scholarly journals Combined Internal and External Fixation for Charcot Neuroarthropathy: A Learning Curve

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0026
Author(s):  
Muhammed H. Iqbal ◽  
Sultan N. Qasim ◽  
Simon Chambers
Keyword(s):  
Learning Curve ◽  
Internal Fixation ◽  
External Fixation ◽  
Limb Salvage ◽  
Case Series ◽  
Deformity Correction ◽  
Fusion Rate ◽  
Ulcer Recurrence ◽  
Foot And Ankle ◽  
Soft Tissue Envelope

Category: Diabetes; Trauma Introduction/Purpose: Management of complex foot and ankle deformities secondary to charcot neuroathropathy represents a significant challenge. This is a consequence of medical co-morbidities, vascular disease, peripheral neuropathy, and immune compromise with the surgical challenges of progressive bony defomity and bone resorption. To combat these challenges ‘superconstructs’ have been developed to improve fixation. These aim for fusion beyond the zone of injury with adequate deformity correction all whilst maintaining viability of the soft tissue envelope and mechanical function. This can be achieved with internal fixation using indication specific plates and beaming techniques, external fixation with a circular frame or a combination of the two. The aim of this study was to evaluate of a tertiary referral hospital in the operative management of charcot neuroarthopathy. Methods: This is a retrospective two surgeon case series with all cases jointly operated upon. Cases were identified from a locally held diabetic patient registry as those undergoing charcot foot and ankle reconstruction from 2017 to 2019. No exclusion criteria were outlined. Patient demographics and co-morbidities were collected, pre-op radiological markers (meary’s angle) measured and repeated at 6 weeks and one year. Pre-op radiographs were classifed accroding to brodsky classification. Patient outcomes were recorded of amputation, mortality, ulcer recurrence, reported pain, stable heel, ability to ambulate, need for revision surgery, need for prolonged antibiotics, fusion and surgical complications. PROMS were requested and still awaited at time of submission. Results: Eleven Cases were identified from ten patients, all were included for analysis. Three patients had internal fixation, two had external fixation and six had combined internal with external fixation. Eight patients were Brodsky 1, two patients were Brodsky 3 and one patient was Brodsky 2. Limb salvage was 100% with nil amputations, mortality 0%, ulcer recurrence 0%, 100% improved pain score, and 100% with a stable heel. Meary’s angle improved by a mean of 14o from -16o to -2o at 1 year. Fusion rate determined clinically and radiologically with X-ray was 100% with mean of 129 days and range of (360 - 52). Mean follow-up 454 days and range (547-417). Complications of 2 tibial fractures and 1 deep infection with delayed wound healing. Conclusion: The outcomes of using all three methods is positive with 100% limb salvage, 100% fusion rate, 100% ulcer free and maintenace of Meary’s angle at 1 year post op. We believe that combined internal and external fixation, not widely reported in the literature, is a good option in these cases. The complications reported here were in the first three patients undergoing said technique and represent a learning curve.

scholarly journals Lateral open wedge calcaneus osteotomy with bony allograft augmentation in adult acquired flatfoot deformity. Clinical and radiological results

2021 ◽  
Author(s):  
Gabriele Colo’ ◽  
Mattia Alessio Mazzola ◽  
Giulio Pilone ◽  
Giacomo Dagnino ◽  
Lamberto Felli
Keyword(s):  
Range Of Motion ◽  
Case Series ◽  
Deformity Correction ◽  
Tibialis Posterior ◽  
Open Wedge ◽  
Foot And Ankle ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Adult Acquired Flatfoot Deformity

Abstract The aim of this study is to evaluate the results of patients underwent lateral open wedge calcaneus osteotomy with bony allograft augmentation combined with tibialis posterior and tibialis anterior tenodesis. Twenty-two patients underwent adult-acquired flatfoot deformity were retrospectively evaluated with a minimum 2-year follow-up. Radiographic preoperative and final comparison of tibio-calcaneal angle, talo–first metatarsal and calcaneal pitch angles have been performed. The Visual Analog Scale, American Orthopedic Foot and Ankle Score, the Foot and Ankle Disability Index and the Foot and Ankle Ability Measure were used for subjective and functional assessment. The instrumental range of motion has been also assessed at latest follow-up evaluation and compared with preoperative value. There was a significant improvement of final mean values of clinical scores (p < 0.001). Nineteen out of 22 (86.4%) patients resulted very satisfied or satisfied for the clinical result. There was a significant improvement of the radiographic parameters (p < 0.001). There were no differences between preoperative and final values of range of motion. One failure occurred 7 years after surgery. Adult-acquired flatfoot deformity correction demonstrated good mid-term results and low recurrence and complications rate. Level of evidence Level 4, retrospective case series.

