Charcot Neuroarthropathy in Patients With Diabetes: An Updated Systematic Review of Surgical Management.

Charcot neuroarthropathy (CN) of the foot and ankle is a demanding clinical dilemma, and surgical management can be very complicated. Historically, the evidence guiding surgical management of CN has been small retrospective case series and expert opinions. The purpose of the present report was to provide a systematic review of studies published from 2009 to 2014 and to review the indications for surgery. A Medline search was performed, and a systematic review of studies discussing the surgical management of CN was undertaken. Thirty reports fit the inclusion criteria for our study, including 860 patients who had undergone a surgical procedure for the treatment of CN. The surgical procedures included amputation, arthrodesis, debridement of ulcers, drainage of infections, and exostectomy. The midfoot was addressed in 26.9% of cases, the hindfoot in 41.6%, and the ankle in 38.4%. Of the 30 studies, 24 were retrospective case series (level 4), 4 were controlled retrospective studies (level 3), and 2 were level II studies. The overall amputation rate was 8.9%. The quality of the published data on the surgical management of CN has improved during the past several years. Evidence concerning the timing of treatment and the use of different fixation methods remains inconclusive.

Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes.

BACKGROUND: Patients with diabetes mellitus (DM) are believed to have higher complication rates when undergoing ankle and hindfoot fusions, but data is lacking. The purpose of this study was to compare the postoperative outcomes of major foot and ankle arthrodeses in patients with and without DM. Another goal was to evaluate what effect glycemic control had on the outcomes of patients with diabetes. METHODS: A retrospective review of charts from operative years 2005 to 2010 was performed. Inclusion criteria encompassed patients requiring major hindfoot and/or ankle fusion. Exclusion criteria included any patient who did not have at least 6-month followup. Seventy four patients with DM were matched with 74 non-DM patients based on age, gender, and length of surgery. Significance was set at p < 0.05 with associated 95% confidence intervals. RESULTS: The overall complication rate was found to be significantly higher in patients with DM, a history of tobacco use, and peripheral neuropathy. The postoperative infection rate was found to be significantly higher in patients with DM, poor long-term glucose control (Hgb A1c levels greater than or equal to 7%), a history of tobacco use, peripheral artery disease, and peripheral neuropathy. Our rate of noninfectious complications was found to be significantly higher in patients with DM, poor short-term glucose control (a preoperative glucose greater than 200 mg/dL), a history of tobacco use, and previous solid organ transplantation. Patients greater than or equal to 65 years of age were significantly associated with fewer overall complications and postoperative infections. CONCLUSION: This study confirmed our hypothesis that patients with DM were at increased risk for postoperative complications after foot and/or ankle arthrodesis when compared to patients without DM. A secondary finding of this study demonstrated patients with poor short- and long-term glucose control experienced more complications.

Surgical management of Charcot neuroarthropathy of the foot and ankle: a systematic review.

BACKGROUND: Charcot neuroarthropathy (CN) of the foot and ankle is an extremely challenging clinical dilemma and surgical management can be highly complicated. The current literature on this topic is comprised of manuscripts that are retrospective case series and expert opinions. Furthermore, surgery in patients with CN of the foot and ankle is guided by studies with low levels of evidence to support our current surgical practices. METHODS: A Medline/CINAHL search was performed and a systematic review of articles discussing the surgical management of CN was undertaken. RESULTS: Ninety-five articles fit the inclusion criteria for our study. As hypothesized, all reports detailing the surgical management of Charcot neuroarthropathy constituted Level IV or V evidence. CONCLUSION: Surgical algorithms for the treatment of CN of the foot are based almost entirely on level four or five evidence. Uncontrolled retrospective case series and case reports guide the use of exostectomy, fusion, and Achilles tendon lengthening for CN. There is inconclusive evidence concerning timing of treatment and use of different fixation methods. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.

The Use of Cryopreserved Human Skin Allograft for the Treatment of Wounds With Exposed Muscle, Tendon, and Bone.

BACKGROUND: Wounds with exposed bone or tendon continue to be a challenge for wound care physicians, and there is little research pertaining to the treatment of these particular wounds with allograft skin. The purpose of this study was to evaluate the effectiveness and safety of a biologically active cryopreserved human skin allograft for treating wounds with exposed bone and/or tendon in the lower extremities. METHODS: Fifteen patients with 15 wounds at a single hospital-based wound care center were included in the study. Eleven wounds had exposed bone, 1 wound had exposed ten- don, and 3 wounds had exposed bone and tendon. Standard treatment principles with adjunctive cadaveric allograft application were performed on all wounds in the study. RESULTS: In this study 14/15 (93.3%) of the wounds healed completely. The mean duration of days until coverage of the bone and/or tendon with granulation tissue was 36.14 (5.16 weeks) (range 5-117 days). Mean duration to complete healing of the wound was 133 days (19 weeks) (range 53-311 days). The mean number of grafts applied was 2. There were no adverse events directly related to the graft. Zero major amputations and 1 minor amputation occurred. CONCLUSION: This study found biologically active cryopreserved human skin allografts to be safe and effective in treating difficult wounds with exposed bone and/or tendon. To the authors' knowledge, this is the largest study to date focused on the utilization of allograft skin as an adjunct therapy for lower extremity wounds with exposed tendon and/or bone.

