Plantigrade Foot Research Articles

Narrative Review of the objective analysis of long-term outcome of the Ponseti technique: experience from Dallas.

In 2001, Texas Scottish Rite Hospital for Children (TSRH) prospectively began a clubfoot database that included all of our patients with clubfeet who were willing to enroll. Nonoperative treatment, primarily the Ponseti method, was utilized. This article summarizes the experience from Dallas treating idiopathic clubfeet using the Ponseti technique, and is based on previously published studies utilizing information from the database. Patient clinical outcomes were defined as “good” (plantigrade foot achieved either with or without a percutaneous heel-cord tenotomy), “fair” (a plantigrade foot that required a limited procedure, such as tibialis anterior tendon transfer or posterior release), or “poor” (a plantigrade foot that required posteromedial release). Nearly 95% of idiopathic clubfeet obtained initial correction using the Ponseti technique, but relapses occurred and by age two years 24% needed some surgical intervention, usually limited procedures. Use of Dimeglio’s rating system before treatment strongly correlated with the probability of a “good” outcome at two years. Objective measurements of brace wear compliance (iButton) in those who reached age two years with “good” outcomes demonstrated an unexpected pattern of diminishing use of the foot abduction orthoses over the first two years of brace wear. By the 18-month period of brace wear, 1/3 patients wore the orthoses less than 6 hours per day, and nearly half of the patients wore the orthoses less than 8 hours per day. Between ages 2–5 years, nearly 21% of the corrected clubfeet at age two years needed limited procedures to maintain/regain plantigrade positioning. Lateral weight-bearing radiographs between 18–24 months were not helpful in predicting future relapse in these patients, and are no longer routinely obtained. Following these patients for normal development is important, as nearly 9% of infants initially presenting as idiopathic clubfeet were eventually found to have another disorder including neurological, syndromic, chromosomal, or spinal abnormalities. We continue to emphasize the need to devote great attention to detail when using the Ponseti method in an effort to optimize the clinical outcomes.

Neglected clubfoot treated by serial casting: a narrative review on how possibility takes over disability.

The Ponseti Method is recognized as the best treatment for congenital idiopathic clubfoot in newborns and its principles became also adopted for treating older children with neglected deformity. This review aims to evaluate the role and effectiveness of serial casting in the treatment of neglected clubfoot, worldwide. Clubfoot is a complex tridimensional congenital foot deformity that can be easily treated after birth by correct manipulation of the foot and serial casting, with a great majority of cases requiring a percutaneous Achilles tenotomy, which can be organized as an ambulatory day procedure, without need for general anesthesia. However, in many low-income countries, treatment is not readily available, and many children grow up with disabling foot deformities. When compared to a newborn’s clubfoot, a neglected clubfoot is different and more challenging to treat, as bones become ossified while malaligned and exposed to abnormal forces. Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The upper age limit for the use of Ponseti Method in clubfoot treatment is yet to be established. Success of clubfoot treatment is mostly defined as a pain-free, aesthetically acceptable plantigrade foot, with no need for extensive surgical tissue release after casting and tenotomy. The results of the Ponseti method for the treatment of clubfoot in children after the walking age are encouraging, with more than 80% of success in achieving initial correction and 18–62.5% of relapses. If Ponseti casting is not successful, any further interventions should be carefully selected and planned, in order to maintain the length of the foot and avoid intracapsular scarring or bony fusions.

Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual Deformity Correction and Arthroscopic Ankle Arthrodesis.

Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications. We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period. Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2. Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results. Level IV, retrospective case series.

