Charcot Reconstruction Research Articles

Charcot reconstruction using a novel intramedullary nail along the medial column: 3-5 year follow-up results

Charcot neuroarthropathy is a destructive, chronic disease of the bone structure and joints, and is identified in patients experiencing peripheral neuropathy, frequently associated with diabetes. The foot and ankle are most impacted by Charcot neuroarthropathy; whereas the goal of management is to stabilize the joint to avoid pedal collapse, infection, and foot amputation. Novel surgical approaches and hardware have shown promise in achieving these goals, allowing patients to return to ambulation, while avoiding late-stage complications. This multicenter, retrospective, consecutive case series reviewed individuals with midfoot Charcot neuroarthropathy who underwent surgical reconstruction using a novel locking intramedullary nail (LIN) in the medial column with at least 36 months of follow-up. Patients were treated between 2019 and 2021.This report presents data and outcomes on 30 patients with Charcot disease treated with a LIN to achieve stability and fusion along the medial column of the reconstruction, with 36-60 months of follow-up data. Of these patients, 93.3% (n = 28) demonstrated complete (multiple joint) fusion along the medial column while there were zero nonunions. Overall, the mean time to fusion was 14.1 weeks (range 10-18 weeks) and 18.1 weeks mean time to functional braced-weightbearing (range 12-28 weeks). Overall, this retrospective review investigated the long-term use of a novel LIN in Charcot neuroarthropathy patients. The success of this LIN was demonstrated by the rate of fusion and time to functional braced-weightbearing, and safety was demonstrated by the low incidence of adverse events. Overall, these results indicate that use of a LIN within the medial column to be successful in the surgical reconstruction of an unstable midfoot Charcot deformity.

THE IMPORTANCE OF ANATOMICAL CHARCOT RECONSTRUCTION UTILIZING STANDARDIZED OSTEOTOMIES TO IMPROVE SURGICAL OUTCOMES

IntroductionCharcot neuroarthropathy is a debilitating condition that frequently leads to skeletal instability, and has an increased risk of ulceration leading to infection and amputation. However, surgical reconstruction may offer limb salvage and restauration of an ulcer-free, plantigrade stable foot for functional weight-bearing. We report on our case series according to a prospective protocol and analyse factors leading to a favourable outcome.MethodsWe report a prospective follow-up of 62 patients undergoing Charcot reconstruction, May 2014- Jan 2022, by two surgeons. Peripheral vascular disease was routinely assessed using Duplex scan and major arterial disease was treated before reconstruction. Utilising 3D modelling, pre-operative planning and standardised osteotomies, we performed anatomical correction with radiological evidence. Definitive fixation was undertaken with internal fixation to stabilise the hindfoot. Multivariant analysis was performed to assess risk factors for failure (P>0.05 statistical significance).Results59 feet were included, 3 patients did not progress to definitive surgery and 3 patients had bilateral surgery. 62.7% patients were male with an average age of 56, 88.13% had Type 2 diabetes, 56% were hypertensive, 14% were on dialysis. Twenty (54.1%) single stage reconstructions had pre-operative ulceration, 3 pts had ischaemic heart disease and 36 pts had evidence of peripheral arterial disease. 81% of patients achieved normalisation of the 3 out of 4 anatomical angles (P<0.05). Two patients (3.1%) required metalwork removal for infection and limb salvage, 11 (18.6%) had delayed wound healing. Survivorship was 97% at 3yrs, and 94% at 6yrs, however if pre-existing vascular disease was present, it was 94% at 3yrs 85.3% at 6yrs. All patients were mobile at a 3 years mean follow up.ConclusionCareful patient selection, multidisciplinary team and anatomic reconstruction led to predictable outcomes and functional limb salvage. Pre-operative vascular compromise led to a slight reduction in survivorship, but no major amputation.

