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.

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 present a novel approach to the management of patients with longstanding heel ulcers complicated by open calcaneal fractures. The principles of management of diabetic foot ulcers were combined with applied physiology of fracture healing.

Case notes of 6 consecutive patients who presented to our diabetic foot clinic between January 2009 and December 2009 were reviewed. Type of diabetes, duration of heel ulcer, type of fracture and treatment given were recorded. Initial treatment consisted of regular local debridement and application of dressing. Vacuum Assisted Continuous (VAC) pump application was deferred until 6 weeks to preserve fracture hematoma and thereby initiate fracture healing. In all patients, VAC pump was started at 6 weeks and continued till healing of ulcer to adequate depth. Infection was treated aggressively with appropriate antibiotics according to the microbiology results.

The average age was 53 (40-60) and the mean duration of follow up was 6 months. All wound healed completely, fractures united and patients returned to previous function.

An open calcaneal fracture presents a severe injury likely to be complicated by infection and consequent osteomyelitis leading to amputations. In our group of patients, a novel treatment approach consisting of multidisciplinary model resulted in successful limb preservation and return to function.