Ilizarov method in treatment of neurological foot deformities

Introduction Diseases related to the lesions of upper or lower motor neurons, such as spina bifida, myopathy, and residual polio, often cause severe deformities of the foot and ankle. The treatment goal is to convert a deformed and rigid foot into a plantigrade foot. Matherial and method We treated 51 neurological feet from 2001 to 2018 with the Ilizarov method. They were polio outcomes in 27 cases, 17 feet were affected by spina bifida, 6 other patients had Charcot-Marie-Tooth disease. Results Results were assessed by comparing appearance and function before and after surgery described by Dimeglio, and modified by Dong Y.L. et al. Before surgery, there were 33 moderate and 28 severe deformities (average preoperative scores, 6.3). The mean time required to correct a deformity was 37.1 days (range, 22–58 days) and the mean time for stabilization was 67.2 days (range, 45–98 days). At latest follow-up (mean 7.42 years, from 13 month to 16 years), clinical outcomes and patient satisfaction were considered acceptable. 28 patients achieved an excellent outcome and 21 patients had a good outcome, two feet were classified as having a poor result. Nearly 86 % of patients (44 patients) were satisfied with their outcomes and replied they would repeat their procedure. Complications include infection in 15 % of K-wire tracts, Dysesthesia in 5 cases, superficial necrosis in 3. One patient developed knee contracture. 2 patients were re-operated with V osteotomy. Conclusions The Ilizarov method represents a great resource in the treatment of severe neurological deformities of the foot.

Beaming in the Charcot foot: A case series with 12-month minimum follow-up

BackgroundCharcot neuropathic arthropathy is a progressive degeneration of the weightbearing joints of the foot induced by denervation and disturbance of sensorial perception. This entity clinically behaves as a destructive fast-progressive arthropathy, resulting in loss of independent walking and often requiring amputation of the leg. This study analyzes our experience with midfoot realignment arthrodesis and stabilization by intramedullary beaming in patients with Charcot diabetic foot as a limb-sparing procedure. MethodsPatients with Charcot foot treated in our Foot and Ankle unit between January 2018 and December 2019 were analyzed. In all of the patients beaming technique was performed: open reduction and stabilization by a midfoot medial fusion beam and a lateral fusion bolt. Demographical, clinical and radiological pre and post-surgery data were assessed. The primary outcome measure was defined as an autonomous ambulation through an ulcer-free plantigrade foot. A minimum follow-up of 12 months was performed. ResultsA total of 5 patients were treated. Median age 64 years, mean follow-up 25 months (12–31). An ulcer-free plantigrade foot was obtained in 80% of the patients. Complications were observed in 80% of patients: 1 deep infection, 2 hardware failure, 3 Charcot foot progression. Rate of reoperation 40%, including 1 amputation. Significant improvement in all radiographic angles was observed. ConclusionBeaming the medial and lateral columns of the foot in patients with Charcot foot enabled the restoration of a functional plantigrade foot and an ulcer-free autonomous ambulation, despite a relatively high complication rate. Level of evidenceIV, prospective case series.

Long-term follow-up of conservative treatment of Charcot feet

BackgroundCharcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN.MethodsA total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development.ResultsMajor amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2–11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations.ConclusionsWith consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking.Level of EvidenceIII, long-term retrospective cohort study

Talo-calcaneal smile osteotomy as a treatment of rigid residual equinus deformity

Foot deformities are usually complex. Equinus deformity can be a residual foot deformity element or isolated. A rigid type is the most difficult for treatment. The aim of work is the treatment of rigid equinus deformity by a minimally invasive technique using Ilizarov fixator to restore plantigrade foot and to prevent further recurrence. 17 feet in 14 patients with stiff ankles and rigid equinus after failed surgical correction of club feet, with mean age 6.6 years (4 to 10 years), all treated by smile talocalcaneal osteotomy and Ilizarov ring fixator with a mean follow up 20.9 months (5 to 30 months). 5 feet (29.9%) had excellent results, 8 (47.1%) had good results, 1(5.9%) had a fair result and 3 feet (17.6%) had poor results and underwent revision surgery. In conclusion, our technique Talo-calcaneal smile osteotomy based on distraction osteogenesis method appears to provide similar or better results compared to other literature results without discrimination of foot size, provide some range of motion and plantigrade foot. Keywords: Clubfoot- equinus- rigid -deformity, Ilizarov- Smile osteotomy.