PREDICTORS OF METALWORK FAILURE AND NONUNION AFTER HINDFOOT CHARCOT RECONSTRUCTION

IntroductionSurgical 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.MethodsWe 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.ResultsThere 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).ConclusionSatisfactory 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.

AOFAS Diabetic Foot Survey Results

Introduction: Foot and ankle pathology in patients with diabetes mellitus is prevalent in the United States and may be associated with significant morbidity. Patient outcomes can be improved by optimal medical management; deformity management and correction to limit the development of infection and ulceration; and timely, appropriate treatment of infection and ulceration when it occurs. Orthopaedic foot and ankle surgeons are well-qualified to treat these patients, either individually or as members of a healthcare professional team. However, there are some healthcare professionals and members of the public who are under the impression that orthopaedic foot and ankle surgeon are either unwilling or uninterested in treating this patient population. The authors hypothesized that this impression was a misconception and this study was designed to address this question. Methods: An online survey was sent to 1376 AOFAS members practicing in the United States. There were six questions, two of which were demographic and one that asked for additional comments. The survey was completed by 297 (22%) members from 45 states and the District of Columbia. Results: Nonoperative treatment of foot and ankle disorders in patients with diabetes mellitus was performed by 98.7% of responders including 98.7% for fractures; 97.6% for common disorders (e.g., bunions, hammer toes, flatfeet, plantar fasciitis, osteoarthritis, tendon disorders); 89.9% for Charcot arthropathy; 77.1% for infections; and 69.0% for ulcers. Operative treatment of foot and ankle disorders in patients with diabetes mellitus was performed by 98.7% of responders including 97.0% for fracture fixation; 96.3% for gastrocnemius recession and/ or Achilles tendon lengthening; 94.6% for arthrodesis for osteoarthritis; 94.3% for hammer toe surgery; 92.6% for bunion surgery; 89.6% for Charcot exostectomy; 83.8% for Charcot reconstruction; 83.5% for amputations within foot; 81.1% for below knee amputations; 74.8% for operative debridement of infections/ ulcers; and 57.9% for total ankle replacement. When asked which healthcare professionals treat diabetic patients in their community, 96.6% listed podiatrists; 91.3% listed orthopaedic foot and ankle surgeons; 69.0% listed other MD/ DO surgeons (e.g. general, plastics, vascular); 64.0% listed nurses (e.g., APRN, wound care specialist); 37.4% listed other orthopaedic surgeons; 31.7% listed non- surgeon MD/ DO physicians; 32.3% listed physician assistants; and 2% listed other. Conclusion: The vast majority of orthopaedic foot and ankle surgeons practicing in the United States who responded to the survey provide operative and nonoperative treatment to patients with diabetes mellitus and foot and ankle disorders. Given the extensive medical education and training of orthopaedic foot and ankle surgeons, their knowledge and surgical skill, and the benefits patients with diabetes receive from appropriate and timely foot and ankle care, efforts should be made to educate the public and other healthcare professionals of the availability of most orthopaedic foot and ankle surgeons to provide this care.

Deap-seated infection and nonunion following internal fixation for Charcot foot deformity correction. A proportional meta-analysis of level 4 evidence

BackgroundGiven the paucity of literature on the management of infected metalwork and nonunion in neuropathic diabetic patients, a meta-analysis was designed to investigate the two major complications following Charcot reconstruction performed by means of internal fixation methods. MethodsWe searched PubMed, Scopus and CENTRAL until the 17th of May 2022 for completed studies investigating outcomes following midfoot and/or hindfoot and/or ankle diabetic Charcot reconstruction. For a paper to qualify for inclusion, an internal fixation element should have been considered. Random effects meta-analysis of proportion was performed to calculate the rate of post-operative deep-seated infections with the associated amputation rate and nonunions by using Open Meta-analyst software. Sub-analysis linked to anatomical location of reconstruction was performed and the quality of the included studies was appraised using the Moga tool. ResultsThirty studies with 492 eligible reconstructions were considered. Of those, deep-seated infections were diagnosed in 46 cases (Estimated proportion was 6.7%, 95% CI [4.2%–9.2%]). Debridement and antibiotic administration with or without metalwork removal were considered in the majority of the participants with successful clinical outcomes. Amputation was performed in 15 patients due to unmanageable post-operative infection and nonunion was reported in 17 studies (Estimated rates were 36.6%, 95% CI [18.4%–56.3%]; and 11.9%, 95%CI [6.6%–18.1%]; respectively). ConclusionsMeta-analysis showed that although the overall risk of infection development is less than 10%, just below one third of the infected cases undergo late amputation. Moreover, internal fixation reconstructions carry a nonunion risk of just above 10%.

