Neuropathic ulcerations plantar to the lateral column in patients with charcot foot deformity: A flexible approach to limb salvage

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.

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Limb Salvage in Charcot Foot and Ankle Osteomyelitis: Combined Use Single Stage/Double Stage of Arthrodesis and External Fixation

Foot & Ankle International ◽

10.3113/fai.2009.1065 ◽

2009 ◽

Vol 30 (11) ◽

pp. 1065-1070 ◽

Cited By ~ 53

Author(s):

Luca Dalla Paola ◽

Tanja Ceccacci ◽

Sasa Ninkovic ◽

Sara Sorgentone ◽

Maria Grazia Marinescu

Keyword(s):

External Fixation ◽

Limb Salvage ◽

Single Stage ◽

Foot And Ankle ◽

Charcot Foot ◽

Combined Use

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Consensus for the Indication of Lateral Column Lengthening in the Treatment of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950732 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1286-1288

Author(s):

David B. Thordarson ◽

Lew C. Schon ◽

Cesar de Cesar Netto ◽

Jonathan T. Deland ◽

Scott J. Ellis ◽

...

Keyword(s):

Subtalar Joint ◽

Consensus Statement ◽

Talonavicular Joint ◽

Foot Deformity ◽

Foot Care ◽

Level Of Evidence ◽

Lateral Column ◽

Fluoroscopic Imaging ◽

Lateral Column Lengthening ◽

Important Sign

Recommendation: Progressive collapsing foot deformity (PCFD) is a complex 3D deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot supination. Although a medial displacement calcaneal osteotomy can correct heel valgus, it has far less ability to correct forefoot abduction. More severe forefoot abduction, most frequently measured preoperatively by assessing talonavicular coverage on an anteroposterior (AP) weightbearing conventional radiographic view of the foot, can be more effectively corrected with a lateral column lengthening procedure than by other osteotomies in the foot. Care must be taken intraoperatively to not overcorrect the deformity by restricting passive eversion of the subtalar joint or causing adduction at the talonavicular joint on simulated AP weightbearing fluoroscopic imaging. Overcorrection can lead to lateral column overload with persistent lateral midfoot pain. The typical amount of lengthening of the lateral column is between 5 and 10 mm. Level of Evidence: Level V, consensus, expert opinion. CONSENSUS STATEMENT ONE: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. The amount of lengthening needed in the lateral column should be judged intraoperatively by the amount of correction of the uncoverage and by adequate residual passive eversion range of motion of the subtalar joint. Delegate vote: agree, 78% (7/9); disagree, 11% (1/9); abstain, 11% (1/9). (Strong consensus) CONSENSUS STATEMENT TWO: When titrating the amount of correction of abduction deformity intraoperatively, the presence of adduction at the talonavicular joint on simulated weightbearing fluoroscopic imaging is an important sign of hypercorrection and higher risk for lateral column overload. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: The typical range for performing a lateral column lengthening is between 5 and 10 mm to achieve an adequate amount of talonavicular coverage. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus)

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Early Foot Structural Changes After Lateral Column Exostectomy in Patients With Charcot Foot

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734619848553 ◽

2019 ◽

Vol 18 (2) ◽

pp. 129-134 ◽

Cited By ~ 3

Author(s):

Raúl Juan Molines-Barroso ◽

José Luis Lázaro-Martínez ◽

Juan Vicente Beneit-Montesinos ◽

Francisco Javier Álvaro-Afonso ◽

Esther García-Morales ◽

...

Keyword(s):

Revision Surgery ◽

Structural Changes ◽

Sagittal Plane ◽

Weight Bearing ◽

Case Series ◽

Wilcoxon Test ◽

Charcot Foot ◽

Lateral Column ◽

Plantar Ulcer ◽

Radiographic Alignment

Although exostectomy for chronic midfoot plantar ulcers in Charcot foot is apparently effective, with healing rates of nearly 75%, a subset of patients develop recurrent ulceration and show an unstable foot position, especially after undergoing exostectomy confined to the lateral column. The reasons for this failure have not been investigated. The main objective of this study was to evaluate the early changes in radiographic alignment after an exostectomy in patients with Charcot neuropathic osteoarthropathy (rocker bottom) and plantar ulcer located in the lateral column. The present study evaluated retrospectively changes in radiographic alignment after an exostectomy in 12 Charcot feet (rocker bottom) with plantar ulcer located in the lateral column. Indication for plantar exostectomy was the treatment of ulcer affected by osteomyelitis. We evaluated the early changes in the alignment of the foot on weight-bearing lateral radiographs 6 months after exostectomy. Paired sample Wilcoxon test was used to calculate the differences between preoperative and postoperative measurements. Furthermore, the relationship between revision surgery and early changes in radiographic angular measurements was determined by using the Mann-Whitney U test. After exostectomy, the inclination of the calcaneal bone decreased ( P = .003; r = 0.849) and declination of talus bone increased ( P = .041; r = 0.589). The change in calcaneal inclination was associated with revision surgery ( P = .042; r = 0.586). The present case series demonstrates that exostectomy procedure for the lateral column in patients with Charcot foot results in radiological changes in the hindfoot over the sagittal plane. The inversion of the calcaneal pitch angle suggests the possibility of further adverse events and the need for revision surgery.