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

2009 ◽  
Vol 30 (11) ◽  
pp. 1065-1070 ◽  
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

Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot

2018 ◽  
Vol 100-B (2) ◽  
pp. 190-196 ◽  
Author(s):  
M. Chraim ◽  
S. Krenn ◽  
H. M. Alrabai ◽  
H-J. Trnka ◽  
P. Bock
Keyword(s):  
Limb Salvage ◽  
Case Series ◽  
Foot And Ankle ◽  
Charcot Arthropathy ◽  
Charcot Neuroarthropathy ◽  
Additional Surgery ◽  
Functional Scores ◽  
Compression Nail ◽  
Hindfoot Arthrodesis

Aims 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. Patients and Methods We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70). Results The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) – Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS). Conclusion The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190–6.

scholarly journals Outcomes of Hindfoot and Ankle Arthrodesis in Neuropathic Patients

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0028
Author(s):  
David Macknet ◽  
Andrew Wohler ◽  
Carroll P. Jones ◽  
J. Kent Ellington ◽  
Bruce E. Cohen ◽  
...  
Keyword(s):  
Internal Fixation ◽  
External Fixation ◽  
Limb Salvage ◽  
Median Number ◽  
Ankle Arthrodesis ◽  
High Rate ◽  
Hardware Failure ◽  
Radiographic Outcomes ◽  
Fixation Group

Category: Ankle Arthritis, Diabetes, Hindfoot Introduction/Purpose: Charcot neuropathy of the ankle and hindfoot is a progressive and destructive process that can lead to instability and ulceration resulting in significant morbidity which can end with amputation. The foot and ankle surgeon’s aim is to reconstruct the high risk foot with the creation of a stable plantigrade foot, while reducing the risk of ulceration and allowing the patient to mobilize in commercially available footwear. There are numerous techniques for the reconstruction of the neuropathic hindfoot, but the most utilized of these include multiplanar external fixation or internal fixation with a plate or intramedullary nail. It is our goal to further elucidate outcomes of Charcot patients undergoing corrective ankle and hindfoot fusion comparing internal versus external fixation. Methods: We retrospectively collected 377 patients undergoing hindfoot and ankle arthrodesis at our institution from 2006- 2017. 77 patients were identified that underwent arthrodesis for Charcot arthropathy, 56 of which met our inclusion and exclusion criteria. This included 47 who had internal fixation as their primary procedure and 9 patients who underwent external fixation with a multi-planar external fixator. Our median follow up time was 3.4 years (IQR .5 to 12.9). Preoperatively we collected basic demographic variables, reasons for neuropathy, and ulcer status. Postoperatively we collected complications including infection, hardware failure, ulceration, recurrent deformity, and radiographic outcomes including union and hardware backout. Reoperation numbers and indications were also collected. Our primary outcome was limb salvage at final follow up. Secondarily, we collected final ambulatory and footwear status. Results: The limb salvage rate was 82% with 10 patients undergoing amputation, which did not vary between groups (p=.99). The primary reasons for amputation were persistent infection (4 of 10) and nonunion (4 of 10). Thirteen (24%) patients developed an infection. The median number of reoperations per patient was 1 (IQR 0-2) with the patients who underwent amputation undergoing a median of 2 (IQR 2-4) reoperations. The rate of union was 54%, occurring at a median of 26.5 (IQR 12-47) months. 44% (4/9) of patients in the external fixation group had a preoperative ulceration versus 19% (9/47) of the patients in the internal fixation group (p=.19). Preoperative ulceration was not a risk factor for amputation. Forty-two (75%) patients were ambulatory at final follow up. Conclusion: We report on the single largest series of Charcot patients undergoing hindfoot and ankle arthrodesis. The surgical management of this population has a high rate of complications with infection and reoperation being common. Despite a high nonunion rate most patients are able to ambulate in a brace or orthotic. Limb salvage can be expected with either internal or external fixation techniques.

scholarly journals Integrated Reconstruction for Chronic Foot Dislocations

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0012
Author(s):  
Douglas N. Beaman ◽  
Cassandra B. Tomczak ◽  
Paul T. Fortin
Keyword(s):  
Soft Tissue ◽  
Internal Fixation ◽  
External Fixation ◽  
Treatment Protocol ◽  
Case Series ◽  
Clinical Results ◽  
Deep Infection ◽  
Taylor Spatial Frame ◽  
Fixation Methods ◽  
Spatial Frame