Intraoperative Radiation Exposure During Midfoot Charcot Reconstruction

While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ .05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5 ± 5.39 mGy and 256.64 ± 130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p = .32) or fluoroscopy times (p = .71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p = .01) body mass index (p = .03) and number of stages (p = .04). Similarly, a relationship existed between fluoroscopy time with weight (p = .02), body mass index (p = .03), and number of beams/screws (p = .003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.

Long-Term Mortality After Charcot Reconstruction.

Charcot neuroarthropathy is a complicated phenomenon with the potential to cause significant deformity, morbidity, and mortality. Costs associated with Charcot-related complications are substantial, with thousands of amputations occurring annually. The purpose of this study was to retrospectively review a single surgeon's experience and record the 10-year mortality rate among patients after Charcot reconstruction at a single institution between 2007 and 2013. Lower-extremity limb salvage is crucial to reduce the burden of Charcot neuroarthropathy. This article provides an example of the potential long-term success of reconstruction surgery for this condition.

“No Care Pin Care” Following Charcot Reconstruction With Static External Fixation

Charcot reconstruction with static external fixation provides stability in deformity correction. Concern for pin site health remains forefront to prevent premature fixator removal should infection develop. While previous investigations examined a spectrum of pin care protocol with a similar variation in outcomes, this study assesses results following a “no care pin care” routine. A retrospective analysis of patients with Charcot neuroarthropathy treated with static external fixation was performed where all pin sites were dressed using a chlorhexidine-soaked sponge without postoperative maintenance. Demographics, reconstruction-specific, and postoperative variables including pin site irritation, pin site infection, and pin tract infection were collected through frame removal. A comparison between uncomplicated and complicated pin sites was made. Statistical significance was set as p ≤ .05. Among 85 patients and their respective pin holes that posed potential spots of infection, 6 (7%) experienced pin site irritation and 5 (6%) experienced pin site infection. Moreover, 2 (2%) experienced a pin tract infection requiring removal. Out of the 768 wires/half-pins 2 (0.3%) were removed. There existed no statistically significant predictors of pin site irritation/infection other than age (p = .03). “No care pin care” proves an effective means at pin site care following static external fixation in Charcot reconstruction. Limited maintenance reduces the postoperative burden on providers and patients.

