purpose of this work was to evaluate outcome after tibiocalcaneal arthrodesis achieved with an Ilizarof fixator. Material and methods: The procedure was performed in nine patients between 1991 and 2002. Male gender predominated (seven men). Mean age was 65 years. Eight patients had diabetes and seven of them had complicated mal perforant. Two patients had bilateral involvement so a total of eleven arthrodeses were performed. The procedure began with de-articulation of the Chopard space and talectomy. After high section of the lateral maleolus, the tibia was cut flush with the joint. The calcaneal cut was vertical passing just behind the tarsal sinus. After verticalising the calcaneum, the two cut surfaces were joined. Arthrodesis was maintained with a circular Ilizarof fixator using two rings on the tibia and one on the calcaneum. Results: At mean 20 months, we reviewed ten arthrodeses. Good results were obtained for seven and failure was observed in three (necrosis = 2 and severe suppuration = 1). All these problems resolved and fusion was achieved at five months on average. The type of diabetes, renal failure, duration of the infection, presence of severe contralateral lesions, and type of germ involved appeared to affect outcome. Discussion: Alternatives to the Pirogoff procedure include Chopard amputation, with or without subtalar arthrodesis, and Syme amputation. The technique used in this cohort offers several advantages. The circular external fixator avoids the classic cross screwing in an infectious setting. The mechanical properties of the Ilizarof fixator favour healing and bone fusion. Finally, vericalisation of the calcaneum produces a longer stump so excessively anterior cicatrisation, which can be bothersome for the orthesis, is avoided. Conclusion: This surgical technique provides a radical treatment for proximal osteoarticular infections of the forefoot, often observed in diabetics. Indications are exceptional and should be reserved for lesions which are inaccessible to transmetatarsal amputation. The arthrodesis cannot be achieved without healthy talar stock. The procedure produces a long stable stump which is painless and easy to fit

Introduction. Osteoarthritis of the glenohumeral joint leads to global degeneration of the shoulder and often results in humeral or glenoid osteophytes. It is established that the axillary neurovascular bundle is in close proximity to the glenohumeral capsule. Similar to other compressive neuropathies, osteophytic impingement of the axillary nerve could result in axillary nerve symptoms. The purpose of this study was to compare the proximity of the axillary neurovascular bundle to the inferior humerus in shoulders to determine distance of the neurovascular bundle as the osteophyte (goat's beard) of glenohumeral osteoarthritis develops. Methods. In this IRB approved study, preoperative MRI's of 98 shoulders (89 patients) with primary osteoarthritis (OA group) were compared to 91 shoulders (86 patients) with anterior instability (Control group). For MRI measurements (mm) two coronal-oblique T1 or proton density weighted images were selected for each patient located at 5 and 6 o'clock position of the glenoid in the parasagittal plane. Humeral head diameter to standardize the glenohumeral measurements, size of the spurs, and 6 measurements between osseus structures and axillary neurovascular bundle were obtained on each image using a calibrated measurement system (Stryker Office PACS Power Viewer). Level of significance was set at p>.05. Results. Since results were both significant at 5 and 6 o'clock, for clarity we will only give the results at 6 o'clock. Humeral head osteophytes were present in 52% (51/86) of arthritic patients with an average size of 9.90 mm (range 0–24.31). Distance between humeral head or inferior osteophyte and neurovascular bundle was significantly decreased (p<0.05) in the OA group, 19.74 mm (range 2.80–35.12) compared to the control group 23.8 mm (14.25–31.89). If we compare the same distance between the Control group, OA group with a spur and OA group without a spur, the difference is only significant between the Control group and OA with spur. (p<0.05) In non-arthritic patients, the neurovascular bundle was closest to the inferior glenoid rim in all patients (91/91). By contrast, the neurovascular bundle was closest to the humeral head in 26.5% (26/98) of arthritic patients. Among these 26 patients, a large humeral head osteophyte was present in 96% (25/26). The neurovascular bundle distance and humeral head osteophyte size were inversely correlated (r=−0.45 at 5 o'clock, r=−0.546 at 6 o'clock) in the arthritic group (p<0.05). Discussion. The axillary neurovascular bundle was significantly closer to the osseous structures (humerus) in arthritic patients compared to non-arthritic patients (p<0.05). The neurovascular bundle was significantly closer to the bone when there was a humeral osteophyte, and the distance was inversely proportional to humeral osteophyte size (p<0.05). This study indicates humeral osteophytes are capable of encroaching on the axillary nerve. Axillary nerve entrapment may be a contributing and treatable factor of pain in patients with glenohumeral osteoarthritis