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Radiographic Evaluation of Charcot Foot Involving the Lateral Column

Foot & Ankle: Studies ◽

10.26420/footanklestud.2021.1023 ◽

2021 ◽

Vol 3 (1) ◽

Author(s):

Hale T ◽

◽

Bennett J ◽

Keyword(s):

Radiographic Evaluation ◽

Charcot Foot ◽

Lateral Column

In the study of Charcot foot, the lateral column has been largely neglected in previous research. The purpose of the current study is to radiographically characterize the lateral column in Charcot midfoot collapse.

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Benchmark Analysis of Diabetic Patients with Neuropathic (Charcot) Foot Deformity

Foot & Ankle International ◽

10.1177/107110079902000905 ◽

1999 ◽

Vol 20 (9) ◽

pp. 564-567 ◽

Cited By ~ 57

Author(s):

Michael S. Pinzur

Keyword(s):

Diabetic Patients ◽

Charcot Foot ◽

Foot Deformity ◽

Benchmark Analysis

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Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950742 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1302-1306

Author(s):

Jonathan T. Deland ◽

Scott J. Ellis ◽

Jonathan Day ◽

Cesar de Cesar Netto ◽

Beat Hintermann ◽

...

Keyword(s):

Ligament Reconstruction ◽

Joint Space ◽

Valgus Deformity ◽

Deltoid Ligament ◽

Soft Tissue Reconstruction ◽

Foot Deformity ◽

Level Of Evidence ◽

Lateral Column ◽

Spring Ligament ◽

Tissue Reconstruction

Recommendation: There is evidence supporting medial soft tissue reconstruction, such as spring and deltoid ligament reconstructions, in the treatment of severe progressive collapsing foot deformity (PCFD). We recommend spring ligament reconstruction to be considered in addition to lateral column lengthening or subtalar fusion at the initial operation when those procedures have given at least 50% correction but inadequate correction of the severe flexible subluxation of the talonavicular and subtalar joints. We also recommend combined flatfoot reconstruction and deltoid reconstruction be considered as a joint sparing alternative in the presence of PCFD with valgus deformity of the ankle joint if there is 50% or more of the lateral joint space remaining. Level of Evidence: Level V, expert opinion.

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The Development of a Neuropathic Ankle following Successful Correction of Non-Plantigrade Charcot Foot Deformity

Foot & Ankle International ◽

10.3113/fai.2012.0644 ◽

2012 ◽

Vol 33 (8) ◽

pp. 644-646 ◽

Cited By ~ 5

Author(s):

Michael S. Pinzur

Keyword(s):

External Fixator ◽

Weight Bearing ◽

Case Series ◽

Disease Process ◽

Circular Ring ◽

Surgical Correction ◽

Charcot Foot ◽

Foot Deformity ◽

Retrospective Case ◽

Level Of Evidence

Background: The treatment of Charcot foot arthropathy has traditionally involved immobilization during the acute phase followed by longitudinal management with accommodative bracing. In response to the perceived poor outcomes associated with nonoperative accommodative treatment, many experts now advise surgical correction of the deformity, especially when the affected foot is not clinically plantigrade. The significant rate of surgical and medical-associated morbidity accompanying this form of treatment has led surgeons to look for improved methods of surgical stabilization, including the use of the circular ring external fixation. Methods: Over a 7-year period, a single surgeon performed surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a statically applied circular external fixator. Following successful correction, five patients developed a neuropathic deformity of the ipsilateral ankle after removal of the external fixator and subsequent weight bearing total contact cast. Results: Three of the five patients progressed to successful healing of the neuropathic (Charcot) ankle arthropathy following treatment with a series of weightbearing total contact casts. Two underwent successful ankle fusion with retrograde locked intramedullary nailing. Discussion: This unusual clinical scenario likely represents either a progression of the disease process in the foot or a complication associated with surgical correction of the original neuropathic foot deformity. A better understanding of this observation will likely become apparent as we acquire more experience with this disorder. Level of Evidence: IV, Retrospective Case Series

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