Two-stage reconstruction of infected Charcot foot using internal fixation

2021 ◽  
Vol 103-B (10) ◽  
pp. 1611-1618
Author(s):  
Venu Kavarthapu ◽  
Basil Budair
Keyword(s):  
Internal Fixation ◽  
Limb Salvage ◽  
Care Plan ◽  
Surgical Reconstruction ◽  
Charcot Foot ◽  
Foot Deformity ◽  
Two Stage ◽  
Infected Nonunion ◽  
Hardware Failure

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.

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.

Surgical Reconstruction of the Diabetic Foot: A Salvage Approach for Midfoot Collapse

1996 ◽  
Vol 17 (6) ◽  
pp. 325-330 ◽  
Author(s):  
John S. Early ◽  
Sigvard T. Hansen
Keyword(s):  
Internal Fixation ◽  
Limb Salvage ◽  
Diabetic Foot ◽  
Plantar Pressure ◽  
Pressure Ulcers ◽  
Surgical Reconstruction ◽  
Postoperative Course ◽  
Ambulatory Status ◽  
Radiographic Union

Between 1985 and 1993, 18 patients representing 21 feet underwent surgical reconstruction for diabetic neuroarthropathy with collapse of the midfoot. Forty-seven percent (10/21) of these feet presented with plantar pressure ulcers. Reconstruction involved reduction and fusion of collapsed joints, using internal fixation to restore foot shape and improve weightbearing alignment. The average follow-up in these patients was 28 months (range, 6–84 months). Limb salvage was obtained in 18 of 21 feet. Average time to radiographic union was 5 months (range, 3–9 months). Improvement in shoe fit and ambulatory status was noted for 13 of the 15 patients who had successful reconstruction. Forty-seven percent of the reviewed cases were without any complication throughout their postoperative course. Seventy percent of the presenting ulcers healed without incident. There were no recurrent midfoot ulcers.

Surgical reconstruction for unilateral iliac artery lesions in patients younger than 50 years

VASA ◽  
2011 ◽  
Vol 40 (6) ◽  
pp. 474-481 ◽  
Author(s):  
Radak ◽  
Babic ◽  
Ilijevski ◽  
Jocic ◽  
Aleksic ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Limb Salvage ◽  
Iliac Artery ◽  
Graft Patency ◽  
Long Term Results ◽  
Surgical Reconstruction ◽  
Safe Procedure ◽  
Term Survival

Background: To evaluate safety, short and long-term graft patency, clinical success rates, and factors associated with patency, limb salvage and mortality after surgical reconstruction in patients younger than 50 years of age who had undergone unilateral iliac artery bypass surgery. Patients and methods: From January 2000 to January 2010, 65 consecutive reconstructive vascular operations were performed in 22 women and 43 men of age < 50 years with unilateral iliac atherosclerotic lesions and claudication or chronic limb ischemia. All patients were followed at 1, 3, 6, and 12 months after surgery and every 6 months thereafter. Results: There was in-hospital vascular graft thrombosis in four (6.1 %) patients. No in-hospital deaths occurred. Median follow-up was 49.6 ± 33 months. Primary patency rates at 1-, 3-, 5-, and 10-year were 92.2 %, 85.6 %, 73.6 %, and 56.5 %, respectively. Seven patients passed away during follow-up of which four patients due to coronary artery disease, two patients due to cerebrovascular disease and one patient due to malignancy. Limb salvage rate after 1-, 3-, 5-, and 10-year follow-up was 100 %, 100 %, 96.3 %, and 91.2 %, respectively. Cox regression analysis including age, sex, risk factors for vascular disease, indication for treatment, preoperative ABI, lesion length, graft diameter and type of pre-procedural lesion (stenosis/occlusion), showed that only age (beta - 0.281, expected beta 0.755, p = 0.007) and presence of diabetes mellitus during index surgery (beta - 1.292, expected beta 0.275, p = 0.026) were found to be significant predictors of diminishing graft patency during the follow-up. Presence of diabetes mellitus during index surgery (beta - 1.246, expected beta 0.291, p = 0.034) was the only variable predicting mortality. Conclusions: Surgical treatment for unilateral iliac lesions in patients with premature atherosclerosis is a safe procedure with a low operative risk and acceptable long-term results. Diabetes mellitus and age at index surgery are predictive for low graft patency. Presence of diabetes is associated with decreased long-term survival.

scholarly journals Deformity and Clinical Outcomes for Surgical Correction of Charcot Ankle