Clinical Comparison of Internal Fixation Constructs in Midfoot Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot can lead to instability, deformity and ultimately ulceration that can be limb threatening. Previous authors have described a variety of surgical stabilization techniques and constructs including intramedullary fixation (“beaming”) across the midfoot in varying orientations. More recently, intramedullary compression nails (“IM nail”) have been introduced. In contrast with static screws, these devices provide compression across the joints of the midfoot by engaging a compression mechanism against a fixed interlock screw. To our knowledge no clinical comparison between traditional beaming techniques and modern compression nails for midfoot Charcot has been reported. We hypothesize that using IM nails will result in a higher union rate, and lower reoperation and hardware failure rates. Methods: Our electronic medical record was queried to identify patients from 2016-2021 who underwent midfoot reconstruction. Only patients with midfoot Charcot who underwent extended intramedullary fixation were included. Patients with active ulceration at the time of surgery, Charcot that included the ankle, or external fixation as part of the construct were excluded. IM nails were used exclusively for medial column constructs. Basic demographic information was collected. Radiographs and operative notes were evaluated and construct type and implants used were noted. Radiographs at final follow-up were evaluated for union and hardware complication. Clinical notes were evaluated for weightbearing status, plantigrade foot position, ulceration, and wound care requirements. Finally, all complications and reoperations were recorded. Chi-squared or Fisher’s Exact tests were used as appropriate to compare categorical variables and t-tests were used to compare numerical variables. Results: 48 feet (47 patients) with a median age of 58 years (IQR 50, 64) were included. Diabetes was the Charcot etiology in 34/48 (70.8%) feet. There were 19 beaming and 29 IM nail constructs. Basic demographics and Brodsky classification were equally distributed (p>0.05). Median follow-up time was 1.3 years (IQR 0.8, 2.9). Combined medial and lateral column fixation was performed in 39/48 (81.3%) patients. 52% (25/48) included subtalar arthrodesis. Beaming constructs had higher re-operation rates (57.9% versus 27.6%, p < 0.05), and higher hardware failure rates (57% versus 6.9%, p< 0.001). IM nail group had higher union rates (75.9% versus 31.6%, p = 0.001), and higher rates of full weight-bearing at final follow up (86.2% versus 68%, p < 0.05). Two (4.2%) patients required amputation. Conclusion: In a cohort of 48 feet undergoing midfoot Charcot reconstruction, the use of medial column IM nails was associated with lower reoperation rates, lower rates of hardware failure, higher union rates, and higher rates of full weightbearing at final follow-up compared with traditional screw fixation. Surgeons who treat midfoot Charcot may consider these results when planning their stabilization constructs in this high-risk patient population.

Trends in Utilization of Charcot Reconstruction

Category: Ankle; Diabetes Introduction/Purpose: Charcot arthropathy of the foot and ankle is a challenging complication of peripheral neuropathy with a 0.1% and 5.0% incidence in the diabetic population. The purpose of this study is to assess rates of foot or ankle reconstructions (fusions) for Charcot arthropathy, describe the associated patient demographics and hospital settings, and project the volume of Charcot reconstructions anticipated to be performed in 2030. Methods: The National Inpatient Sample database was queried from 2016-2019 using International Classification of Diseases (ICD) codes for foot or ankle fusion (midfoot, hindfoot, or ankle) and a diagnosis of Charcot arthropathy, ultimately identifying 1,343 patients undergoing surgical procedures. Patient information collected included age, sex, race, primary payer status, year of surgery, length of hospital stays, and median household income quartile. Hospital information included bed size, census region, teaching status, and ownership. Results: Between 2016-2019, there were approximately 1,343 patients treated surgically with midfoot, hindfoot, or ankle arthrodesis for Charcot arthropathy, and the number of cases increased by 12.11% annually. Between 2019-2030, there is projected to be a 121.41% increase in the frequency of Charcot reconstruction procedures from 383 to 848 total annual cases. Patients undergoing these procedures are predominantly white, male, and in their 50s. The most common payers were Medicare and private insurance. The mean hospital length of stay was 5.80 days. The procedures performed were predominantly large, urban teaching hospitals in the south with a private, non-profit ownership structure. Conclusion: Surgical reconstruction of Charcot arthropathy of the foot and ankle is steadily increasing in prevalence. These patients are predominantly white, male, and in their 50s. It is important for orthopaedic foot and ankle surgeons to be trained in the surgical management and reconstruction of Charcot arthropathy to meet the expected growing surgical need, which is projected to be 848 procedures annually by 2030.

Three-Dimensional Patient-Specific Cut Guides for Correction of Charcot Midfoot Deformities

Charcot arthropathy of the foot and ankle is a challenging pathology that can require intensive surgical reconstruction. Most often the pathology involves breakdown of the midfoot. Osteotomies of the midfoot to resect and correct the deformity can be unpredictable and time-consuming. With the advent of 3D printing, we propose a new technique utilizing custom cut-guides for midfoot osteotomies in Charcot reconstruction.

