RESUMO
INTRODUCTION: Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge. METHODS: This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score. RESULTS: Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002). CONCLUSION: This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.
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Articulação do Tornozelo , Artrodese , Artropatia Neurogênica , Pinos Ortopédicos , Qualidade de Vida , Humanos , Pessoa de Meia-Idade , Artrodese/métodos , Artrodese/instrumentação , Feminino , Masculino , Artropatia Neurogênica/cirurgia , Articulação do Tornozelo/cirurgia , Articulação do Tornozelo/diagnóstico por imagem , Idoso , Resultado do Tratamento , Seguimentos , Tíbia/cirurgia , AdultoRESUMO
Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.
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Artropatia Neurogênica , Humanos , Artropatia Neurogênica/cirurgia , Resultado do Tratamento , Articulação do Tornozelo/cirurgia , Procedimentos Ortopédicos/métodosRESUMO
BACKGROUND: Even with the best conservative care, patients with Charcot neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has been associated with risk of recurrent ulceration, potentially due to poor bone quality prone to recurrent deformity and ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation. METHODS: A protocol was developed to create characteristic CN midfoot fragmentation both visually and fluoroscopically in each of 12 matched-pair cadaveric feet. Afterward, the pairs were divided into 2 groups: (1) midfoot beam fusion surgery alone, and (2) midfoot beam fusion surgery augmented with PMMA. A solid 7.0-mm beam was placed into the medial column and a solid 5.5-mm beam was placed across the lateral column. In the PMMA group, 8 to 10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded. RESULTS: One specimen in the beam alone group failed before reaching the 1800th cycle and was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared with the PMMA group, P < .05. The maximum force (N), stiffness (N/mm), and toughness (Nmm) were all significantly greater in the group augmented with PMMA, P < .05. CONCLUSION: In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared with midfoot beams alone. CLINICAL RELEVANCE: The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct. This increased mechanical toughness may help reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.
Assuntos
Artropatia Neurogênica , Cadáver , Polimetil Metacrilato , Humanos , Artropatia Neurogênica/cirurgia , Artropatia Neurogênica/fisiopatologia , Fenômenos Biomecânicos , Cimentos Ósseos , Artrodese/métodos , IdosoRESUMO
While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ .05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5 ± 5.39 mGy and 256.64 ± 130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p = .32) or fluoroscopy times (p = .71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p = .01) body mass index (p = .03) and number of stages (p = .04). Similarly, a relationship existed between fluoroscopy time with weight (p = .02), body mass index (p = .03), and number of beams/screws (p = .003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.
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Artropatia Neurogênica , Exposição à Radiação , Humanos , Estudos Retrospectivos , Feminino , Pessoa de Meia-Idade , Artropatia Neurogênica/cirurgia , Artropatia Neurogênica/diagnóstico por imagem , Fluoroscopia , Masculino , Adulto , Idoso , Procedimentos de Cirurgia Plástica/métodos , Doses de RadiaçãoRESUMO
Charcot neuroarthropathy's (CN) anatomic classification was originally formulated by the Brodsky article and the Trepman et al modification, including midfoot (type 1), rearfoot (type 2), ankle (type 3a), calcaneus (type 3b), multiarticular (type 4), and forefoot (type 5). In these classic studies, ankle joint and multijoint CN are reported as 9% and 6% to 9%, respectively, but we believe ankle CN to be more common than that in a tertiary setting. We retrospectively reviewed patients presenting initially or as referral between 2004 and 2020. Initial presentation radiographs were reviewed and classified by 3 authors based on Brodsky's model with Trepman and colleagues' modification, and any discrepancies were reviewed by the fourth author. A total of 175 patients (205 feet) were assessed. This revealed 80 cases classified as type 1 (39.0%), 23 cases type 2 (11.2%), 17 cases type 3a (8.3%), 2 cases type 3b (1.0%), and 83 cases type 4 (40.5%). After subdividing type 4, total prevalence included 150 with type 1 anatomic location (73.2%), 103 type 2 (50.2%), 44 type 3a (21.5%), and still 2 type 3b (1.0%). This study revealed a similar prevalence of isolated ankle CN (8.5%) compared to the Trepman et al article (9%), however, in total, ankle CN (21.5%) occurred 2.4-times more than the original 9%. Our study also found there to be a higher prevalence of ankle CN in the setting of multiarticular CN, which has not been evaluated in past studies. The prevalence of multiarticular CN was found to be 4.5-fold greater than the Trepman article (6%-9%).
