Preoperative Ulceration Research Articles

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.

MEDIUM- AND LONG-TERM OUTCOMES OF SURGICAL RECONSTRUCTION IN ACUTE CHARCOT NEUROARTHROPATHY

IntroductionCharcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction.MethodsBetween December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients.ResultsMean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration.ConclusionSurgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot.

Midfoot and Hindfoot Charcot Deformity Correction is Well Maintained with Beam Fixation

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot arthropathy is a neurotraumatic foot disorder seen in patients with peripheral neuropathy. Surgical reconstruction via medial column arthrodesis with beams can restore plantigrade foot anatomy with decreased soft tissue dissection and improved bony compression. Methods: We identified 12 patients with midfoot (n=7) or hindfoot (n=5) Charcot who underwent medial column beaming arthrodesis between 2015 and 2021 b y one of two fellowship-trained foot and ankle surgeons at an academic medical center. Data collected from patient charts included demographics, medical history, complications, and reoperation rate. Meary’s angle was measured on lateral weightbearing radiographs preoperatively and up to two years postoperatively. Mean follow-up time was 2.50 (range, 1.04-6.98) years. Statistical analysis included correlation, two-tailed Student t-test, and Chi-squared test. Results: Meary’s angle was recorded preoperatively for 12 patients (19.3° ± 6.7°) and postoperatively at three months for 12 patients (4.0° ± 6.7°), at six months for 12 patients (7.1° ± 9.7°), at one year for 11 patients (6.1° ± 9.4°), and at two years for five patients (10.2° ± 6.4°). However, two (16.7%) patients showed a loss of deformity correction, which was demonstrated by a Meary’s angle that was greater at final follow-up than preoperatively. Overall complication, infection, reoperation rates were 50.0%, 41.7%, and 58.3%, respectively. Finally, dependent on preoperative ulceration, those with and without an ulcer did not differ in Meary’s angle at any time point, overall complication, infection, nor reoperation rate. Conclusion: Although the results showed a relatively high complication rate, the use of beaming arthrodesis was generally able to maintain a plantigrade foot and overall alignment, while decreasing the recurrence of plantar ulceration.

No effect of preoperative ulceration on outcomes of tibiotalocalcaneal arthrodesis

BackgroundTibiotalocalcaneal (TTC) arthrodesis is a commonly performed operation for complex hindfoot pathology, but the effect of preoperative ulceration on TTC outcomes has been debated. This study aims to examine infection rates in patients undergoing TTC arthrodesis with internal fixation with and without concomitant hindfoot ulceration. MethodsWe conducted a retrospective review of 31 patients who underwent a TTC arthrodesis between June 2016 and February 2021 with a fellowship-trained foot and ankle surgeon at an academic medical center. Nine (29.0%) patients had preoperative ulceration. Mean follow-up duration was 1.49 (range, 0.51–4.28) years. Other data collected included demographics, comorbidities, surgical approach, fixation method, and complication and reoperation rates. ResultsThere was no difference in overall complication (ulcer [U]=66.7%, no ulcer [NU]=50.0%; p = .397), infection (U=33.3%, NU=31.8%; p = .935), or reoperation (U=55.6%, NU=27.3%; p = .135) rates between groups. ConclusionsTTC arthrodesis with internal fixation appears to be a reasonable treatment method for patients with a preoperative ulcer.