Forward dynamic simulation of Japanese macaque bipedal\xa0locomotion demonstrates better energetic economy in a virtualised plantigrade posture

A plantigrade foot with a large robust calcaneus is regarded as a distinctive morphological feature of the human foot; it is presumably the result of adaptation for habitual bipedal locomotion. The foot of the Japanese macaque, on the other hand, does not have such a feature, which hampers it from making foot–ground contact at the heel during bipedal locomotion. Understanding how this morphological difference functionally affects the generation of bipedal locomotion is crucial for elucidating the evolution of human bipedalism. In this study, we constructed a forward dynamic simulation of bipedal locomotion in the Japanese macaque based on a neuromusculoskeletal model to evaluate how virtual manipulation of the foot structure from digitigrade to plantigrade affects the kinematics, dynamics, and energetics of bipedal locomotion in a nonhuman primate whose musculoskeletal anatomy is not adapted to bipedalism. The normal bipedal locomotion generated was in good agreement with that of actual Japanese macaques. If, as in human walking, the foot morphology was altered to allow heel contact, the vertical ground reaction force profile became double-peaked and the cost of transport decreased. These results suggest that evolutionary changes in the foot structure were important for the acquisition of human-like efficient bipedal locomotion.

The use of circular frame external fixation in the treatment of ankle/hindfoot Charcot Neuroarthropathy

Charcot Neuroarthropathy (CN) of the ankle/hindfoot is a devastating condition that results in a loss of alignment, bony malleolar protrusions and frequently leads to ulceration, infection, and amputation. Major limb amputations in this patient population has a 5-year mortality rate approximating 39%–68%. The treatment goal for CN of the ankle/hindfoot is to provide stability with a plantigrade foot that is infection free, shoeable and allows independent weight bearing. The use of a circular frame external fixator is often required when treating patients with CN of the ankle/hindfoot because they often present late with deformity, soft tissue compromise and infection which are contraindications to primary internal fixation. These patients require urgent surgical attention to salvage the limb or risk amputation. In this narrative review article we will discuss the indications, management options, surgical technique, evidence and describe our experience in the use of circular frame external fixation in patients with ankle/hindfoot Charcot Neuroarthropathy.

Functional Outcomes of Talectomy in Pediatric Feet.

Historically, talectomy has been predominantly performed to operatively treat severely rigid equinovarus feet. A limited number of investigators have studied functional outcomes in pediatric patients posttalectomy. We aimed to assess the outcomes of pediatric patients undergoing talectomy using the American Orthopaedic Foot & Ankle Society (AOFAS) score and a subjective survey of patients' and their caregivers' satisfaction. We performed a retrospective cohort study that included 31 patients with nonidiopathic severely rigid talipes equinovarus, in a single center, using consecutive sampling. All medical records of those patients were reviewed, and relative data were extracted. The AOFAS score was used to measure the outcomes during the last visit (April 2020). Satisfaction was evaluated in a binary manner by questioning the patients and their caregivers if they would undergo the same surgery again for the same result. Thirty-one patients were included. Myelomeningocele was the primary diagnosis in 13 patients (41.9%), and arthrogryposis was diagnosed in 11 patients (35.5%). Twenty-two patients had bilateral procedures. The mean age at the time of surgery was 6.0 ± 3.0 years, and the mean follow-up was 6.0 ± 1.0 years. Plantigrade feet following the primary surgery were achieved in 88.5% of cases. Postoperatively, braces were well tolerated in 86.5% of patients. Deformity recurrence was observed in 21.2% of patients, and 17.3% of patients required subsequent surgeries. Patients with arthrogryposis had significantly higher AOFAS scores than those with myelomeningocele and other diagnoses (P = .017). Further, patients who tolerated braces had higher AOFAS scores than those who did not tolerate braces (P = .006). However, patients who developed hindfoot varus and dorsal bunion postoperatively had lower AOFAS scores (P = .054 and P = .006, respectively). Patients who had recurrent deformities or required further surgeries also had lower AOFAS scores (P = .025 and P = .015, respectively). Although 17.3% of patients were not able to comment about their satisfaction due to their general medical condition, 63.5% of patients reported that they were satisfied. Furthermore, 75.0% of caregivers were satisfied with the outcomes and their children's functional status posttalectomy. The observed outcomes of primary and salvage talectomies demonstrate the general overall effectiveness of this operative intervention as an end-stage treatment for pediatric patients with severely rigid talipes equinovarus. Level III; retrospective cohort study.