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Articulação do Tornozelo , Artropatia Neurogênica , Humanos , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Tornozelo/diagnóstico por imagem , Tornozelo/cirurgia , Estudos Retrospectivos , Centros de Atenção Terciária , Prevalência , Artropatia Neurogênica/diagnóstico por imagem , Artropatia Neurogênica/epidemiologia , Artropatia Neurogênica/cirurgiaRESUMO
Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.
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Artropatia Neurogênica , Pé Diabético , Procedimentos de Cirurgia Plástica , Humanos , Artrodese/métodos , Artropatia Neurogênica/cirurgia , Artropatia Neurogênica/complicações , Pé Diabético/cirurgia , Pé Diabético/complicaçõesRESUMO
The objective of this article is to review the etiology and pathophysiology of Charcot neuroarthropathy as it contributes to the breakdown of the midfoot. The article will also discuss the emerging techniques in minimally invasive surgery and how this is applied to Charcot reconstructive surgery as well as reflect on a newer thought processes to surgical intervention.
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Artropatia Neurogênica , Procedimentos Cirúrgicos Minimamente Invasivos , Procedimentos de Cirurgia Plástica , Humanos , Artropatia Neurogênica/cirurgiaRESUMO
BACKGROUND: Several studies demonstrated a considerable complication rate for open ankle or TTC arthrodesis in patients with diabetes, revision surgery and ulceration. Extensive approaches in combination with multimorbide patients have been suggested as the rationale behind the increased complication rate. METHODS: Single-centre, prospective case-control study compared arthroscopic vs. open ankle arthrodesis in patients with Charcot Neuro-Arthropathy of the foot. 18 patients with septic Charcot Neuro-Arthropathy Sanders III-IV received an arthroscopic ankle arthrodesis with TSF (Taylor Spatial Frame®) fixation combined with different additional procedures required for infect treatment and hindfoot realignment. The ankle arthrodesis was required for the realignment of the hindfoot in Sanders IV patients, arthritis or in case of infection. 12 patients were treated with open ankle arthrodesis and TSF fixation combined with various additional procedures. RESULTS: A significant improvement has been shown in radiological data in both groups. A significant lower complication rate has been registered in arthroscopic group. A significant correlation was seen between major complications and therapeutic anticoagulation as well as smoking. CONCLUSION: In high-risk patients with diabetes and plantar ulceration excellent results could be demonstrated in arthroscopically performed ankle arthrodesis with midfoot osteotomy using TSF as fixation devise.
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Artropatia Neurogênica , Diabetes Mellitus , Humanos , Tornozelo , Estudos de Casos e Controles , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Artropatia Neurogênica/etiologia , Artropatia Neurogênica/cirurgia , Artrodese/efeitos adversos , Artrodese/métodos , Estudos RetrospectivosRESUMO
Charcot neuroarthropathy (CN) is a serious diabetic complication with a poor prognosis and a high rate of misdiagnosis. Furthermore, beta(2)-microglobulin amyloidosis (Abeta2M) makes the diagnosis and therapy more difficult and complex. This case report highlights the pathophysiology, clinical evaluation, treatment, and prevention of the major diabetic complications associated with CN and Abeta2M that cause poor quality of life, limit the patient's ability to walk independently, and are directly or indirectly linked with a high risk for lower limb amputation. Ankle CN was discovered in a 36-year-old single female with a history of type 1 diabetes mellitus and diabetic nephropathy. We performed early internal fixation. However, because she lived alone and needed hemodialysis three times a week, wearing a brace and non-weight-bearing were extremely inconvenient. Furthermore, she did not experience any pain and only some edema; thus, she proceeded to bear weight ahead of schedule without authorization. Due to the premature weight-bearing and poor compliance, the patient suffered severe bone resorption and infection and eventually had to undergo amputation. Abeta2M was suggested by bone pathological sections. We present a case of failed internal fixation of ankle CN with Abeta2M, emphasizing the importance of social factors and postoperative management.
