Management of Infections and Osteomyelitis in Patients With Charcot Foot Arthropathy.

There is growing interest in performing reconstruction of deformities associated with Charcot foot arthropathy. At least half of the patients undergoing this reconstruction will have chronic wounds and osteomyelitis overlying the deformity. It is important to provide orthopaedic surgeons with tools for making the diagnosis of osteomyelitis in this patient population and creating a strategy for treatment.

Management of Acute Ankle Fractures in Patients With Diabetes.

Ankle fractures in patients with diabetes can be difficult to manage, especially when patients present with hyperglycemia. Treatment often requires a combination of both medical and surgical care, especially in patients with poorly controlled diabetes. The goal of any treatment is to obtain a well-aligned ankle fracture that heals without any further displacement and to avoid the development of a Charcot joint. Nonsurgical treatment is usually reserved for nondisplaced fractures. Displaced fractures often require surgical treatment, and there are different options available, including standard fixation, fixation with multiple syndesmotic screw placement, external (thin wire) fixation alone, hybrid or combined internal and external fixation techniques, and primary arthrodesis. It is important to discuss the approach to the evaluation and treatment of these patients.

Ankle fusion following failed initial treatment of complex ankle fractures in neuropathic diabetics.

BACKGROUND: Unstable ankle fractures in diabetics with peripheral neuropathy have an increased risk of postoperative complications, often leading to amputation. Primary ankle arthrodesis has been suggested as an alternative when acceptable reduction and mechanical stabilization cannot be obtained. METHODS: Over a fourteen year period, thirteen diabetic patients with peripheral neuropathy underwent an attempt at primary ankle arthrodesis following the early post-fracture development of acute neuropathic (Charcot) deformity of the ankle after sustaining a low energy unstable ankle fracture. Eight patients with open wounds and osteomyelitis underwent single stage debridement of the osteomyelitis and primary ankle fusion with an ankle fusion construct circular external fixator. Five patients without evidence of infection underwent primary arthrodesis with a retrograde locked intramedullary nail used for fixation. A successful clinical outcome was achieved with either successful radiographic arthrodesis or stable pseudarthrosis, when community ambulation was achieved with commercially-available therapeutic footwear and a short ankle orthosis. RESULTS: Eight of the thirteen patients achieved a successful clinical outcome at a mean follow-up of 48 (range 12-136) months following the initial surgery. Three achieved clinical stability following a second surgery and one following a third. One patient with radiographic nonunion expired due to unrelated causes. One patient underwent transtibial amputation due to persistent infection. Of the five patients with failure of radiographic union, three successfully ambulated in the community with a short ankle orthosis. Postoperative complications included wound and pin-site infection, infected nonunion, chronic wounds, and tibial stress fracture. CONCLUSION: In spite of the high risk for complications and initial failure, primary ankle fusion is a reasonable option for diabetic neuropathic patients who develop acute neuropathic arthropathy following ankle fracture. LEVEL OF EVIDENCE: Level IV retrospective case series.

Surgical Management of Charcot Arthropathy.

The historic management of Charcot foot arthropathy has consisted of immobilization until the active phase of the disease resolves, followed by longitudinal accomodative bracing of the acquired deformity. This historic management of Charcot foot arthropathy has not resulted in improved quality of life and has fostered interest in the surgical correction of the acquired deformity. Orthopaedic surgeons should understand the current indications for the surgical management of and the specific surgical techniques to correct acquired deformities in patients with Charcot foot and ankle disorders.

Surgical treatment of the Charcot foot.

With the increased number of diabetics worldwide and the increased incidence of morbid obesity in more prosperous cultures, there has become an increased awareness of Charcot arthropathy of the foot and ankle. Outcome studies would suggest that patients with deformity associated with Charcot Foot arthropathy have impaired health related quality of life. This awareness has led reconstructive-minded foot and ankle surgeons to develop surgical strategies to treat these acquired deformities. This article outlines the current clinical approach to this disabling medical condition.

Diabetic Deformities of the Lesser Toes.