Category: Hindfoot; Diabetes; Midfoot/Forefoot Introduction/Purpose: Chronic dislocations of the hindfoot and midfoot are a treatment challenge due to difficulties in achieving re-alignment without bone or soft tissue compromise. Neuropathy and diabetes are often associated with the chronic foot dislocation, and further complicate treatment. Our prior studies with integrated fixation methods (ring external fixation and internal fixation) for severe tibia pilon fractures and deformed, infected neuroarthopathic ankles has shown that internal fixation around the ankle can be safely combined with external fixation in single stage procedures.In this study, a staged approach is utilized to limit bone resection and minimize risks of soft tissue compromise and neurovascualar injury with severe and rigid defomity corrections. The purpose is to assess the results and complications of this surgical treatment approach. Methods: Medical records, clincal evaluation, and radiographs for 9 patients treated with gradual hexapod realignment and staged arthrodesis of chronic foot dislocations were retrospectively reviewed. There were six female and three male patients with a mean age of 59 (range, 43-71) years. Follow-up ranged from 12 months to 12 years. All had neuropathy; seven were diabetic, one CMT, one idiopathic, and one rheumatoid. Dislocation was present for a minimum of 16 weeks (range, 4 to 36 months). Seven patients had preoperative ulcerations. Seven had peritalar dislocations (subtalar and talonavicular), and two had midfoot dislocations (naviculocuneiform-1, talonavicular-1).Treatment protocol included: Surgical stage 1- soft tissue releases and Taylor spatial frame application; gradual correction of dislocation; Surgical stage 2-open arthrodeses with internal fixation and frame modification or removal. Results: All nine patients achieved a stable plantigrade and functional foot position. All fusions healed except for one talonavicular nonunion. All preoperative ulcerations healed. Six patients with peritalar dislocations had frame modification at the time of arthrodesis (mean frame time was 5.9 months). Three patients had frame removal at time of arthrodesis (mean frame time was 3 months). Average time from hexapod realignment to arthrodesis surgery was 8 (range, 3-16) weeks.Outcome with the Reinker/Carpenter scale was 5 excellent, 2 good, and 2 fair. Two peritalar dislocations developed complications; one talonavicular nonunion, and one deep infection. Other complications included further surgery in two midfoot dislocations, two forefoot wire complications, and one ankle deformity during peritalar correction. Conclusion: Staged integrated realignment/arthrodesis for chronic neuropathic foot dislocations resulted in good clinical outcomes with manageable complications. The Taylor spatial frame miter and butt constructs were successful in reducing hindfoot and midfoot dislocations, respectively. There was reliable fusion and ulcer healing with our staged protocol. This case series furthers our successful clinical results with the combined use of ring external fixation and internal fixation methods for complex foot and ankle pathology.

scholarly journals Complication Rates in Ankle and Hindfoot Charcot Arthropathy Treated with Arthrodesis

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0034
Author(s):  
David M. Macknet ◽  
Andrew Wohler ◽  
Bruce E. Cohen ◽  
J. Kent Ellington ◽  
Carroll P. Jones ◽  
...  
Keyword(s):  
Internal Fixation ◽  
External Fixation ◽  
Limb Salvage ◽  
Ankle Arthrodesis ◽  
Limb Salvage Rate ◽  
Charcot Arthropathy ◽  
Non Union ◽  
Radiographic Union ◽  
Salvage Rate