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Amiloidose , Artropatia Neurogênica , Humanos , Feminino , Adulto , Articulação do Tornozelo/cirurgia , Qualidade de Vida , Artropatia Neurogênica/cirurgia , Artropatia Neurogênica/complicações , Artropatia Neurogênica/diagnóstico , Fixação Interna de Fraturas , Amiloidose/complicaçõesRESUMO
Hindfoot osteoarthritis (OA) or deformity involving the ankle and subtalar joint is a disabling condition. Tibiotalocalcaneal (TTC) fusion is an effective salvage option in pathologies where total ankle replacement is contraindicated. The purpose of this study is to compare the union rate of the ankle joint in proximal static versus dynamically locked retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis. An institutional review board-approved comprehensive chart and radiographic review was performed. TTC arthrodesis performed in patients with OA, post-traumatic arthritis, or deformity corrected by retrograde nail were included. Patients with Charcot arthropathy, failed joint replacement, neuropathy, or avascular necrosis were excluded. The primary outcome was ankle joint union with secondary measure of mean time to fusion. A total of 60 patients met inclusion criteria with 30 in the static group (SG) and 30 in the dynamic group (DG). The average age of the static group (SG) and dynamic group (DG) was 56.9 and 54.1 years, respectively. Mean body mass index was 34.03 kg/m2 for SG and 33.43 kg/m2 for DG. The union rate of the ankle joint was slightly higher in the DG but not statistically significant [SG 83.3%, DG 86.6%, p > .05 (p = .83)]. Time to fusion (TTF) in SG was 111.6 days compared to 97.2 days in DG. Dynamically locked intramedullary nails allow continued compression across the arthrodesis site as fusions remodel. Time to union and union rate of the ankle joint was superior in the dynamic group but this was not statistically significant. In this cohort, union rates were excellent in both groups, and no statistically significant difference was seen in the number of nonunions.
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Artropatia Neurogênica , Fixação Intramedular de Fraturas , Osteoartrite , Humanos , Pinos Ortopédicos , Osteoartrite/diagnóstico por imagem , Osteoartrite/cirurgia , Artropatia Neurogênica/cirurgia , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Artrodese , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Charcot neuroarthropathy (CNA) is a disabling and progressive disease that affects the bones and joints of the foot. Successful Charcot reconstruction focuses on restoring anatomic alignment, obtaining multiple joint arthrodesis, selecting stable fixation, preserving foot length, and creating a foot suitable for community ambulation in supportive shoegear. Intramedullary fixation arthrodesis of the medial and lateral columns has been previously reported to produce improvement in midfoot Charcot reconstruction. More recently, a growing trend of stabilization of the subtalar joint (STJ) has been incorporated alongside the medial and lateral column fusion. Our objectives were to retrospectively review patients who underwent midfoot Charcot reconstructive surgery, whether with or without accompanying STJ arthrodesis, and establish which patients progressed to ankle CNA. Of the 72 patients who underwent midfoot Charcot reconstruction, 28 (38.9%) underwent STJ arthrodesis, and 22 converted to ankle CNA (30.6%). Fourteen (63.6%) of 22 ankle CNA cases had not undergone STJ arthrodesis; 8 patients (36.4%) had it. A Fisher exact test was performed to identify the relationship between those without STJ arthrodesis and those progressing to ankle CNA; it revealed statistical significance (p = .001). Performing an STJ arthrodesis with midfoot Charcot reconstructive surgery may be beneficial to aiding in hindfoot stability, establishing a plantigrade foot, and providing further insight into the management of midfoot Charcot.