The United States Centers for Disease Control and the National Institute of Diabetic, Digestive and Kidney Disorders now estimates that there are now over 34.2 million patients with diabetes in the United Sates, or over 10.2% of our population. Diabetic foot pathology leads to over 150,000 lower extremity amputations yearly in the United States alone. Many of these infections are initiated from externally applied shearing forces applied to deformities of the lesser toes.

Outcomes Following Surgical Correction of Talocalcalcaneal Joint Dislocation in Diabetes Associated Charcot Foot Arthropathy.

BACKGROUND: Growing clinical interest in the treatment of acquired foot deformity due to diabetes-associated Charcot foot arthropathy has led to multiple reports of favorable clinical outcomes in patients when their acquired deformity is at the midfoot level. Clinical failures and less than optimal clinical outcomes are achieved when the deformity is at the hindfoot or ankle levels. METHODS: A retrospective review was performed of all patients who underwent surgical correction of diabetes-associated Charcot foot arthropathy with talocalcaneal dislocation over an 18-year period. Reduction of the talocalcaneal dislocation, and maintenance of the correction with percutaneous pins and circular external fixation after subtalar joint preparation for fusion, was used as the method of surgically achieving a clinically plantigrade foot. Clinical outcomes were based on resolution of infection, limb salvage, and the ability to ambulate with commercially available therapeutic footwear. RESULTS: Forty-three feet in 39 patients were included. A favorable clinical outcome was achieved in 32 of 43 feet (74%) with 26 (60%) considered to have an "excellent" result with minimal shoeing issues and 6 (14%) considered to have a "good" outcome based on their need for a custom shoe modification and/or some form of short ankle-foot orthosis. Eleven feet (26%) were judged to have a "poor" clinical outcome and among those 11 feet, 6 underwent partial, or whole-foot amputation, 2 had persistent wounds, and 5 required the use of a standard ankle foot orthosis or Charcot Restraint Orthotic Walker (CROW). CONCLUSION: Subtalar dislocation in Charcot arthropathy is a complex clinical problem. In our series, reduction and maintenance of the reduction after subtalar dislocation was essential for a favorable clinical outcome.

Painful Nonunion in Patients With Clinically Plantigrade Diabetes-Associated Charcot Foot Arthropathy.

BACKGROUND: It has been assumed that diabetic patients with peripheral neuropathy should not have pain associated with Charcot foot arthropathy. METHODS: During a 19-year period, 14 diabetic patients (15 feet) presented for treatment with pain following resolution of the acute phases of midfoot Charcot foot arthropathy. All were clinically plantigrade with plain radiographic evidence of bony union without deformity. Pain did not resolve with the use of appropriate therapeutic footwear. When used, CT scans uniformly demonstrated nonunion. RESULTS: All 14 patients had resolution of their presenting pain following successful arthrodesis. Nonunion was confirmed at surgery in all of the patients. One patient developed a fatal pulmonary embolus following removal of the external fixator. Two required late exostectomy for bony overgrowth at the surgical site of fusion for nonunion. CONCLUSION: This small series of patients would suggest that nonunion of the Charcot neuroarthropathy process was responsible for complaints of pain not able to be managed with therapeutic footwear. Successful arthrodesis resolved the pain. CT imaging may help identify a treatable source of pain in this population.

Preliminary Experience With Commercially Available Trabecular Metal Tibial Cones Combined With a Retrograde Locked Intramedullary Nail for Bony Defects in Tibiotalocalcaneal Arthrodesis.