Progression to Hindfoot Charcot Neuroarthropathy After Midfoot Charcot Correction in Patients With and Without Subtalar Joint Arthrodesis

Charcot neuroarthropathy (CNA) is a disabling and progressive disease that affects the bones and joints of the foot. Successful Charcot reconstruction focuses on restoring anatomic alignment, obtaining multiple joint arthrodesis, selecting stable fixation, preserving foot length, and creating a foot suitable for community ambulation in supportive shoegear. Intramedullary fixation arthrodesis of the medial and lateral columns has been previously reported to produce improvement in midfoot Charcot reconstruction. More recently, a growing trend of stabilization of the subtalar joint (STJ) has been incorporated alongside the medial and lateral column fusion. Our objectives were to retrospectively review patients who underwent midfoot Charcot reconstructive surgery, whether with or without accompanying STJ arthrodesis, and establish which patients progressed to ankle CNA. Of the 72 patients who underwent midfoot Charcot reconstruction, 28 (38.9%) underwent STJ arthrodesis, and 22 converted to ankle CNA (30.6%). Fourteen (63.6%) of 22 ankle CNA cases had not undergone STJ arthrodesis; 8 patients (36.4%) had it. A Fisher exact test was performed to identify the relationship between those without STJ arthrodesis and those progressing to ankle CNA; it revealed statistical significance (p = .001). Performing an STJ arthrodesis with midfoot Charcot reconstructive surgery may be beneficial to aiding in hindfoot stability, establishing a plantigrade foot, and providing further insight into the management of midfoot Charcot.

Combined Charcot hindfoot and midfoot reconstruction using internal fixation method-surgical technique and single surgeon series.

Isolated midfoot and hindfoot Charcot reconstruction using internal fixation is increasingly a common procedure in multidisciplinary diabetic foot units, and the surgical techniques using internal fixation have well been described. However, about a third of Charcot deformities that require surgical limb salvage present with the involvement of midfoot and hindfoot. Surgical reconstruction of a combined hindfoot and midfoot deformity is an evolving technique and technically challenging. We present the surgical technique of deformity correction and stabilisation using internal fixation, developed by the senior author (VK), and present the outcomes. All patients that had undergone combined hindfoot and midfoot reconstruction to address a limb threatening deformity due to Charcot neuroarthropathy, performed by the senior author, with a minimum follow-up of 12 months, have been included in this study. The principles of surgical reconstruction included adequate pre-operative optimisation of the patient, sequential deformity correction and stabilisation of the hindfoot followed by midfoot using the principle of long-segment rigid internal fixation with optimal bone opposition. Standard post-operative regime, including offloading, has been used in all patients. A total of 34 patients (35 feet) had undergone combined midfoot and hindfoot Charcot reconstruction between January 2009 and December 2019. Active ulcers were noted in 13 feet at the time of the procedure. Eleven reconstructions were performed as two-stage procedures due to the presence of active infection. At a mean follow-up of 53 months, 11/13 ulcer healed, and 32 patients (33 feet) were full weightbearing in surgical shoes or a brace at the latest follow-up. Bone fusion was noted in 28 feet in the hindfoot region and 32 feet in the midfoot. Metal work failure was noted in 5 feet requiring removal in 3 feet. Revision procedures were required in 4 patients. Our newly described technique of combined hindfoot and midfoot Charcot has provided functional limb salvage in majority of presentations, with an acceptable level of complications, at a medium-term follow-up of 53 months.