Incidence and Risk Factors for Flap Coverage After Total Ankle Arthroplasty.

Wound complications following total ankle arthroplasty (TAA) can have a significant impact on patient morbidity, particularly when they require flap coverage. We sought to determine the risk factors associated with the need for flap coverage after TAA and hypothesized that medical and operative risk factors such as diabetes and additional procedures would be associated with the need for flap coverage after TAA. We performed a single-center retrospective review of TAAs from April 2007 to February 2019. Patient demographics and medical comorbidities were collected, in addition to other procedures performed at the time of TAA. Patients were stratified by the need for flap coverage, and unadjusted inferential statistics were performed to evaluate the risk factors associated with subsequent need for flap coverage. Among 2065 patients undergoing TAA, 28 (1.4%) patients required flap coverage after the index arthroplasty. Patients requiring flap coverage were older (P = .045), had higher Charlson comorbidity indices (P = .017), and had higher rates of diabetes and pulmonary disease (P = .038). Patients requiring flap coverage also had higher rates of additional procedures (P = .043, P = .007). The most common flap was a radial forearm free flap, which was performed in 14 (50%) patients. Twenty-one patients (75%) requiring flap coverage had a stable, plantigrade foot at median 1.5-year follow-up. Patient and operative risk factors, including advanced age, increased comorbidity burden, diabetes, pulmonary disease, and increased number of simultaneous procedures, were significantly associated with need for subsequent flap coverage. This should be considered as the indications for TAA expand. Level III, retrospective, prognostic cohort study.

A Simple Corrective Strategy for Adolescent Hallux Valgus by Ilizarov Method

Background: Management of adolescent hallux valgus is controversial. There is no one procedure that is described for this condition. Materials and Methods: The authors report for the first time a simple surgical strategy in a 14-year-old patient presenting with painful hallux valgus using the Ilizarov approach. It uses small cosmetic incisions and involves soft tissue procedures, 2-level osteotomy of the metatarsal and fixation with a novel fixator assembled with Ilizarov components. Results: The patient was made to weight bear with the fixator immediately after the surgery and the fixator was removed in 8 weeks. At a follow-up of 3 years, the patient has a painless plantigrade foot with acceptable deformity parameters. Conclusion: The authors recommend this technique in adolescent hallux valgus and propose that this technique will work equally well in adults.

Three-dimension correction of Charcot ankle deformity with a titanium implant

Background Charcot neuroarthropathy of the ankle is an extremely challenging clinical dilemma, and its surgical management can be highly complicated. The goal of Charcot ankle treatment is to to restore a plantigrade and stable foot, and thus to avoid ulceration with subsequent infection. This report aims to introduce a method of correcting ankle deformity using a novel 3D printing technique. Patient and methods One patient with Charcot ankle deformity was operated in this study. The ankle deformity of this patient was quantified in three dimensions through computed tomography. On the basis of the computed tomography scans, a new titanium implant was designed and manufactured using 3D printing. The implant was applied in the surgery of tibio-talo-calcaneal arthrodesis to restore local anatomy of the affected ankle of the patient with Charcot neuroarthropathy. Results Evaluation of the post-operative radiography indicated union in the affected ankle. After surgery, the planar foot in this patient was restored. The patient was satisfied with the post-operative course, and joint fusion was successful as indicated by 2-year post-operative evaluation. The results of post-operative follow-up showed that the lower limb length of the patient with Charcot neuroarthropathy was salvaged, and the patient retained the plantigrade foot. Conclusion Three-dimensional printing technique combined with tibio-talo-calcaneal arthrodesis may help to correct ankle deformity in patients with Charcot neuroarthropathy.