Category: Diabetes; Ankle; Hindfoot; Other Introduction/Purpose: Charcot arthropathy of the ankle and hindfoot is a progressive and destructive process that can lead to instability and ulceration resulting in significant morbidity. When indicated, the surgical goals are to restore a stable plantigrade foot, reduce the risk of ulceration, and improve function to independent ambulation. Techniques for reconstruction of the neuropathic ankle/hindfoot include external and/or internal fixation. Current literature involving small series of surgical patients has shown a high rate of limb salvage and low complication rate. Our experience has been less promising, although we believe it remains a viable option. It is our goal to report the outcomes of Charcot patients undergoing corrective ankle and hindfoot reconstruction. Methods: We retrospectively reviewed 377 patients undergoing hindfoot and ankle arthrodesis at our institution from 2006- 2017. 77 patients were identified that underwent arthrodesis for Charcot arthropathy, 51 of which met inclusion and exclusion criteria with a minimum one year follow up. 42 had internal fixation as their primary procedure (plate or nail) and 9 patients underwent external fixation with a multi-planar external fixator. Median follow up time was 4 years (IQR 2.97 years). Preoperatively, basic demographic variables, etiology of neuropathy, ulcer status, radiographic measurements, Brodsky classification, and presence of a viable talus were collected and analyzed. Postoperatively, we collected complications including infection, hardware failure, ulceration, recurrent deformity, and nonunion. Reoperation numbers and indications for reoperation were also collected. The primary outcome measure was limb salvage at final follow up. Secondary outcome measures were ambulatory and footwear/bracing status. Results: 11 patients (20%) underwent amputation at final follow up and 26 (47.3%) achieved radiographic union, both of which did not vary by fixation type (p=0.67 and p=0.88). The primary reasons for amputation were persistent infection and non-union. 74.5% of patients developed a post-operative complication and 58.2% had at least one reoperation. 25.5% of patients developed a post- operative infection. Patients with a pre-operative ulceration were more likely to undergo external fixation (p=0.02), but amputation rates did not differ between groups (p>0.99). There was a trend toward increased risk of post-operative infection in the ulceration group (p=0.07). A pre-operative Meary’s angle >25° was more likely to undergo amputation (p=0.04) and less likely to achieve radiographic union (p=0.05). 75.9% of patients were ambulatory at final follow up. Conclusion: Our rates of amputation (20%), post-operative infection (25%), complications (74.5%) and non-union (52%) are higher than previously described. Previous literature has described a near 100% limb salvage rate, but in our report on a large series of Charcot patients undergoing hindfoot/ankle arthrodesis we describe an 80% limb salvage rate. Pre-operative Meary’s angle >25° was predictive of treatment failure.

Novel Use of Active Leptospermum Honey for Ringed Fixator Pin Site Care in Diabetic Charcot Deformity Patients

2017 ◽  
Vol 11 (2) ◽  
pp. 117-122 ◽  
Author(s):  
Alexander L. Lazarides ◽  
Kamran S. Hamid ◽  
Michael S. Kerzner
Keyword(s):  
External Fixation ◽  
Case Series ◽  
Deformity Correction ◽  
Controlled Study ◽  
Control Group ◽  
Diabetic Patients ◽  
Superficial Infection ◽  
Safety And Efficacy ◽  
Fine Wire ◽  
Pin Site

Introduction. Open reduction with external fixation (OREF) utilizing fine wire ringed fixators for correction of Charcot deformity has gained popularity over the past decade. Pin site infections are a well-documented complication of external fixation as well as a driver of escalating health care costs. We aimed to demonstrate the safety and efficacy of a novel method of pin site care utilizing active Leptospermum honey–impregnated dressings (MediHoney) in diabetic patients undergoing deformity correction with OREF. Methods. Twenty-one diabetic patients with Charcot deformities of the lower extremity were prospectively enrolled and followed for pin site complications following OREF for deformity correction. Active Leptospermum honey dressings were applied at metal-cutaneous interfaces at the end of the OREF procedure and replaced weekly for a total of 8 weeks. Patients were monitored for pin site infections from the time of surgery until external fixator removal. Sixteen consecutive patients receiving standard OREF for Charcot deformities were evaluated retrospectively to serve as a control group. Results. Of the 21 enrolled patients, 19 underwent OREF and followed up throughout the study period. Treated patients had a mean age of 58.5 years and mean body mass index measuring 33.3 kg/m2 as documented prior to surgery. The 15 patients with hemoglobin A1c labs drawn in the 3 months preceding surgery averaged 7.5. Fixators were removed at an average of 12.1 weeks after adequate bony healing. Of the 244 pin sites in 19 patients, 3 pin sites (1.2% of pins) in 2 patients (10.5% of patients) showed evidence of superficial infection. All infections resolved with oral antibiotics. Infection rates were significantly reduced when compared to the standard care control group. Conclusions. Pilot data in a prospectively collected case series demonstrate safety and efficacy of active Leptospermum honey–impregnated dressings when used for fine wire ringed fixator pin site care in diabetic Charcot deformity patients. Further investigation in the form of a prospective randomized controlled study is warranted to demonstrate the potential value of this novel intervention. Levels of Evidence: Level IV

scholarly journals Identification of Postoperative Step-Offs and Gaps With Brodén’s View Following Open Reduction and Internal Fixation of Calcaneal Fractures

2019 ◽  
Vol 40 (7) ◽  
pp. 797-802 ◽  
Author(s):  
Rosalie C. Looijen ◽  
Dominique Misselyn ◽  
Manouk Backes ◽  
Siem A. Dingemans ◽  
Jens A. Halm ◽  
...  
Keyword(s):  
Internal Fixation ◽  
Excellent Agreement ◽  
Open Reduction ◽  
Interobserver Reliability ◽  
Case Series ◽  
Intraobserver Reliability ◽  
Foot And Ankle ◽  
Calcaneal Fractures ◽  
Intraoperative Fluoroscopy ◽  
Level Of Agreement

