Aims

Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England.

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.

Ankle replacements have improved significantly since the first reported attempt at resurfacing of the talar dome in 1962. We are now at a stage where ankle replacement offers a viable option in the treatment of end-stage ankle arthritis. As the procedure becomes more successful, it is important to reflect and review the current surgical outcomes. This allows us to guide our patients in the treatment of end-stage ankle arthritis. What is the better surgical treatment – arthrodesis or replacement?

Failed Hallux Valgus Surgery Aim

We aim to explore the reasons behind long term failure of hallux valgus surgery.

The influence of the timing of surgery for closed ankle fractures on complications is unclear. Previous studies have failed to demonstrate any associations with clear statistical support. This is a retrospective review of 221 patients presenting with closed ankle fractures treated with open reduction and internal fixation. The patients were similar in respect to age, gender, fracture type, surgeon grade, American Society of Anaesthesiologists grade, grade of anaesthetist and tourniquet time. Power analysis was performed for sample size. Patients were followed up until fracture union. The mean duration of inpatient care was greater in the delayed group (p = 0.0002). There was an increased rate of local (p = 0.0451) and total complications (p = 0.0116) if surgery was delayed more than 24 hours. This observational study demonstrates that for the management of closed ankle fractures there is an adverse clinical outcome in patients who undergo delayed operative intervention.

Introduction: This study compares two diaphyseal osteotomies (scarf and Ludloff), which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow up at six and twelve months.

Material and methods: Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardised weight bearing radiographs were analysed.

Results: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. There was no statistically significant difference in the two groups at 6 and 12 months in subjective satisfaction, AOFAS forefoot score, improvement in functional activities and range of movements. The improvement in pain (at best) and plantar callosities at 12 months was significantly better in the scarf group (p< 0.001). The radiological results at 6 and 12 months including intermetatarsal angle (p< 0.001), hallux valgus angle and shortening of the first ray (p< 0.01), distal metatarsal articular angle and sesamoid position (p< 0.05) were significantly better in the scarf osteotomy group. There were six complications in the Ludloff group with three delayed unions, two dorsiflexion malunions and one complex regional pain syndrome. There were two wound complications in the scarf group.

Conclusion: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months.