Aims: Only gangrene of the entire foot and life-threatening sepsis with severe infection require a high amputation. Method: Between 1984 and 1999, 188 amputations in the area of the lower extremity were carried out at Bad Düben specialist hospital for orthopaedics. In 31 cases, partial amputation (so-called amputation of border zones) was required in the area of the foot owing to diabetic foot syndrome. The medical records were analysed and the patients who were still living underwent a follow-up examination; 8 patients had died. Results: Of the 31 patients, 20 were men and 11 were women. From 1982 to 1987 there were 4 partial amputations of the foot, from 1988 to 1993 there were 12 and from 1994 to 1999 there were 11. The average age was 69.1 years. In 11 cases, amputation of the lower leg as a subsequent operation was necessary. Here the average age was 71,8 years. It was noted that from 1994 to 2001 subsequent amputation of the lower leg had only been required twice (eight times from 1984 to 1993). The patients who underwent a follow-up examination were satisfied after partial amputation of the foot. Conclusions: For diabetic feet with neuropathy and infection, partial amputation of the foot can be regarded as the treatment of choice. Prompt referral to hospital is necessary to ensure optimum glucose adjustment and any treatment required for accompanying diseases. With interdisciplinary management between the physician, vascular surgeon and orthopaedist, and with treatment in a team with the orthopaedic shoemaker, in addition to surgical measures, we the necessary local can prevent gangrene of the entire foot and life-threatening sepsis from leading to a high amputation

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 and Aims: Despite being a relatively common condition in childhood, there is little information in the world literature documenting the foot deformities seen in the Hereditary Motor and Sensory Neuropathies (HMSN). The aim of this paper was to thoroughly investigate the foot deformities seen in children with HMSN.

Method: We reviewed 104 feet from 52 children with HMSN seen for the first time in clinics at the Central Remedial Clinic, Dublin and The Children’s Hospital at Westmead, Sydney between January 1996 and June 2003. All patients were reviewed by a consultant neurologist and orthopaedic surgeon. The data we collected included: HMSN type, sex, age at first presentation, type of foot deformity, bilaterality of deformity, symmetricality of deformity, whether surgery had been required, age at surgery and the details of the surgery performed. We divided surgery types into soft tissue procedures alone and combined soft tissue and bony procedures.

Results: Sixty-nine feet had a cavovarus deformity, 23 feet had a planovalgus deformity and 12 feet had no significant deformity. All cases with deformity had bilateral involvement, and of those with deformity, only 45% had symmetrical involvement. In HMSN I, III, IV, V and X linked HMSN, cavovarus was the most common deformity. However, in HMSN II, 55% of feet had a planovalgus deformity, 36% had a cavovarus deformity and 9% no deformity. Forty-three feet required surgery of some type. Thirty-four feet with a cavovarus deformity had surgery, 17 required soft tissue surgery and 17 combined bony and soft tissue surgery. Nine feet with a planovalgus deformity had surgery, seven required soft tissue surgery alone, and two had combined surgery.

Conclusion: Cavovarus is the most common foot deformity seen in patients with HMSN. However, a planovalgus deformity is not uncommon, and in HMSN II, planovalgus is seen more frequently than cavovarus. Surgical intervention was required in just under half of the feet with deformity. Surgery, and in particularly combined soft tissue and bony surgery, is required more often to treat feet with a cavovarus deformity than with a planovalgus deformity.