Critical sized bone defects in the ankle are becoming increasingly more common in patients undergoing limb reconstruction with tibiotalocalcaneal arthrodesis. Bulk allografts have not fared well over time. There have been scattered preliminary reports using custom spinal cages or 3D-printed Titanium Implants to address the critical bony defect; however, the cost of these devices is prohibitive in many clinical practice settings. The purpose of this investigation is to report the preliminary experience using a commercially available Trabecular Metal (Zimmer-Biomet) tibial metaphyseal cone combined with a retrograde locked intramedullary nail to address this challenging problem. Eight consecutive patients underwent tibiotalocalcaneal arthrodesis using a commercially available Trabecular Metal tibial metaphyseal cone combined with a retrograde locked intramedullary nail. Five developed bone loss secondary to neuropathic (Charcot) bony resorption and 3 underwent surgery for failed total ankle arthroplasty. All 8 patients eventually achieved clinical and radiographic healing and were able to ambulate with standard footwear. One patient developed a postoperative wound infection at the site of calcaneal locking screws, which resolved with debridement and parenteral antibiotic therapy. Critical bone defects about the ankle have successfully addressed with custom 3D titanium implants. This small series suggests that similar clinical outcomes can be achieved with the use of a commercially available porous tantalum metaphyseal spacer borrowed from our arthroplasty colleagues, combined with the use of a retrograde locked intramedullary nail.Levels of Evidence: Level 4: Retrospective case series.

Cost comparison: limb salvage versus amputation in diabetic patients with charcot foot.

BACKGROUND: The negative impact on health-related quality of life in patients with Charcot foot has prompted operative correction of the acquired deformity. Comparative effectiveness financial models are being introduced to provide valuable information to assist clinical decision making. METHODS: Seventy-six patients with Charcot foot underwent operative correction with the use of circular external fixation. Thirty-eight (50%) had osteomyelitis. A control group was created from 17 diabetic patients who successfully underwent transtibial amputation and prosthetic fitting during the same period. Cost of care during the 12 months following surgery was derived from inpatient hospitalization, placement in a rehabilitation unit or skilled nursing facility, home health care including parenteral antibiotic therapy, physical therapy, and purchase of prosthetic devices or footwear. RESULTS: Fifty-three of the patients with limb salvage (69.7%) did not require inpatient rehabilitation. Their average cost of care was $56,712. Fourteen of the patients with amputation (82.4%) required inpatient rehabilitation, with an average cost of $49,251. CONCLUSIONS: Many surgeons now favor operative correction of Charcot foot deformity. This investigation provides preliminary data on the relative cost of transtibial amputation and prosthetic limb fitting compared with limb salvage. The use of comparative effectiveness models such as this simple attempt may provide valuable information in planning resource allocation for similar complex groups of patients. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

The Modern Treatment of Charcot Foot Arthropathy.

The National Institute of Health now estimates that there are well over 37 million persons with diabetes in the United States alone, a number well over 11 per cent of our population. The associated multiple organ system disease is responsible for more than 327 billion dollars in direct and indirect medical costs and more than 140,000 lower extremity amputations yearly in the United States. Because healthcare professionals have begun to appreciate the economic and pathologic burden that diabetes imparts on our society, there has been a growth in both the understanding and treatment of the responsible pathologic disorders. The goal of this monograph is to provide an evidence-supported foundation to better understand the pathophysiology that leads to the development of neuropathic (Charcot) foot arthropathy and provide insight into developing a treatment plan for addressing this complex disease process that presents in a highly comorbid patient population.

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty.

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Executive summary: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Charcot foot: a surgical algorithm.

The historic treatment of Charcot foot has entailed non-weight-bearing immobilization during the acute active phase, followed by longitudinal management with accommodative bracing. This treatment plan yields poor outcomes, even in cases classified as successful. An appreciation of poor outcomes convinced experts to attempt correction of the resultant deformities. Early attempts at surgical correction of the acquired deformities in patients with medical comorbidities were complicated by infection, wound failure, and mechanical loss of correction. New surgical techniques have been designed to obtain and maintain correction and minimize the risks for complications and poor outcomes in this complex patient population.

The development of a neuropathic ankle following successful correction of non-plantigrade charcot foot deformity.