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Artropatia Neurogênica , Articulação Talocalcânea , Humanos , Articulação Talocalcânea/diagnóstico por imagem , Articulação Talocalcânea/cirurgia , Estudos Retrospectivos , Artropatia Neurogênica/diagnóstico por imagem , Artropatia Neurogênica/cirurgia , Pé/cirurgia , ArtrodeseRESUMO
BACKGROUND: The cause of Charcot neuro-osteoarthropathy (CN) is diabetes in approximately 75% of patients. Most reports on the clinical course and complications of CN focus on diabetic CN, and reports on nondiabetic CN are scarce. No study, to our knowledge, has compared the clinical course of patients initially treated nonoperatively for diabetic and nondiabetic CN. QUESTIONS/PURPOSES: Among patients with CN, are there differences between patients with diabetes and those without in terms of (1) the frequency of major amputation as ascertained by a competing risks survivorship estimator; (2) the frequency of surgery as ascertained by a competing risks survivorship estimator; (3) frequency of reactivation, as above; or (4) other complications (contralateral CN development or ulcers)? METHODS: Between January 1, 2006, and December 31, 2018, we treated 199 patients for diabetic CN. Eleven percent (22 of 199) were lost before the minimum study follow-up of 2 years or had incomplete datasets and could not be analyzed, and another 9% (18 of 199) were excluded for other prespecified reasons, leaving 80% (159 of 199) for analysis in this retrospective study at a mean follow-up duration since diagnosis of 6 ± 4 years. During that period, we also treated 78 patients for nondiabetic Charcot arthropathy. Eighteen percent (14 of 78) were lost before the minimum study follow-up and another 5% (four of 78 patients) were excluded for other prespecified reasons, leaving 77% (60 of 78) of patients for analysis here at a mean of 5 ± 3 years. Patients with diabetic CN were younger (59 ± 11 years versus 68 ± 11 years; p < 0.01), more likely to smoke cigarettes (37% [59 of 159] versus 20% [12 of 60]; p = 0.02), and had longer follow-up (6 ± 4 years versus 5 ± 3 years; p = 0.02) than those with nondiabetic CN. Gender, BMI, overall renal failure, dialysis, and presence of peripheral arterial disease did not differ between the groups. Age difference and length of follow-up were not considered disqualifying problems because of the later onset of idiopathic neuropathy and longer available patient follow-up in patients with diabetes, because our program adheres to the follow-up recommendations suggested by the International Working Group on the Diabetic Foot. Treatment was the same in both groups and included serial total-contact casting and restricted weightbearing until CN had resolved. Then, patients subsequently transitioned to orthopaedic footwear. CN reactivation was defined as clinical signs of the recurrence of CN activity and confirmation on MRI. Group-specific risks of the frequencies of major amputation, surgery, and CN reactivation were calculated, accounting for competing events. Group comparisons and confounder analyses were conducted on these data with a Cox regression analysis. Other complications (contralateral CN development and ulcers) are described descriptively to avoid pooling of complications with varying severity, which could be misleading. RESULTS: The risk of major amputation (defined as an above-ankle amputation), estimated using a competing risks survivorship estimator, was not different between the diabetic CN group and nondiabetic CN group at 10 years (8.8% [95% confidence interval 4.2% to 15%] versus 6.9% [95% CI 0.9% to 22%]; p = 0.4) after controlling for potentially confounding variables such as smoking and peripheral artery disease. The risk of any surgery was no different between the groups as estimated by the survivorship function at 10 years (53% [95% CI 42% to 63%] versus 58% [95% CI 23% to 82%]; p = 0.3), with smoking (hazard ratio 2.4 [95% CI 1.6 to 3.6]) and peripheral artery disease (HR 2.2 [95% CI 1.4 to 3.4]) being associated with diabetic CN. Likewise, there was no between-group difference in CN reactivation at 10 years (16% [95% CI 9% to 23%] versus 11% [95% CI 4.5% to 22%]; p = 0.7) after controlling for potentially confounding variables such as smoking and peripheral artery disease. Contralateral CN occurred in 17% (27 of 159) of patients in the diabetic group and in 10% (six of 60) of those in the nondiabetic group. Ulcers occurred in 74% (117 of 159) of patients in the diabetic group and in 65% (39 of 60) of those in the nondiabetic group. CONCLUSION: Irrespective of whether the etiology of CN is diabetic or nondiabetic, our results suggest that orthopaedic surgeons should use similar nonsurgical treatments, with total-contact casting until CN activity has resolved, and then proceed with orthopaedic footwear. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach. LEVEL OF EVIDENCE: Level III, prognostic study.