Diabetes mellitus is a risk factor for complications after operative management of ankle fractures. Generally, diabetic sequelae such as neuropathy and nephropathy portend greater risk; however, the degree of risk resulting from these patient factors is poorly defined. We sought to evaluate the effects of the diabetic sequelae of neuropathy, chronic kidney disease (CKD), and peripheral vascular disease (PVD) on the risk of complications following operative management of ankle fractures. Using a national claims-based database we analyzed patients who had undergone operative management of an ankle fracture and who remained active in the database for at least two years thereafter. Patients were divided into two cohorts, those with a diagnosis of diabetes and those without. Each cohort was further stratified into five groups: neuropathy, CKD, PVD, multiple sequelae, and no sequelae. The multiple sequelae group included patients with more than one of the three sequelae of interest: CKD, PVD and neuropathy. Postoperative complications were queried for two years following surgery. The main complications of interested were: deep vein thrombosis (DVT), surgical site infection, hospital readmission within 90 days, revision internal fixation, conversion to ankle fusion, and below knee amputation (BKA). We identified 210,069 patients who underwent operative ankle fracture treatment; 174,803 had no history of diabetes, and 35,266 were diabetic. The diabetic cohort was subdivided as follows: 7,506 without identified sequelae, 8,994 neuropathy, 4,961 CKD, 1,498 PVD, and 12,307 with multiple sequelae. Compared to non-diabetics, diabetics without sequelae had significantly higher odds of DVT, infection, readmission, revision internal fixation and conversion to ankle fusion (OR range 1.21 – 1.58, p values range Compared to uncomplicated diabetics, diabetics with neuropathy alone and diabetics with multiple sequelae were found to have significantly higher odds of all complications (OR range 1.18 – 31.94, p values range < 0.001 - 0.034). Diabetics with CKD were found to have significantly higher odds of DVT, readmission, and BKA (OR range 1.34 – 4.28, p values range < 0.001 - 0.002). Finally, diabetics with PVD were found to have significantly higher odds of DVT, readmission, conversion to ankle fusion, and BKA (OR range 1.62 - 9.69, p values range < 0.001 - 0.039). Diabetic patients with sequelae of neuropathy, CKD or PVD generally had higher complication rates than diabetic patients without these diagnoses. Unsurprisingly, diabetic patients with multiple sequalae are at the highest risk of complications and had the highest odds ratios of all complications. While neuropathy is known to be associated with postoperative complications, our analysis demonstrates that CKD represents a significant risk factor for multiple complications following the operative management of ankle fractures and has rarely been discussed in prior studies

Aims. There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA). Methods. We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal. Results. The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis. Conclusion. The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Jt Open 2023;4(1):19–26

Background. Ankle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including early post-operative weight bearing and surgical complications. Methods. A national-multicentre retrospective cohort study was conducted between January to June 2019 in 56 centres (10 Major- Trauma-Centres and 46 Trauma-Units) in the United Kingdom; 1360 specifically defined complex ankle-fractures were enrolled. Demographics, fixation choice, surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with/without diabetes. Results. There were 316 patients in the diabetes cohort with mean age 63.9yrs (vs. 49.3yrs in non-diabetes cohort), and greater frailty score >4 (24% vs.14% (non-diabetes cohort) (p<0.03); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% a HFN compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p<0.02) but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications to non-diabetes, even though early-weight- bearing rates were greater than standard-ORIF. Conclusion. Ankle fractures in diabetes occur in older, frailer patients; whilst lower than expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weight-bearing without increasing complications in keeping with modern guidelines in ankle fracture management

Ceramic-on-ceramic (CoC) articulations in total hip arthroplasty (THA) have low wear, but the unique risk of fracture. After revision for CoC fracture, ceramic third bodies can lead to runaway wear of cobalt chrome (CoCr) causing extremely elevated blood cobalt. We present five cases of ceramic liner fractures revised to a CoCr head associated with the rapid development of severe cobalt toxicity. We identified 5 cases of fractured CoC THA treated with revision to CoCr on highly cross-linked polyethylene (HXLPE) – three to conventional bearings and two to modular dual mobility bearings (CoCr acetabular liner, CoCr femoral head, and HXLPE). Mean follow up was 2.5 years after CoCr/HXLPE re-revision. Symptoms of cobalt toxicity occurred at average 9.5 months after revision for ceramic fracture (range 6–12). All patients developed vision and hearing loss, balance difficulties, and peripheral neuropathy. Several had cardiomyopathy, endocrinopathy, and local skin discoloration. Two reported hip pain. Re-revision for cobalt toxicity occurred at an average of 22 months (range 10–36) after revision for ceramic fracture. Average serum cobalt level at re-revision was 991 μg/L (range 734–1302, normal <1 μg/L). All CoCr heads exhibited massive wear with asphericity; deep tissues exhibited prominent metallosis. Treatment consisted of debridement and revision to a ceramic head with HXLPE. Serum cobalt improved to an average of 25 μg/L at final follow up. All patients reported partial improvement in vision and hearing; peripheral neuropathy and balance did not recover. Systemic cobalt toxicity is a rare but devastating complication of ceramic fracture in THA treated with cobalt-alloy bearings. Cobalt alloy bearings should be avoided in this setting. The diagnosis of systemic cobalt toxicity requires a high index of suspicion and was typically delayed following systemic symptoms. Debridement and revision to a ceramic-on-HXLPE leads to improvement but not resolution of cobalt toxicity complications