BACKGROUND: The treatment of Charcot foot arthropathy has traditionally involved immobilization during the acute phase followed by longitudinal management with accommodative bracing. In response to the perceived poor outcomes associated with nonoperative accommodative treatment, many experts now advise surgical correction of the deformity, especially when the affected foot is not clinically plantigrade. The significant rate of surgical and medical-associated morbidity accompanying this form of treatment has led surgeons to look for improved methods of surgical stabilization, including the use of the circular ring external fixation. METHODS: Over a 7-year period, a single surgeon performed surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a statically applied circular external fixator. Following successful correction, five patients developed a neuropathic deformity of the ipsilateral ankle after removal of the external fixator and subsequent weight bearing total contact cast. RESULTS: Three of the five patients progressed to successful healing of the neuropathic (Charcot) ankle arthropathy following treatment with a series of weightbearing total contact casts. Two underwent successful ankle fusion with retrograde locked intramedullary nailing. DISCUSSION: This unusual clinical scenario likely represents either a progression of the disease process in the foot or a complication associated with surgical correction of the original neuropathic foot deformity. A better understanding of this observation will likely become apparent as we acquire more experience with this disorder.

Treatment of osteomyelitis in charcot foot with single-stage resection of infection, correction of deformity, and maintenance with ring fixation.

BACKGROUND: There is both increased interest and awareness in diabetes-associated Charcot foot arthropathy. The number of affected patients will likely increase as the incidence of both diabetes and morbid obesity increases. Many experts now favor surgical correction of the deformity rather than longitudinal management with accommodative bracing. In patients with open wounds and exposed bone and/or chronic osteomyelitis, it is controversial whether resolution of the bony infection should be achieved before attempting surgical correction of the acquired deformity. METHODS: During a 78-month period, 178 patients underwent surgical correction of deformity with diabetes-associated Charcot foot or ankle arthropathy by a single surgeon. Seventy-three had evidence of osteomyelitis at the time of surgery. There were 41 males and 32 females. Their average age was 57.9 (range, 31 to 76) years, and body mass index was 36.9 (range, 21.8 to 60.9). The clinical diagnosis of osteomyelitis was made by (a) an open wound overlying the deformity with exposed bone and chronic drainage; (b) a history of biopsy-diagnosed osteomyelitis that was not currently draining, but had clinical and pathologic evidence of abnormal bone in the region of the previous infection; or (c) a history of previous wound overlying bony deformity with abnormal bone observed at the time of surgery. Surgery involved radical resection of the clinically infected bone, combined with acute correction of the deformity to a plantigrade foot. Parenteral culture-specific antibiotic therapy was administered and monitored by an infectious disease comanagement service. A three-level preconstructed static circular external fixator was applied to maintain the surgically obtained correction. RESULTS: Sixty-eight of 71 patients (95.7%) achieved limb salvage and were able to ambulate with commercially available therapeutic footwear. One patient died shortly after removal of the external fixator from unrelated causes. Three patients required amputation. Resolution of infection and wound closure was achieved in five patients following a second surgical debridement. Two noninfected wounds were resolved with local soft tissue flaps. Two patients have persistent noninfected wounds that have been resistant to wound care therapy. DISCUSSION: A plantigrade noninfected foot can be achieved in patients with infected diabetic Charcot foot deformity with single-stage radical resection of osteomyelitis, correction of the deformity, maintenance of the correction with static external fixation, and culture-specific antibiotic therapy.

Unstable Ankle Fractures in Neuropathic Diabetics.

Connolly recognized as early as 1998 that a displaced ankle fracture in a neuropathic diabetic puts that patient at risk for an amputation. It is well appreciated that the risk of a poor clinical outcome secondary to failure of the surgical construct, deep wound infection and osteomyelitis or a combination of both, is greatly increased in neuropathic diabetic patients, that is, those that are insensate to the Semmes-Weinstein 5.07 (10 g) monofilament, as compared with sensate diabetics or similar non-diabetic patients. Despite this understanding, there is little objective evidence to guide treatment. The goal of this monograph is to provide the practicing Orthopaedic Surgeon the best consensus expert opinion and the most current new innovations to optimize clinical outcomes and avoid complications in this highly co-morbid patient cohort.