Intramedullary Beaming Superconstructs for the Treatment of Midfoot Deformity in Patients with Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Charcot arthropathy is a debilitating condition often accompanied by rocker-bottom deformity and plantar ulcerations. Patients with this condition historically experienced poor results, with varying rates of postoperative wound complications, infection, and amputation. Intramedullary beaming in midfoot reconstructions has been previously identified as a viable treatment option for these patients. However, these studies have been limited to small case series. The purpose of this study was to report our experience with realignment and extended fusion with the use of intramedullary beaming superconstructs in patients with Charcot arthropathy and resultant midfoot deformity. Methods: We retrospectively reviewed patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct between January 2017 to January 2021. Bone resection and/or osteotomy were required to reduce the deformity. Intramedullary screws were placed, either antegrade or retrograde, across the arthrodesis sites. Additional hindfoot and/or tibio- talar arthrodesis was performed as indicated by the patient's deformity. Supplemental plate fixation was performed at the discretion of the treating surgeon. All patients were followed for a minimum of three months. Postoperative imaging was assessed to determine fusion at the arthrodesis site. Patient demographics and comorbidities were recorded to assess for risk factors. Patient deformities were classified according to the Brodsky classification. Postoperative rates of infection, limb salvage, reoperation, hardware fatigue, and return to walking were also recorded. Descriptive statistics, Fisher's exact test, Students T- test, and logistic regression were used to analyze outcomes. Results: Thirty-six patients were included. Limb salvage occurred in 35 (97%) patients, while one patient underwent below knee amputation. Fusion was achieved in 30 (83%) patients at an average time of 5.4+-1.3 months. A stable pseudarthrosis allowing ambulation was achieved in 5 (14%) patients. Thirty-three (92%) patients returned to ambulation. Seven patients (19%) required revision surgery (3 for recurrent ulcer, 4 for deep infection). Four (11%) patients experienced hardware fatigue, but all returned to ambulation. Five (14%) patients required assistive devices and seven (19%) required bracing. No patient characteristics were associated with non-union. Absence of supplemental plate fixation was associated with nonunion (P=0.04) and confirmed as an independent risk factor with regression analysis (P=0.03). Additional subtalar and/or hindfoot fixation was not associated with increased fusion rates. Conclusion: Open reduction and arthrodesis using an intramedullary beaming superconstruct for the surgical correction of midfoot collapse in patients with Charcot arthropathy provides a stable and reliable construct with high rates of limb salvage, fusion, and return to ambulation while minimizing complications. Supplemental plate fixation may provide increased construct stability and higher rates of union. However, this clinical importance of this is unknown.

Predictors of metalwork failure and nonunion after hindfoot Charcot reconstruction.

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. 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. 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). 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 J2022;104-B(6):703-708.

Incidence of Scholarly Publication by Selected Content Experts Presenting at National Society Foot and Ankle Meetings From 2016 to 2020

Continuing medical education (CME) is an important element to maintain licensing requirements, enhance professional competence, and disseminate up to date, evidence-based, treatment recommendations. A key resource of CME are the 2 annual society meetings hosted by the American College of Foot and Ankle Surgeons (ACFAS) and American Orthopedic Foot and Ankle Society (AOFAS). It is assumed that the selected speakers at these meetings are content experts, providing validated expertise on treatment recommendations, rather than anecdotal experience or opinion. Across all medical specialists, peer-reviewed publication(s) on a particular subject matter have long bestowed the ultimate validity of “expertise.” The purpose of this study was to assess the incidence of scholarly publication for invited speakers at the ACFAS and AOFAS annual meetings from 2016 to 2020, in relation to the topic they were selected to present. A review of invited lectures given at the ACFAS and AOFAS annual meetings from 2016 to 2020 was conducted, and lecturer demographics were categorized into predetermined content areas for assessment. Selected speakers were individually cross-referenced with content-specific peer-reviewed published literature, and overall h-index using Scopus. Topic and society specific comparisons were then made. Overall, 1028 lectures were identified during the temporal period. Only 300 (29.18%) presentations were given by a speaker with least one or more publication on the society specific lecture-topic presented. The greatest proportion of lecturers with content-specific publications was Charcot reconstruction (67.57%) followed by ankle fusion/replacement (55%). The average presenter h-index was greatest among total ankle replacement/ankle fusion (12.16 ± 6.90) and Charcot reconstruction (11.27 ± 7.10) content. The results of the present study illustrate a disparity of expertise among different content areas. While both meetings provide well-published lecturers, this study reveals areas for improvement.