Effect of Preoperative Ulceration on Outcomes of Tibiotalocalcaneal Arthrodesis

Category:Hindfoot; DiabetesIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is commonly performed for complex deformity, arthritis, or unstable Charcot about the hindfoot. In patients with neuropathy, hindfoot deformity, and preoperative hindfoot ulceration, management options can be limited and very challenging. Previously, some authors have advocated for fine wire circular frames and avoidance of internal fixation in an effort to decrease the risk of infection in patients with preoperative ulceration, however, there is very limited data on the outcomes of TTC arthrodesis with internal fixation in this patient population. We hypothesized that internal fixation of TTC arthrodesis in patients with preoperative ulceration would lead to higher infection rates compared to patients without ulceration.Methods:A retrospective review was conducted on the TTC fusions performed from 2016-2020 by a single fellowship trained foot and ankle surgeon at an academic medical center. Preoperative diagnosis and indications, fixation method, clinical success, and complications were obtained from the patients' charts. Patients were excluded if their clinical or radiographic data were unavailable for review, or if they had less than 3 months of follow-up. 34 patients (34 ankles) underwent TTC arthrodesis Mean age was 60.7 years and mean follow-up was 1.3 years. Statistical analysis was performed using t-Student and Chi-squared tests with a p-value of 0.05 defining significance. Midline tibiotalar angle (MTA) was measured before and after surgery to assess position of fusion. Nine patients had preoperative ulcers at the time of surgery.Results:Common surgical indications included Charcot neuropathy (n=17), post-traumatic (n=14), and cavovarus (n=3). All patients with preoperative ulcers underwent TTC fusion with an intermedullary rod. Of the patients without ulceration, 18 underwent intermedullary nailing, 5 underwent plating, and 1 had an external fixator placed. There was no difference in deep wound infection rates between patients with (2/9, 22.2%) and without (2/25, 8.0%; p=.386) preoperative ulceration; nor was there a difference in rate of fusion, wound healing, or radiographic alignment. One patient without preoperative ulceration underwent a below knee amputation due to infection.Conclusion:TTC arthrodesis with internal fixation appears to be a reasonable consideration in patients with a preoperative hindfoot ulcer. There was no statistical difference in infection rate in patients undergoing TTC fusion with and without preoperative ulceration. Further, the rate of infection in those with an ulcer and internal fixation was acceptable, and internal fixation can be considered in these patients.

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.

Charcot Reconstruction: Outcomes in Patients With and Without Diabetes

The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.

Outcomes of Hindfoot and Ankle Arthrodesis in Neuropathic Patients

Category:Ankle Arthritis, Diabetes, HindfootIntroduction/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.

Clinical Outcomes and Complications of Midfoot Charcot Reconstruction With Intramedullary Beaming

The purpose of this study was to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Consecutive patients with midfoot Charcot treated at a tertiary-care foot and ankle center from January 2013 to July 2016 who underwent corrective osteotomy with internal beam fixation were identified; 25 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, weightbearing radiographs, and patient-reported outcome measures. The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Median age was 58 years, median BMI was 32, and 80% were diabetic (75% insulin-dependent). An ulcer-free, stable, plantigrade foot was obtained in 84% of patients. The radiographic lateral and anteroposterior Meary angle medians improved 9° and 15°, respectively, from preoperative to final postoperative weightbearing measurements ( P < .001 and P = .02). Overall, 46% of midfoot osteotomies were united on final radiographs at a median 18-month radiographic follow-up. Deep infection developed in 6 (24%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (P = .04); all 6 deep infections occurred in patients with preoperative ulceration. Four (16%) patients progressed to amputation at a mean 15 postoperative months, all for deep infection. Midfoot Charcot reconstruction with intramedullary beaming allowed for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates were high, especially in patients with preoperative ulceration. Level IV, retrospective case series.

Musculoskeletal modeling and gait analysis can improve diabetic foot preventive management

Toe deformities are common in people with diabetes and are often associated with toe ulcers. Operative procedures have been used to reduce toe deformities, because these were proposed to be beneficial in the management of toe ulcers. The present systematic review investigated the effect of flexor tenotomy to address toe deformity for healing and preventing diabetes-related toe ulcers. Four electronic databases were searched in January 2016. Studies were included if they had reported the effects of flexor tenotomy for healing and/or preventing diabetes-related toe ulcers. Six studies with a total of 264 flexor tenotomies performed on toes with ulcers and 57 performed as a prophylactic procedure were included. The mean duration of preoperative ulceration was 207.9 (range 7 to 1825) days. The mean duration to postoperative ulcer healing was 29.5 days, with an overall healing rate of 97%. The rate of ulcer recurrence was 6%. All the toes that had undergone prophylactic flexor tenotomy remained free of ulceration. Overall, the rate of complications was low. Flexor tenotomy to address toe deformity is relatively safe and effective in healing and preventing diabetes-related toe ulcers. Flexor tenotomy should be considered in the management of diabetes-related toe ulcers in the presence of toe deformities.