Assuntos
Artropatia Neurogênica , Diabetes Mellitus , Pé Diabético , Artropatias , Doença Arterial Periférica , Humanos , Estudos Retrospectivos , Úlcera/complicações , Amputação Cirúrgica , Pé Diabético/epidemiologia , Pé Diabético/cirurgia , Pé Diabético/complicações , Doença Arterial Periférica/complicações , Progressão da Doença , Artropatias/complicações , Artropatia Neurogênica/complicações , Artropatia Neurogênica/cirurgia , Artropatia Neurogênica/diagnósticoRESUMO
Lateral column deterioration and subsequent loss of function poses a challenge for limb preservation in patients with Charcot neuroarthropathy (CN). Application of "superconstructs" provides stability and clinical improvement to an often-ulcerated lateral foot. This study examines radiodensity in Hounsfield units (HU) to compare bone quality of lateral column fixation targets using computed tomography (CT) scans between patients with and without midfoot CN. A retrospective chart review identified control (nondiabetic, non-CN; n = 29) and midfoot CN (n = 21) groups. Patient demographics and medical history were collected. Two reviewers measured the mean HU of circular regions of interest centered on the fourth and fifth metatarsal heads as well as the anterior, middle, and posterior thirds of the calcaneus. Radiodensity was compared between groups, among calcaneal locations, Eichenholtz stages and Brodsky types. A p value ≤.05 was considered statistically significant. Age and body mass index were not significantly different between groups. The CN group exhibited greater HU than the control group at the metatarsal head and calcaneus (p < .001). The anterior calcaneus exhibited greater HU than the posterior calcaneus in the CN group (p = .02). The difference in HU was not statistically significant between Stages 0-1 and Stages 2-3 or midfoot Brodsky Types. Indirect bone density analysis revealed an increased density in CN compared to control patients with no significant difference between midfoot CN stages or types. The anterior calcaneus was the densest rearfoot bone among the CN patients, a result that may have implications in surgical fixation.
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Artropatia Neurogênica , Calcâneo , Pé Diabético , Ossos do Metatarso , Humanos , Estudos Retrospectivos , Pé , Pé Diabético/cirurgia , Ossos do Metatarso/cirurgia , Artropatia Neurogênica/cirurgiaRESUMO
PURPOSE: Corrective midfoot resection arthrodesis is the standard treatment of Charcot arthropathy type Sanders 2 and 3 with severe dislocation. In order to critically evaluate the effect of surgical correction, a retrospective analysis of our patient cohort was performed. Hereby, special emphasis was set on the analysis of the pre- and post-operative equinus position of the hindfoot. METHODS: Retrospectively, all patients (n = 82) after midfoot resection arthrodesis in Charcot type Sanders 2 or 3 were included. Complications were recorded, and the mean complication-free interval was calculated. Additionally, the calcaneal pitch as well as Meary's angle were measured pre- and post-operatively and in case of complications. RESULTS: Overall complication rate was 89%. Revision surgery was necessary in 46% of all patients. The mean complication-free interval was 285 days (0-1560 days). Calcaneal pitch and Meary's angle significantly improved after operation but returned to pre-operative values after onset of complications. Achilles tendon lengthening showed no significant effects on the mean complication-free interval. CONCLUSION: Operative treatment of Charcot arthropathy remains a surgical challenge with high complication rates. Surgical correction of equinus position has been highlighted for successful treatment but was not able to prevent complications in this study, which is demonstrated by the recurrent decrease of the calcaneal pitch in cases of reoperation. Therefore, as a conclusion of our results, our treatment algorithm changed towards primarily addressing the equinus malpositioning of the hindfoot by corrective arthrodesis of the hindfoot.