Hardware Choice and Risk Factors of Talonavicular Arthrodesis Non-Union

Category:Midfoot/Forefoot; AnkleIntroduction/Purpose:Talonavicular arthrodesis is a commonly performed procedure in orthopedic foot and ankle surgery, for conditions including osteoarthritis, instability, and others. The surgery is frequently performed as part of a double or triple arthrodesis. Multiple surgical constructs have been described, including screws, plate/screw constructs, and staple/screw constructs. Few studies exist that specifically focus on the talonavicular joint, and those that do are often limited by low patient volumes. Studies that do examine non-union of the talonavicular joint do not offer comparative data on non-union rates between the different methods of fixation. The purpose of this study was to determine the rate of arthrodesis in talonavicular fusion surgery among different fixation techniques and determine if hardware has a significant effect on union rate among patient factors.Methods:This is a retrospective single institution, multi-surgeon study evaluating arthrodesis rates in the talonavicular joint. Adult patients undergoing primary talonavicular fusion (isolated or as part of double/triple arthrodesis) from 2015-2018 with a minimum of 3-month radiographic follow-up were studied. Patients undergoing revision talonavicular fusion or fusion as part of Charcot reconstruction were excluded. Patient radiographic and chart notes were reviewed to assess fixation type (single screw, 2-hole compression plate, or screw + staple), the status of the arthrodesis at >=3 months and any hardware complications or reoperations following the index procedure. Descriptive statistics were generated for standard patient demographics and co- morbidities. Non-union rates were calculated for the cohort as a whole and for each fixation technique utilized along with the frequency of hardware complications/removal. Univariate analysis was performed to determine risk factors for increased non- union rate, including patient demographics, co-morbidities, and fixation technique.Results:A total of 198 patients were included. Hardware included 131 double straight screws, 42 two-hole compression plates, and 25 screw + staple constructs. Seventeen patients (8.59%) had a nonunion of the talonavicular joint at >3 months, while 18 patients (9.09%) had hardware complications of breakage or prominence and 11 (5.56%) required eventual removal. Hardware type was not a significant predictor of nonunion, as 11 patients had straight screw hardware (8.40%), while 3 had a two-hole plate (7.14%) and 3 had screw + staple (12%) (p=0.801). Hardware breakage or backing out occurred in 6/131 patients with straight screws (4.58%), 5/42 with 2-hole plates (11.90%), and 7/25 with staple + screw (28%) (p=0.001). Hardware removal was necessary in 5 (3.82%) straight screw patients, 3 (7.14%) two-hole plate patients, and 3 (12%) screw + staple patients (p=0.186). Patient age, sex, diabetic and smoking status were not significant for nonunion or hardware complication.Conclusion:The type of hardware used in talonavicular arthrodesis is not a significant factor in achieving union. Staple + screw constructs may be more susceptible to hardware breakage or migration, but was not significant for the necessity of hardware removal, as a number of patients remain painless and achieve the intended union. The authors recommend that physicians can make decisions of which to utilize based on familiarity and preference. Further study is indicated on even larger patient cohorts with increased population of nonunion cases so that further significant patient risk factors for nonunion of the joint can be identified.