Treatment results of teratologic arthrogryposis in a case of Freeman-Sheldon syndrome

Freeman-Sheldon syndrome (FSS) is a very rare genetic disorder, also called “whistling-face syndrome.” Patients with this condition have distinctive facial appearance of small mouth and pursed lips, and skeletal malformations such as talipes equinovarus, hip dysplasia, camptodactyly, and scoliosis. The reports for the arthrogryposis of such cases by management are rare. A 2-year-old girl with FSS presented with hypertelorism, increased philtrum length, small nose and nostrils, and pursed lips, with skeletal deformities including (1) bilateral windmill vane hands, (2) bilateral rigid talipes equinovarus, and (3) bilateral high riding hip dislocation. To provide the patient with a pair of plantigrade feet for future standing, we performed a bilateral clubfoot soft tissue release and total talectomy with tibiocalcaneal fusion. For the bilateral high riding hip dislocation, we chose the nonoperative treatment by rehabilitation, given that the pelvis was relatively stable and in a leveled position. At the 25-year follow-up, she walked independently with mild waddling gait without support, on a stable, plantigrade foot. From the outcome, performing radical soft-tissue release with talectomy to obtain a plantigrade foot and conservative treatment for the bilateral hip dislocation to ensure a leveled pelvis may be a proper option for such cases.

Triple Arthrodesis for Equinovarus Foot using Ilizarov Technique: A Retrospective Study

Introduction: Equinovarus foot deformity is a significant problem in adolescents and its treatment remains challenging. Triple arthrodesis, even though an effective palliative tool in management of complex foot deformity, has its own limitations if it is done for acute deformity correction. Ilizarov technique offers gradual deformity correction, fusion and takes care of many known complications of acute correction. However, there are very few studies about effectiveness and functional outcome of triple arthrodesis for equinovarus deformity when done gradually with an Ilizarov fixator. Aim: To study the effectiveness of triple arthrodesis, performed with Ilizarov technique for equinovarus foot deformity in adolescents and adults and to evaluate the early functional outcome and patient satisfaction rate for this procedure. Materials and Methods: A retrospective analysis of 22 feet in 20 patients with equinovarus foot deformity between January 2015 and December 2018 was done. Patients underwent gradual deformity correction and triple fusion with Ilizarov fixator. Foot was assessed for any residual deformity and shortening. Functional outcome and patient satisfaction were assessed by Ankle Hind Foot Scale (AHFS) and Likert scale, respectively using paired t-test. Final analysis was done with Statistical Package for Social Sciences (SPSS) software version 21.0. Results: Twelve males and eight females with mean age of 15.9±3.4 years fulfilled the inclusion criteria and were included for final analysis of results. Fusion rate was 86.1% with mean union time of 12.5 weeks. Mean AHFS improved from 61.27 before surgery to 76.9 which was statistically significant (p<0.0001). One or more complications were seen in 15 (68.1%) feet but were managed satisfactorily without any significant impact on final outcome. Patient satisfaction rate for the procedure was 80%. After a mean follow-up of 18.1 months, plantigrade foot with equal foot length was obtained in all patients. Conclusion: Triple arthrodesis with gradual deformity correction by Ilizarov technique effectively corrects equinovarus foot deformity and foot length discrepancy. Known complications of acute deformity correction can be avoided with equally good results. It corrects deformity and restores alignment of foot more accurately leading to a high patient satisfaction rate.

