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

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.

Aims. 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. Methods. We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, 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 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). Conclusion. Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703–708

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.

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

We retrospectively reviewed 31 patients who underwent reconstruction procedure for PTT D (Type II Johnson). The surgery was mostly performed by the senior author.

Fifty patients underwent 55 procedures, 31 patients were available for review (34 procedures)

Clinical and functional outcome were assessed using AOFAS hindfoot score, and the SF-36 health assessment score.

The patients had a calcaneal medialising (chevron) osteotomy to correct heel valgus, with or without a calcaneal lengthening osteotomy, and transfer of the FDL tendon to the navicular. All patients were immobilized in non-weight (to partial) bearing POP for 5 weeks, followed by CAM for 6 weeks.

There were 7 males and 24 female, with an average age of 60.5 years. The average follow up was 54 months (range 11.5–111.2). The average hindfoot valgus deformity was 15 degrees preoperatively.

Eight patients had and additional procedures including (TA lengthening, Lapidus). Four patients required bone graft for calcaneal column lengthening, and in 5 patients the posterior screw was removed due to continuous discomfort.

The average AOFAS hindfoot score was 74 (47–100), the average pain score was 31/40 and the average subscore of the heel alignment was 7.9/10.

Nineteen patients (61%) were able to perform single heel raise, and 27 patients (87%) were able to perform bilateral heel raise. 26 patients (83.8%) had no lateral impingement pain post operatively.

The SF-36 health assessment showed similar functional outcome with age matched population. Two patients had superficial wound infection required oral antibiotics.

Hindfoot and midfoot reconstructive surgery for type II PTTD after failed orthotic treatment is well established. However, the post operative care and rehabilitation period is lengthy and protracted. This must be emphasized during informed consent in order to fulfil realistic expectations.

Aims: Neuregenic osteoarthropathy often results in a deformity of the foot needing surgical intervention. Indications for surgery are reulcerations, deep infections and decompensation of the static structure of the foot architecture. External fixation is a promising technique for correction.

Methods: Between 1997 and 2003, 65 feet which could be examined retrospectively, were operated for neuroarthropathy in 21 women and 43 men. A diabetic polyneuropathy was present in 56 patients. In 59 cases, an external fixation was used while in nine cases Steinmann pins were used. Follow-up treatment consisted of mobilisation in a ankle-foot-orthosis (AFO) for up to a year.

Results: For diabetics, the mean duration of the disease was 24.8 years (Type 1) and 13.7 years (Type 2). All feet were at a stage 3 or 4 according to Levin and were classified as types II–V according to Sanders. In five cases there was luxation alone was observed, another nine cases exhibited a combination of luxation and osseous changes. Surgical revision was necessary in seven cases, sometimes repeatedly. As the illness progressed additional operations were necessary in 13 times. It became necessary in six cases due to loss of correction. The fitting of a prosthesis was necessary in two patients (three feet) following amputation. The mean duration was 752 days. Pin infections and disturbances in wound healing were commonly observed but could be treated successfully by conservative means. The occurrence of this complication was independent of previous ulcerations or infections. Within the first year after operation, 13.9% of the feet developed an ulcer. All of the patients could be mobilised with the help of an orthosis (47 cases) or orthopedic shoes (15 cases)

Conclusions: External fixation is a suitable and variable method for correcting malalignment of the foot in cases of neuroarthropathy. It has a low complication rate and can be used for rapidly developing as well as non-progressing osteoarthropathies. In general, a fibrous ankylosis is the result of treatment, which allows pain free mobilisation under full whight bearing. In suitable cases, with a good alignment of the foot and good patient cooperation, the use of the AFO can be changed to orthopedic shoes after about 12 months.

Aims: Foot deformities following diabetic-neuropathic osteoarthropathy are often responsible for major amputations at the lower limbs. To preserve foot and lower limb length salvage procedures have to be introduced. Methods: In 59 patients with severe deformities of the foot (Sanders II-IV) surgical reposition and resection of necrotic bony substance has resulted in an axial correction of foot-malposition. Stabilization was effected using a fixateur externe device (Hoffmann II) over a period of 6 weeks. After removal of the fixateur externe stabilization of the lower leg was performed for another 6 weeks by means of orthotic devices. Results: Surgical reposition and stabilization in a total of 59 feet has resulted in 57 cases to conservation of the foot, in 2 cases later amputation was necessary. Immobilization in the fixateur externe resulted in a fast detumenescence of accompanying oedemas and in wound healing without special problems. Post-treatment examination after two years on the average revealed in all patients a stable pseudarthrosis without bony connection. 43 from 57 patients after about 6 months were provided with orthopaedic footwear. Conclusions: Surgical procedures which refrain from the use of implants and which do not increase arthropathic activities are capable to correct severe malpositioning of the foot without increasing the activity of arthropathy and result in superior long-term results in diabetic patients. They should therefore be applied with preference.