Case Report: Tibiotalocalcaneal Arthrodesis Utilizing a Titanium Mesh Implant for Limb Salvage after Failed Charcot Reconstruction

Category:Other; Ankle; Diabetes; TraumaIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis has been employed as a mean to achieve hindfoot fusion and limb salvage. A particular challenge in limb salvage is achieving successful fusion in the setting of massive bone deficit. Several augmentation strategies have been trialed in this setting, such as structural allografts, 3D printed implants, fibular strut grafts, to name a few.Methods:We present a case describing TTC fusion for limb salvage utilizing a titanium mesh implant, combined with bone graft in the setting of massive bone deficit in an individual with Charcot arthropathy from Diabetes Mellitus and HIV after Pilon fracture, performed as revision procedure after failed Charcot reconstruction with a ringed external fixator and femoral head allograft with subsequent nonunion.Results:At last follow-up (22 months postoperative) patient is weight bearing as tolerated in Charcot Restraint Orthotic Walker boot. CT imaging at 18 months postoperative demonstrates stable implant and arthrodesis.Conclusion:Use of a titanium mesh implant is a reasonable option combined with bone graft for augmentation of TTC fusion in the setting of massive bone deficit.

The Charcot Reconstruction Preoperative Prognostic Score's Evaluation with Complication Rate and Functional Outcome.

Charcot's neuroarthropathy (CN) treatment is still controversial, and the results are controversial. Owing to patient comorbidities, surgical intervention carries a high risk of complications. Thus, foreseeing the possible results of planned treatment is crucial. We retrospectively evaluated the Charcot Reconstruction Preoperative Prognostic Score (CRPPS) in patients with surgically treated CN. Twenty-two feet of 20 patients were included in the study. Two groups were formed according to their CRPPS. Twelve patients with values less than 4 were defined as group A, and eight patients with values of 4 or greater were defined as group B. Mean follow-up was 61 months (range, 5-131 months). Groups were compared according to American Orthopaedic Foot and Ankle Society (AOFAS) scores, Foot and Ankle Disability Index (FADI) scores, and complication rates. Group A and B mean AOFAS scores were 76.83 (range, 71-85) and 70.5 (range, 20-85), respectively. All of the patients were improved according to AOFAS and FADI scores, but no correlation was found with the CRPPS. None of the group A patients required additional intervention, but five patients in group B underwent revision surgery. No amputations were performed. The CRPPS is focused on feasibility. The data needed to fill the scoring system is easily obtainable from medical records even retrospectively, and the score is helpful to predict a patient's outcome after CN-related surgery. Herein, CRPPS values of 4 or greater were related to high complication rates and lower functional outcomes.

Complications of Charcot Reconstruction in Patients With Peripheral Arterial Disease

The primary aim was to determine the rate of complications in patients with peripheral arterial disease and diabetic Charcot neuroarthropathy who underwent osseous reconstruction. Complications included delayed healing, dehiscence, and major lower extremity amputation. A review of patients with Charcot neuroarthropathy requiring reconstruction secondary to ulceration or acute infection was performed. Descriptive analysis compared outcomes between those with and without peripheral arterial disease. Bivariate analysis and multivariate logistic regression were analyzed for delayed healing, dehiscence, and major amputation. In a cohort of 284 patients with diabetic Charcot neuroarthropathy who underwent osseous reconstruction, the rate of peripheral arterial disease was 20.8% (59/284). Bivariate analysis for delayed healing found hypertension (p = .0352), peripheral arterial disease (p = .0051), and smoking history (p = .0276) to be statistically significant factors. Delayed healing was 2.012 times more likely in the presence of peripheral arterial disease [OR 2.012 (95% CI 1.088-3.720)]. Bivariate analysis for major lower extremity amputation found renal disease (0.0003) (renal disease: ESRD and CKD) and peripheral arterial disease (0.0001) to be statistically significant factors. Major amputation was 4.414 times more likely in the presence of peripheral arterial disease [OR 4.414 (95% CI 2.087-9.334)]. Peripheral arterial disease was identified in 20.8% (59/284) of diabetic patients who underwent Charcot osseous reconstruction. Peripheral arterial disease increased the risk of delayed healing by 2.012 fold, and increased the risk of major lower extremity amputation by 4.414 fold. The rates of complications in patients with peripheral arterial disease were significantly higher than those without peripheral arterial disease who underwent osseous reconstruction.