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes

Charcot neuroarthropathy is a rare but serious complication of diabetes, causing progressive destruction of the bones and joints of the foot leading to deformity, altered biomechanics and an increased risk of ulceration. Management is complicated by a lack of consensus on diagnostic criteria and an incomplete understanding of the pathogenesis. In this review, we consider recent insights into the development of Charcot neuroarthropathy. It is likely to be dependent on several interrelated factors which may include a genetic pre-disposition in combination with diabetic neuropathy. This leads to decreased neuropeptides (nitric oxide and calcitonin gene-related peptide), which may affect the normal coupling of bone formation and resorption, and increased levels of Receptor activator of nuclear factor kappa-B ligand, potentiating osteoclastogenesis. Repetitive unrecognized trauma due to neuropathy increases levels of pro-inflammatory cytokines (interleukin-1β, interleukin-6, tumour necrosis factor α) which could also contribute to increased bone resorption, in combination with a pre-inflammatory state, with increased autoimmune reactivity and a profile of monocytes primed to transform into osteoclasts - cluster of differentiation 14 (CD14). Increased blood glucose and loss of circulating Receptor for Advanced Glycation End-Products (AGLEPs), leading to increased non-enzymatic glycation of collagen and accumulation of AGLEPs in the tissues of the foot, may also contribute to the pathological process. An understanding of the relative contributions of each of these mechanisms and a final common pathway for the development of Charcot neuroarthropathy are still lacking. Cite this article: S. E. Johnson-Lynn, A. W. McCaskie, A. P. Coll, A. H. N. Robinson. Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy. Bone Joint Res 2018;7:373–378. DOI: 10.1302/2046-3758.75.BJR-2017-0334.R1

Abstract. The aim is to describe the safety and efficacy of TAL in out-patient clinics when managing diabetic forefoot ulcers. Patients and Methods. Consecutive patients, who underwent TAL and had minimum 12m follow-up were analysed. Forceful dorsiflexion of ankle was avoided and patients were encouraged to walk in Total contact cast for 6-weeks and further 4-weeks in walking boot. Results. 142 feet in 126 patients underwent this procedure and 86 feet had minimum follow-up of 12m. None had wound related problems. Complete transection of the tendon was noted in 3 patients and one-patient developed callosity under the heel. Ulcers healed in 82 feet (96%) within 10 weeks however in 12 feet (10%), the ulcer recurred or failed to heal. MRI showed plantar flexed metatarsals with joint subluxation. The ulcer in this subgroup healed following proximal dorsal closing wedge osteotomy. Conclusion. Tightness of gastroc-soleus-Achilles complex and subluxed MTP joint from soft tissue changes due to motor neuropathy result in increased forefoot plantar pressures. A 2-stage approach as described result in long-term healing of forefoot ulcers, and in 96% of patients, the ulcer healed following TAL alone. TAL is a safe and effective out-patient procedure with improved patient satisfaction outcomes

Introduction. A common acute orthopaedic presentation is an ulcerated or infected foot secondary to diabetic neuropathy. Surgical debridement or amputation are often required to manage this complication of diabetes. International literature indicates that amputation may lead to further complications and an increased mortality rate. The aim of this study is to investigate the mortality rate associated with different surgical interventions. This will inform surgical management of patients presenting with acute foot complications from diabetes. Methods. This is a retrospective review of patients with diabetic foot infections aged >16 years attending Middlemore Hospital over a 10-year period (2012–2021). Clinical records were examined to determine whether patients were managed with no surgery, surgery but not amputation, or amputation. We recorded relevant baseline characteristics and comorbidities. Regression models were used to determine factors associated with mortality. Results. Over the study period, 1260 patients were included in analysis. Patients were divided into three groups, a control group who received no surgical intervention (n=554), those receiving surgery but not amputation (n=269), and those who underwent amputation (n=437). After adjustment for potential confounders, mortality rates were significantly higher in those who underwent amputation compared with those who received surgical intervention without amputation. Survival probability at 1 year and 5 years was highest in the surgical intervention but not amputation group. Conclusion. It is clinically important that there is a lower mortality rate in patients who undergo surgical intervention without amputation. Treatment that aims to salvage the limb rather than amputate should be considered in management of patients with diabetic foot complications to optimise their care