Midfoot Charcot Reconstruction with Intramedullary Beaming

Category: Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Methods: A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients (Median Age: 60; Median BMI: 32.5; Diabetic: 79%; Insulin Dependent: 74%) were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer- free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, post-operative infection, and amputation. Results: The lateral Meary’s angle median improved from -29° preoperatively to -21° on final postoperative radiographs (p&lt;0.001). Likewise, the AP Meary’s angle median improved from 17° to 2° (p&lt;0.001). 43% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.04); all six deep infections occurred in patients with preoperative ulceration. 63% of patients required reoperation. Three (13%) patients progressed to amputation at a median nine postoperative months, all for deep infection. The final postoperative median FAAM score was 21. The VR-12 median score was also 21 (PCS: 32, MCS: 67). Conclusion: Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with ADLs, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in both the lateral and AP Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.

Midfoot Charcot Reconstruction with Intramedullary Beaming

Category: Diabetes, Midfoot/Forefoot, Charcot Introduction/Purpose: Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Methods: A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, postoperative infection, and amputation. Results: Median age was 60 years, median BMI was 32.5, and 79% were diabetic. The lateral Meary’s angle median improved from -29° preoperatively to -20° on final postoperative radiographs (p=0.007). 39% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.05); all six deep infections occurred in patients with preoperative ulceration. 62.5% of patients required reoperation. Three (12.5%) patients progressed to amputation at a median nine postoperative months. The final postoperative median FAAM scores was 19. The VR-12 median score was also 19 with the following breakdown: Physical Component – 30, Mental Component – 67. Conclusion: Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with activities of daily living, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in the lateral Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.

A Retrospective Review of Risk Factors and Conversion Rate of Transmetatarsal Amputations to Below or Above Knee Amputation

Category: Diabetes Introduction/Purpose: Despite the presence of several studies examining the conversion from transmetatarsal amputation (TMA) to a more proximal amputation, few studies identified the possible predictors of failure. The objective of this study is to examine the rate of conversion of transmetatarsal amputation to below or above knee amputation, and to identify the risk factors for conversion. Methods: A retrospective cohort study was performed examining 71 transmetatarsal amputations performed by a single group of foot and ankle subspecialists within a single specialty group between October 1 2005 and August 25 2015. Demographic information and comorbidities were recorded, as were complications, readmission rate, and rate of conversion to a more proximal amputation. Results: Of the 71 patients who underwent transmetatarsal amputation during the study period, 74.7% progressed to a revision amputation or more proximal amputation at a mean of 9.7 months, but a median of only 3.2 months. 87.3% progressed to below knee amputation, 9.9% underwent revision transmetatarsal amputation, and 2.8% received an above knee amputation. Of the patients who progressed to more proximal amputation, 88.2% had diabetes mellitus, 72.4% had a pre-operative ulceration, and 81.7% had peripheral neuropathy. Only 52.7% had diagnosed peripheral vascular disease, 38.1% had a history of renal disease, and 35% were smokers. Conclusion: Transmetatarsal amputation has an extremely high short-term reamputation rate with the vast progressing to a below knee amputation. Comorbidities such as diabetes mellitus, neuropathy, and history of ulceration are often found in these patients, while renal and peripheral vascular disease as well as tobacco abuse are not necessarily present. This high rate of reamputation may bring into question the efficacy of performing transmetatarsal amputation as opposed to a more proximal amputation as a definitive procedure when lower extremity amputation is required.