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0024
Author(s):  
Elizabeth Harkin ◽  
Andrew Schneider ◽  
Michael Murphy ◽  
Adam Schiff ◽  
Michael Pinzur
Keyword(s):  
Clinical Outcomes ◽  
Complication Rate ◽  
Chronic Wounds ◽  
Sagittal Plane ◽  
Case Series ◽  
Surgical Correction ◽  
Surgical Reconstruction ◽  
Charcot Foot ◽  
Operative Complication

Category: Diabetes Introduction/Purpose: Charcot Foot is a complex neuro-arthropathy associated with acquired progressive deformity and a significant impact to patients’ quality of life. Recent reports have suggested that preoperative deformity is predictive of clinical outcomes following surgical correction of the acquired deformity associated with midtarsal diabetes-related Charcot Foot arthropathy. Methods: A retrospective analysis was performed of 56 patients who underwent surgical reconstruction of Charcot ankle arthropathy by a single surgeon over a 14-year time period. Preoperative tibiotalar alignment was reviewed in the coronal and sagittal plane. Preoperative patient characteristics including age, sex, hemoglobin A1c, BMI, insulin use, and presence of a wound or infection at the time of surgery were also recorded. Preoperative coronal plane deformity was observed as valgus 16/56 (28.6%), varus 31/56 (55.4%), and neutral 9/56 (16.1%). Surgery included debridement of active infection when present, corrective osteotomies, and an attempt at ankle arthrodesis with application of a ringed external fixator (39 of 56, 69.6%) when infection was present or retrograde intramedullary nail (17 of 56, 30.3%). Clinical outcomes of excellent, good, or poor were based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with either a CROW, AFO, or therapeutic diabetic footwear. Results: The average total patient follow-up time from index surgery was 115.4 weeks. One patient died after 134.3 weeks of follow-up and 8 underwent amputation. The post-operative complication rate was 69.6% (39 of 56), 79.5% (31 of 39) of which underwent re-operation. Ultimately, only 25 of 55 patients (45.5%) achieved a favorable (excellent or good) clinical outcome. There was no meaningful association between surgical outcome, post-operative complication, reoperation, and amputation and patients’ pre-operative alignment, final alignment, treatment with either ex-fix or IMN, the presence of a wound or infection, age, HgA1c, or BMI. However, compared to insulin dependent diabetics, those not taking insulin were only 0.34 times as likely to have a poor outcome. Conclusion: Operative fixation of Charcot ankle arthropathy was performed with a goal of achieving a plantigrade post for ambulation void of infection or chronic wounds and easily accommodated with a supportive orthosis. This retrospective case series demonstrates a high complication rate in this complex patient population. Clinical outcomes of Charcot ankle can be used to counsel patients on the risks of surgical correction and as a benchmark for improved treatment strategies.

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.

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

1997 ◽  
Vol 36 (5) ◽  
pp. 360-363 ◽  
Author(s):  
Barry I. Rosenblum ◽  
John M. Giurini ◽  
Leonard B. Miller ◽  
James S. Chrzan ◽  
Geoffrey M. Habershaw
Keyword(s):  
Limb Salvage ◽  
Charcot Foot ◽  
Foot Deformity ◽  
Flexible Approach ◽  
Lateral Column

Outcomes of Tibiotalocalcaneal Arthrodesis with a Femoral Nail

2021 ◽  
Vol 111 (3) ◽  
Author(s):  
Nicholas S. Powers ◽  
Paul R. Leatham ◽  
Justin D. Persky ◽  
Patrick R. Burns
Keyword(s):  
Limb Salvage ◽  
Demographic Data ◽  
Deep Infection ◽  
Negatively Associated ◽  
Hardware Failure ◽  
Tibiotalocalcaneal Arthrodesis ◽  
Femoral Nail ◽  
Hindfoot Deformities ◽  
End Stage

Background Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters. Methods We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated. Results At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection–related complications. Conclusions Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.

scholarly journals Treatment of Mandibular Angle Fractures with Single Three-Dimensional Locking Miniplates without Maxillomandibular Fixation: How Much Fixation is Required?