Charcot foot – current concepts

Charcot neuropathic osteoarthropathy (CNO) is painless, progressive, noninfectious, degenerative arthropathy affecting single or multiple joints and soft tissues of foot and ankle caused by an underlying neurological deficit. The primary indication for surgical correction is a nonbraceble, nonplantigrade foot, instability, and impending or established ulceration. The goal of surgical management is to provide a stable, ulcer-free, plantigrade foot that can accommodate therapeutic footwear for self-ambulation. The choice of implants in midfoot CNO can be a combination of plate and screws well beyond the area of deformity to achieve rigid stability and good alignment following the principle of a super construct. The deformities involving the talus and ankle joint require a Total contact casting (TCC) arthrodesis, preferably with an intramedullary nail. The choices for soft tissue coverage as an additional procedure for ulcer management are guided by anatomic location, size, depth of ulcer, condition of surrounding soft tissue, and underlying deformity.

Complex foot deformities associated with lower limb deformities: a new therapeutic strategy for simultaneous correction using Ilizarov procedure together with osteotomy and soft tissue release

AimThe aim of the current study is to introduce a new therapeutic strategy for simultaneous correction of complex foot deformities (CFD) and the associated lower limb deformities (LLD) by using Ilizarov technique with osteotomy and soft tissue procedure and to report its early clinical results.MethodsA retrospective review of CFD associated with LLD simultaneous correction utilizing the Ilizarov procedure together with osteotomy and soft tissue balance from 2015 to 2019 was conducted.ResultsThirty-two patients were followed for an average of 42.8 months. The mean external fixation time (EFT) was 6.5 months. The mean healing index (HI) was 1.7 months/cm. At the time of fixator removal, plantigrade feet were achieved in all patient and lower limb deformities were corrected. No recurrence of the deformities occurred. The mean LLRS AIM score was improved from 7.5 to 0.3. At the final follow-up, the ASAMI-Paley score was graded as excellent in all limbs in the aspect of bone results, and functional results were defined as excellent in 29 (90.6%) limbs and good in 3 (9.4%) limbs. The mean modified Dimeglio score was significantly improved from 7.2 to 1.3. No deep infection of the osteotomy site or nonunion was noted in the current study.ConclusionThe therapeutic strategy by using the Ilizarov procedure together with osteotomy and soft tissue balance is a safe and effective way to simultaneously correct CFD and LLD.Level of evidenceLevel IV, retrospective case series

A Staged Treatment Algorithm for the Management of Severe Charcot Hindfoot Arthropathy, using Tibiotalocalcaneal Arthrodesis with Femoral Head Allograft