Proximal phalangeal osteotomies for hallux abductovalgus deformity.

The primary indication for an osteotomy of the hallux proximal phalanx to correct hallux abductovalgus (HAV) deformities is increased hallux interphalangeus. The typical osteotomy is the Akin osteotomy or a variation. The Akin is a medial closing wedge osteotomy in the proximal phalanx. An Akin-type osteotomy is usually used as an adjunctive procedure for HAV to correct deformity within the great toe. When first metatarsal procedures and soft tissue balancing are not sufficient for realigning the first metatarsophalangeal joint, an Akin can be useful. A hallux proximal phalanx osteotomy is not indicated as the primary correction for HAV deformities.

Permanent antibiotic impregnated intramedullary nail in diabetic limb salvage: a case report and literature review.

Managing complications after attempted hind foot and ankle arthrodesis with intramedullary nail fixation is a challenge. This situation becomes more problematic in the patient with diabetes mellitus and multiple comorbidities. Infection and subsequent osteomyelitis can be a devastating, limb threatening complication associated with these procedures. The surgeon must manage both the infectious process and the skeletal instability concurrently. This article provides a literature review and detailed management strategies for a modified technique of employing antibiotic impregnated polymethylmethacrylate-coated intramedullary nailing.

Internal fixation techniques for midfoot charcot neuroarthropathy in patients with diabetes.

Charcot neuropathic osteoarthropathy (CN) of the foot and ankle is a poorly understood destructive process that poses a great clinical challenge to foot and ankle specialists. Neuropathic fractures or dislocations in the foot and ankle predispose patients to increased morbidity, premature mortality, and can greatly decrease quality of life. Early recognition and treatment of CN is imperative to prevent the development of permanent deformities. The purpose of this article is to review the history, cause, and classification of CN and to discuss commonly used internal fixation techniques and their indications.

Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes.

OBJECTIVE: This prospective study was designed to evaluate the rate of surgical site infection (SSI) after foot and ankle surgery in patients with and without diabetes. RESEARCH DESIGN AND METHODS: The study prospectively evaluated 1,465 consecutive foot and ankle surgical cases performed by a single surgeon. RESULTS: The overall SSI rate in this study was 3.5%, with significantly more infections occurring in individuals with diabetes than in those without (9.5 vs. 2.4%, P < 0.001). Peripheral neuropathy, Charcot neuroarthropathy, current or past smoking, and increasing length of surgery were significantly associated with SSI on multivariate analysis. CONCLUSIONS: This study demonstrates significant associations between the development of SSI and chronic complications of diabetes. We confirm previous findings that it is peripheral neuropathy and not diabetes itself that most strongly determines the development of postoperative infections in these surgical patients.

Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus.

BACKGROUND: Patients with diabetes mellitus may be at increased risk for infection following foot and ankle surgery. This study aimed to determine whether patients with a diagnosis of diabetes mellitus have an increased rate of infection following foot and ankle surgery compared with a cohort of patients without diabetes. Furthermore, our study sought to demonstrate whether patients with complicated diabetes are at greater risk of postoperative wound infection than are patients with uncomplicated diabetes or patients without diabetes. METHODS: We conducted a retrospective review of the charts of 1000 patients who had orthopaedic foot and ankle surgery. The following data were extracted: patient age, sex, history of diabetes mellitus, development of postoperative infection, severity of infection, inpatient or outpatient surgery, use of internal or external fixation, tobacco use, history of organ transplantation, history of rheumatoid arthritis, length of surgery, follow-up time in weeks, and comorbid conditions. RESULTS: The overall infection rate in this study was 4.8%. Fifty-two percent of all infections occurred in our diabetic study group, which represented only 19% of the patient population. Postoperative infections occurred in significantly more persons with diabetes (13.2%) than in those without diabetes (2.8%). Diabetic patients were five times more likely to experience a severe infection requiring hospitalization compared with patients without diabetes. After removing the patients with neuropathy from the analysis, there was no longer a significant association between diabetes and infection. The presence of complicated diabetes increased the risk of postoperative infection by a factor of ten compared with the risk for patients without diabetes and by a factor of six compared with the risk for patients with uncomplicated diabetes. We did not identify a significantly increased risk of infection in patients with uncomplicated diabetes compared with that in patients without diabetes. CONCLUSIONS: Patients with diabetes mellitus are at increased risk of severe infection compared with those without diabetes. Patients with uncomplicated diabetes did not have an increased risk of postoperative infection compared with patients without diabetes, whereas patients with complicated diabetes had a significantly higher rate of postoperative infection.

Tibiotalocalcaneal arthrodesis with the use of a humeral locking plate.

Combined arthrosis or deformity of the subtalar and ankle joints presents a challenge to the foot and ankle specialist. Tibiotalocalcaneal arthrodesis is a well-described surgical technique used for resolution of deformity and end-stage arthrosis of the ankle and subtalar joints and is currently the standard of care for this condition. This article highlights the technique of insertion of the humeral locking plate for the stabilization of tibiotalocalcaneal arthrodesis. A case study is provided to serve as an example of the technique.