Background: To date, there is no consensus regarding which postoperative imaging technique should be used after open reduction and internal fixation of an intra-articular calcaneal fracture. The aim of this study was to clarify whether Brodén’s view is sufficient as postoperative radiologic examination to assess step-offs and gaps of the posterior facet. Methods: Six observers estimated the size of step-offs and gaps on Brodén’s view in 42 surgically treated intra-articular calcaneal fractures. These findings were compared to postoperative CT scans (gold standard). Inter- and intraobserver reliability were calculated and compared using intraclass correlation coefficients (ICCs). Results: An accuracy of approximately 75% for both step-offs and gaps was found in foot and ankle experts. Less experienced observers correctly identified step-offs and gaps in approximately 62% of cases on fluoroscopy and in 48% on radiographs. Interobserver reliability for intraoperative fluoroscopy as well as postoperative radiographs was fair for step-offs, whereas interobserver reliability for gaps was excellent. Intraobserver reliability showed a low level of agreement for intraoperative fluoroscopy, in contrast to postoperative radiographs with excellent agreement for step-offs and good agreement for gaps. Conclusion: Our results show that especially for more experienced foot and ankle surgeons, in the majority of fractures, Brodén’s view accurately showed step-offs and gaps following open reduction and internal fixation. Interobserver reliability showed a fair level of agreement for step-offs and excellent agreement for gaps. Intraobserver reliability was only enough for radiographs, not for fluoroscopy. Level of Evidence: Level IV, case series.

scholarly journals External Fixation versus Primary Open Reduction and Internal Fixation (ORIF) of Intra-articular Calcaneus Fractures

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0002
Author(s):  
Rishin Kadakia ◽  
Catphuong Vu ◽  
Jason Bariteau ◽  
Rahul Rege ◽  
Mara Schenker
Keyword(s):  
Soft Tissue ◽  
Postoperative Complications ◽  
Internal Fixation ◽  
External Fixation ◽  
Open Reduction ◽  
Wound Dehiscence ◽  
Complication Rates ◽  
Soft Tissue Envelope ◽  
Calcaneus Fractures

Category: Hindfoot, Trauma Introduction/Purpose: Calcaneus fractures are common injuries of the foot and account for approximately sixty percent of all tarsal bone fractures. Anatomic reduction of the articular surface is associated with good long-term outcomes. Unfortunately, there is a high rate of complications following surgical fixation due to the fragile soft tissue envelope surrounding these injuries. External fixation of joint depression calcaneus fractures allows for restoration of morphology and preservation of soft tissues. The purpose of this work is to determine if acute external fixation in the management of joint depression calcaneus fractures leads to decreased postoperative complications and better outcomes. Methods: Patients were identified using the appropriate procedure codes over a ten year span at a level one trauma center. Those under the age of eighteen and underwent nonoperative treatment were excluded. Electronic medical records were reviewed to obtain, basic demographic data, comorbidities, and injury specifics. Calcaneus fractures were classified as open or closed and using the Essex-Lopresti classification system. Operative reports were reviewed to determine which patients initially underwent external fixation versus open reduction internal fixation (ORIF), furthermore any staged operative interventions were also noted. Electronic records were also reviewed to determine the length of follow up and incidence of postoperative complications. Bivariate analysis was used to identify an association between collected variables and postoperative complications (wound dehiscence, hardware failure, infection, nonunion). Multivariate logistic regression analysis was used to determine if patients treated with acute external fixation were associated with lower postoperative complication rates. Results: 152 calcaneus fractures were identified and included for analysis. The average age was thirty-eight and the majority of patients were male (111/152 = 73%). Average follow up was approximately five months. Seventeen percent (26/152) were open fractures. Twenty-six (17%) were treated initially with external fixation and eleven of these were a staged ORIF. The overall complication rate was 11% (17/152) with the most common complication being wound dehiscence. Only one complication occurred in the group initially managed with external fixation. Statistical analysis revealed that open fractures were associated with increased postoperative complication rates in a bivariate and multivariate model. Conclusion: External fixation of joint depression calcaneus fractures restores height and preserves the soft tissue envelope. Although there was only one complication in the external fixation group, the difference in complication rates was not statistically significant based on initial treatment. The low number of patients treated with external fixation initially and the short follow up are limitations of this study. Further work is needed with a larger patient cohort in a prospective setting. Acute external fixation may prove to be a useful tool to help prevent postoperative complications following joint depression calcaneus fractures.

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