2017 ◽  
Vol 10 (3) ◽  
pp. 188-196 ◽  
Author(s):  
Sanjay Rastogi ◽  
Sam Paul ◽  
Sumedha Kukreja ◽  
Karun Aggarwal ◽  
Rupshikha Choudhury ◽  
...  
Keyword(s):  
Internal Fixation ◽  
Open Reduction ◽  
Three Dimensional ◽  
Mouth Opening ◽  
Mandibular Angle ◽  
Analog Scale ◽  
Hardware Failure ◽  
Angle Fractures ◽  
Fracture Stability

The aim of this simple nonrandomized and observational study was to evaluate the efficacy of single three-dimensional (3D) plate for the treatment of mandibular angle fractures without maxillomandibular fixation. A total of 30 patients with noncomminuted fractures of mandibular angle requiring open reduction and internal fixation were included in the study. All the patients were treated by open reduction and internal fixation using single 3D titanium locking miniplate placed with the help of transbuccal trocar or Synthes 90-degree hand piece and screw driver. 3D locking titanium miniplates used in our study was four-holed, box-shaped plate, and screws with 2 mm diameter and 8 mm length. The following clinical parameters were assessed for each patient at each follow-up visit: pain (visual analog scale: 0–5), swelling (visual analog scale: 0–5), mouth opening, infection, paresthesia, hardware failure (plate fracture), occlusal discrepancies, and mobility between fracture fragments. A significant decrease in pain level was seen during the follow-up visits. No statistically significant changes were seen in swelling, but mouth opening increased in the subsequent visits. Also better results were seen in terms of fracture stability and occlusion in the postoperative period. Two cases of infection and two cases of hardware failure were noted in sixth postoperative week. 3D plating system is an easy to use alternative to conventional miniplates to treat mandibular angle fractures that uses lesser foreign material, thus reducing the operative time and overall cost of the treatment. Better fracture stability and occlusion was also achieved using the 3D plating system.

scholarly journals Surgical Reconstruction of Charcot Foot Neuroarthropathy, a Case Based Review

2014 ◽  
Vol 57 (3) ◽  
pp. 127-132 ◽  
Author(s):  
Tomáš Kučera ◽  
Pavel Šponer ◽  
Jaromír Šrot
Keyword(s):  
Limb Salvage ◽  
Imaging Techniques ◽  
Large Diameter ◽  
Operative Management ◽  
Plaster Cast ◽  
Surgical Reconstruction ◽  
Charcot Foot ◽  
Charcot Neuroarthropathy ◽  
Case Based

Our case-based review focuses on limb salvage through operative management of Charcot neuroarthropathy of the diabetic foot. We describe a case, when a below-knee amputation was considered in a patient with chronic Charcot foot with a rocker-bottom deformity and chronic plantar ulceration. Conservative treatment failed. Targeted antibiotic therapy and operative management (Tendo-Achilles lengthening, resectional arthrodesis of Lisfranc and midtarsal joints, fixation with large-diameter axial screws, and plaster cast) were performed. On the basis of this case, we discuss options and drawbacks of surgical management. Our approach led to healing of the ulcer and correction of the deformity. Two years after surgery, we observed a significant improvement in patient’s quality of life. Advanced diagnostic and imaging techniques, a better understanding of the biomechanics and biology of Charcot neuroarthropathy, and suitable osteosynthetic material enables diabetic limb salvage.

Drug-eluting stents for treatment of focal infrapopliteal lesions

VASA ◽  
2012 ◽  
Vol 41 (2) ◽  
pp. 90-95 ◽  
Author(s):  
Rastan ◽  
Noory ◽  
Zeller
Keyword(s):  
Limb Salvage ◽  
Bare Metal Stents ◽  
Target Lesion ◽  
Drug Eluting Stents ◽  
Metal Stents ◽  
Target Lesion Revascularisation ◽  
Randomized Studies ◽  
Drug Eluting ◽  
The Mean

We have investigated the role of drug-eluting stents on patency rates after treatment of focal infrapopliteal lesions in patients with intermittent claudication and critical limb ischemia. Reports indicate that drug-eluting stents reduce the risk of restenosis after percutaneous infrapopliteal artery revascularization. A Pub Med, EMBASE, Cochrane database review search of non-randomized studies investigating patency rates, target lesion revascularisation rates, limb salvage rates and mortality rates in an up to 3-year follow-up period after drug-eluting stent placement was conducted. In addition, preliminary results of randomized studies comparing drug-eluting stents with bare-metal stents and plain balloon angioplasty in treatment of focal infrapopliteal lesions were included in this review. A total of 1039 patients from 10 non-randomized and randomized studies were included. Most commonly used drug-eluting stents were sirolimus-eluting. The mean follow-up period was 12.6 (range 8 - 24). The mean 1-year primary patency rate was 86 ± 5 %. The mean target lesion revascularization rate and limb salvage rate was 9.9 ± 5 % and 96.6 %±4 %, respectively. Results from non-randomized and preliminary results from prospective, randomized trials show a significant advantage for drug-eluting stents in comparison to plain balloon angioplasty and bare-metal stents concerning target lesion patency and in parts target lesion revascularisation. No trial reveals an advantage for drug-eluting stents with regard to limb salvage and mortality.

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