Category:Diabetes; Ankle; Diabetes; HindfootIntroduction/Purpose:Charcot neuroarthropathy of the hindfoot (Brodsky type 2 and 3) can involve significant talar collapse / bone loss leading to hindfoot instability, the goal of treatment to create a stable plantigrade shoeable ulcer and infection free foot. This can often be achieved with tibiotalocalcaneal (TTC) arthrodesis but a plantigrade foot can be challenging in setting of significant talar bone loss. Structural allograft has been used in association with TTC fusions in a number of settings but not explored in the treatment of charcot hindfoot. The goal of this study was to examine the outcomes of structural allografting combined with TTC arthrodesis for the treatment of charcot hindfoot.Methods:Retrospective review of all patients treated at our institution with a Brodsky type 2 or 3 was performed over a five year period from 2014 - 2019. We identified twenty-two patients, 12 males and 10 females with a mean age of 57 years. All underwent surgery by the senior author, a fellowship trained foot and ankle orthopedic surgeon. Patients with infection were treated with antibiotics and a Taylor spatial frame prior to definitive stabilization. Non-infected patients were either placed in a total contact cast (TCC) if they were in active charcot or underwent primary charcot reconstruction. If after initial treatment patients had a plantigrade foot, they were placed in stiff soled rocker bottom shoe with custom accommodative insoles. Patients who did not have a plantigrade foot underwent TTC arthrodesis to achieve this. Femoral head allograft was used if excessive talar bone loss or collapse of the hindfoot was noted.Results:At final follow up 13 patients (59%) of the cohort achieved grade 1, an infection and ulcer free plantigrade foot that was able to fit in a shoe. 7 (32%) of patients achieved grade 2, a plantigrade foot in brace, and 2 (9%) achieved level 3 a plantigrade foot. No patients in this cohort underwent amputation. Average duration of treatment until final status was 18 months (minimum 2, maximum 37), number of interventions 3.9 (minimum 1, maximum 10). Of the twelve patients who required allograft, they averaged 4.25 interventions and average time of 17.6 months until final status. Of those who did not require allograft, they averaged 3.4 interventions with follow up of 11.9 months.Conclusion:Our data suggests that patients with Brodsky type 2 and 3 charcot arthropathy of the ankle and hindfoot even with infection can be successfully treated with staged treatment. This includes external fixation and infection management, followed by tibiotalocalcaneal intramedullary nail fixation with or without femoral head allograft to allow for a plantigrade foot and weight bearing in a stiff soled rocker bottom shoe. Further study is needed to determine long term outcomes and relapse rates.

Long-term Outcomes of Immediate Weightbearing with Anchorless Achilles Debridement and Secondary Reconstruction for Insertional Achilles Tendonopathy

Category:Hindfoot; SportsIntroduction/Purpose:Achilles debridement and secondary reconstruction is a widely accepted procedure for treatment of insertional Achilles tendonopathy with or without Haglund resection, calcaneus exostectomy, retrocalcaneal bursectomy, and possible flexor hallucis longus tendon transfer. When less than 50% of the tendon is pathologic and elevated from the calcaneus, primary reconstruction with or without bony fixation (bone tunnels or anchors) has been advocated. Postoperative protocols demonstrate wide variability in the orthopaedic literature. This study is the first to evaluate clinical and radiographic outcomes in patients with insertional Achilles tendonopathy who underwent soft tissue only Achilles debridement and secondary reconstruction with immediate plantigrade weightbearing in plantigrade foot ankle stabilizer (FAS) high walking boot.Methods:All patients with symptomatic insertional Achilles tendonopathy who failed conservative management underwent Achilles debridement and secondary reconstruction with or without Haglund resection, calcaneus exostectomy, and retrocalcaneal bursectomy by a single senior foot and ankle surgeon at a single tertiary center between January 2006 to December 2013 were included in our retrospective case series. Patients with greater than 50% involvement of the tendon requiring flexor hallucis longus transfer were excluded. Demographics, clinical outcomes, patient comorbidity information, and Coughlin satisfaction scores were collected. The primary outcome was change in visual analog scale (VAS) pain score. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence).Results:From 2006 to 2013, 66 patients (40.9% male, 59.1% female) at an average age of 53.6 years (range 19 to 78) underwent Achilles debridement and secondary reconstruction. At final average follow up of 4.3 years, average VAS score improved from 5.9 to 2.3 preoperatively to postoperatively. There were a total of 10 reoperations in 9.1% of patients (n=6). Minor complications were present in 12.1% of patients (n=8; 3 local wound care, 8 use of antibiotics, and 5 skin dehiscence). Physical therapy desensitization was utilized in 25.8% of patients (n=17).Conclusion:The present study demonstrates a significant improvement in VAS pain scores following Achilles debridement and secondary reconstruction for treatment of insertional Achilles tendonopathy with immediate plantigrade weightbearing in plantigrade FAS high walking boot. This technique appears to be safe and effective.

Complication Rates in Ankle and Hindfoot Charcot Arthropathy Treated with Arthrodesis

Category:Diabetes; Ankle; Hindfoot; OtherIntroduction/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.