Predictive Risk Assessment for Major Amputation After Tibiotalocalcaneal Arthrodesis

Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage. One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created. There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: e(x) /(1 + e(x) ) where x is a factor of age, diabetes, revision, and ulceration. TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation. Level II, prognostic.

Retrograde Intramedullary Nail Arthrodesis for Avascular Necrosis of the Talus

Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail. A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint. Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup. Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion.

Use of Implantable Bone Growth Stimulation in Charcot Ankle Arthrodesis

The purpose of this study was to review the results of arthrodesis of the Charcot hindfoot when an implantable bone growth stimulator was added to the procedure. Arthrodesis of the Charcot hindfoot has a high nonunion and complication rate. Ten patients (ages 50 to 69 years) with Charcot neuroarthropathy of the ankle, hindfoot, or both had arthrodesis with use of rigid internal fixation and an implantable bone growth stimulator. There were six tibiotalocalcaneal, two pantalar, and two tibiocalcaneal arthrodeses. An intramedullary nail was used in nine patients and a blade plate was used in one patient. All but one patient was diabetic. Four of the ten patients had preoperative osteomyelitis or postoperative infection. Another patient had purulent drainage, although cultures were negative. Four patients had a preoperative ulceration. Five patients had a two-stage procedure for debridement of infected bone, removal of hardware, and placement of antibiotic beads. Autogenous bone graft from the distal fibula or proximal tibia was used in all patients. One patient with a preoperative osteomyelitis developed a stable ankle pseudarthrosis. The other nine patients fused at an average of 3.7 months after surgery for a fusion rate of 90%. There were two major complications and eight minor complications. There were no amputations. All patients were ambulatory in a double upright brace or shoes for diabetic patients and were free of ulceration at the time of followup. Average American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score improved from 21 preoperatively to 59 postoperatively. The adjunctive use of an implantable bone growth stimulator in conjunction with rigid internal fixation, autogenous bone grafting, and sound operative technique may enhance the outcome and fusion rate in patients undergoing arthrodesis for Charcot neuroarthropathy of the ankle and hindfoot.

Gastrointestinal Stromal Tumor (GIST) of the Stomach: Clinicopathologic Analysis and Outcome

Purpose: Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms of the gastrointestinal tract. GISTs are positive for the expression of c-Kit protein at immunohistochemistry, and their clinical presentations vary. This retrospective study was performed to evaluate the clincopathologic characteristics of GISTs and to define the prognostic factors. Materials and Methods: 40 patients who underwent a complete resection of a GIST during the period at the Department of Surgery, Korea University College of Medicine, were studied. We divided them into low- and high-risk. groups by using tumor size and mitotic count: 23 cases were low risk, and 17 were high risk. Clinicopathologic features, immunohistochemical findings, and prognoses were compared between the low- and the high-risk groups. Results: The mean age of the 40 patients was years, and the male-to-female ratio was 1：1.1. There was no significant difference in age and sex between the groups. A comparative analysis revealed tumor size, mitotic count, clinical symptoms, preoperative pathologic diagnosis, ulceration, and necrosis to be variables that had statistically significant differences between the high- and the low-risk groups. In the univariate analysis, tumor size, mitotic count, ulceration, necrosis, and abnormal endoscopic ultrasound findings were associated with disease-free survival, but in the multivariate analysis, mitotic activity was the only independent factor associated with disease-free survival. 8 patients had recurrences during the follow-up period, and four of them were treated with STI-571 (imatinib mesylate, ). The treated patients have survived until now; however, two of non-treated patients died from disease progression. Conclusion: Based on this study, tumor size, ulceration, and necrosis are significant factors affecting survival, and mitotic activity may be a useful prognostic marker. STI-571 may be used in an adjuvant setting because the drug has shown anticancer activity in patients with recurrence or metastasis.