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

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Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity.

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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.

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Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions.

Aims. In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. Methods. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up. Results. We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. Conclusion. Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of ‘long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion’ is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611–1618

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

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Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres.

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Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis.

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

Aim. The aim of this work was to evaluate, via foot and ankle TC scans, the outcomes of the use of a bone substitute (CERAMENT|™G) and the growth of native bone in the treatment of osteomyelitis (OM) of the diabetic foot. Method. In nine patients from July 2014 to December 2016 we used a Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in OM diabetic foot cases. Of these nine patients, three were female and six were male and their ages were between 49 and 72 years. Four patients had hindfoot involvement and underwent partial calcanectomy. Two patients presented a rocker-bottom Charcot foot pattern III according to Sanders and Frykberg's classification and were treated with esostectomy of the symptomatic bony prominence of the midfoot. One patient presented OM of the 3°, 4° and 5° metatarsal bones. One patient underwent partial resection of the midfoot and hindfoot with arthrodesis stabilised by an internal-external hybrid fixator. One patient with a Charcot foot pattern IV-V underwent partial talectomy and calcanectomy with arthrodesis stabilised by an internal-external hybrid fixator. In all these patients - after removal of the infected bone - we applied 10 to 20 ml CSH + HA + GS filling the residual spaces with the aim of stabilising the remaining bone fragments. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues. In March 2018, the above nine patients underwent foot and ankle TC scans to evaluate bone growth. Results. The first four patients showed new bone formation in the calcaneus. Two patients with previous midfoot destruction showed chaotic but stable bone formation. The patient with metatarsal OM showed partial bone healing with residual pseudoarthrosis. Both the two patients who underwent arthrodesis with hybrid fixators showed a plantigrade and stable foot even though a heel wound is still present in one of the patients. All patients except this one are now wearing suitable shoes as post-operative wounds have healed. The patient still with the heel wound is walking with an aircast brace. Conclusion. The TC scans have shown new bone formation sufficient to stabilise the foot and allow ambulation. In particular, very good results come from the filling of the calcaneus, probably due to the anatomy of the bone itself

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The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

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Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up.

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Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients’ ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated.

Aim. Since July 2013 our group has been using an antibiotic bone substitute, composed of calcium sulphate, hydroxyapatite and gentamicin sulphate (CSH + HA + GS), in the treatment of osteomyelitis (OM) in diabetic foot. The aim of this work was to evaluate the mid-term efficacy of this treatment regime on outcomes. A favourable outcome in diabetic foot includes no recurrence of OM, healed soft tissues and the ability to weight-bear. Method. To date we have used the CSH + HA + GS bone substitute in 24 diabetic patients with OM. In this study we reviewed patients treated from July 2013 to December 2014, in which we used CSH + HA + GS to treat OM of the forefoot, midfoot and hind foot, and evaluated how many patients are able to walk and fully weight-bear at present. We identified 11 pts treated during this time period; 1 with bilateral 1. St. metatarsal-head OM due to plantar ulcers, 5 with midfoot OM secondary to Charcot deformities and ulcers, 5 with hind foot OM due to pressure ulcers or Charcot deformity. We continuously monitored the patients for recurrence of OM, ulcers and soft tissue inflammation in our outpatient department. Results. Of the 11 patients, two died during follow up (both patients had calcaneal ulcers; one died in the 1. st. month and one in the 2. nd. month after treatment, both due to cardiovascular disease). For the remaining nine patients, we had an average of 25 (17–33) months follow-up. One patient did not heal, presenting with a persistent mid-foot lesion in a Charcot foot. Another patient with bilateral forefoot ulcers had a plantar ulcer recurrence under the left 1. st. metatarsal foot, 19 months after bone substitute application and primary healing. This patient is still weight-bearing on the right foot, as are the remaining 6 patients. In 7 patients (1 with bilateral forefoot, 4 with mid-foot and 3 with hind foot OM) no recurrence of OM or ulcers was observed. Conclusions. This study suggests that a CSH + HA + GS bone substitute can be used to treat diabetic foot OM. Our mid-term results show good clinical outcomes in terms of ulcer healing, no recurrence of OM and weight-bearing

Neuropathic changes in the foot are common with a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy is often delayed in diabetic patients with harmful consequences including amputation. The appropriate diagnosis and treatment can avoid an extensive programme of treatment with significant morbidity for the patient, high costs and delayed surgery. The pathogenesis of a Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels. In most cases, changes are due to a combination of both pathophysiological factors. The Charcot foot is triggered by a combination of mechanical, vascular and biological factors which can lead to late diagnosis and incorrect treatment and eventually to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. The clinical diagnostic pathways based on different classifications are presented. Cite this article: Bone Joint J 2016;98-B:1155–9

Background:. Charcot arthropathy is a condition related to the loss of protective sensation of a joint. It normally presents in its early inflammatory phase, followed by bone destruction. Recognised treatment for this is total contact casting (TCC). However, in a small group this may be unsuccessful in preventing deformity progression. TCC can also be difficult in the presence of recalcitrant ulceration and deformed feet. Method:. 40 patients, with a diagnosis of Charcot foot, were followed from presentation in our unit over 3 years. An Ilizarov frame was used for two groups: those in the early phase who showed progressive deformity despite TCC (5 patients) and those with chronic ulceration (4 patients). Frames were modified to allow weight-bearing on the frame (with no foot contact). All other patents were treated with TCC. Results:. There were no amputations or cases of osteomyelitis. The Ilizarov frame successfully prevented further deformity when applied in the inflammatory phase. In patients with ulceration, deformity correction with a modified frame maintained correction and allowed the ulcers to heal rapidly whilst weight bearing. Conclusion:. Our series shows the Ilizarov frame can be used in the management of Charcot to prevent deformity progression and allow recalcitrant ulcers to heal following deformity correction