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Artropatia Neurogênica , Tenotomia , Humanos , Estudos Retrospectivos , Pé , Artrodese/efeitos adversos , Artrodese/métodos , Artropatia Neurogênica/cirurgiaRESUMO
Charcot neuropathic arthropathy is a relatively rare, chronic disease that leads to joint destruction and reduced quality of life of patients. Early diagnosis of Charcot arthropathy is essential for a good outcome. However, the diagnosis is often based on the clinical course and longitudinal follow-up of patients is required. Charcot arthropathy is suspected in patients with suggestive symptoms and an underlying etiology. Failed spinal surgery is not a known cause of Charcot arthropathy. Herein we report a patient with ankle Charcot neuropathic arthropathy that developed after failed spinal surgery. A 58-year-old man presented to the emergency room due to painful swelling of the left ankle for 2 weeks that developed spontaneously. He underwent spinal surgery 8 years ago that was associated with nerve damage, which led to weakness of great toe extension and ankle dorsiflexion, and sensory loss below the knee. CT and T2-weighted sagittal MRI showed a fine erosive lesion, subluxation, sclerosis, fragmentation, and large bone defects. Based on the patient's history and radiological findings, Charcot arthropathy was diagnosed. However, the abnormal blood parameters, positive blood cultures, and severe pain despite the decreased sensation suggested a diagnosis of septic arthritis. Therefore, diagnostic arthroscopy was performed. The ankle joint exhibited continued destruction after the initial surgery. Consequently, several repeat surgeries were performed over the next 2 years. Despite the early diagnosis and treatment of Charcot arthropathy, the destruction of the ankle joint continued. Given the chronic disease course and poor prognosis of Charcot arthropathy, it is essential to consider this diagnosis in patients with neuropathy.
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Artropatia Neurogênica , Doenças do Sistema Nervoso Periférico , Masculino , Humanos , Pessoa de Meia-Idade , Articulação do Tornozelo/cirurgia , Tornozelo , Qualidade de Vida , Artropatia Neurogênica/etiologia , Artropatia Neurogênica/cirurgia , Artropatia Neurogênica/diagnóstico , Doenças do Sistema Nervoso Periférico/complicações , Doença IatrogênicaRESUMO
The Charcot diabetic foot presents unique challenges to the podiatric surgeon in the quest to salvage the limb. This disorder is an intersection of prototypical metabolic diseases and neurodegenerative disorder. Furthermore, it can be considered a disease of bone and ligaments that is often complicated by peripheral vascular disease and serious deep infection. Presently, simplistic ablative surgical procedures and the brace-makers art, still have a valid place in treating this disorder. Newer methods of surgical reconstruction are rapidly evolving to address distorted and nonfunctional limb. This article seeks to evidence the principles and practice of beaming the Charcot midfoot. As will be presented, the beam is a load-sharing device, which can be surgically introduced in an intramedullary method to restore architecture and strength to the Charcot foot. Problems with beam failure and migration have resulted in unsatisfactory outcomes as will be discussed. New Charcot-specific beams are currently reaching the podiatric surgeon with hopes of improving durability. In this article, we aim to address the surgical art of the beam, the engineering principles of beaming, and the novel introduction of a truss/tie rod configuration of beaming.
Assuntos
Artropatia Neurogênica , Pé Diabético , Procedimentos de Cirurgia Plástica , Artropatia Neurogênica/diagnóstico por imagem , Artropatia Neurogênica/etiologia , Artropatia Neurogênica/cirurgia , Pé Diabético/complicações , Pé Diabético/cirurgia , Pé/cirurgia , Humanos , Procedimentos de Cirurgia Plástica/métodosRESUMO
Reconstruction of the Charcot foot and ankle demonstrates significant challenges to the foot and ankle surgeon. At present, there is limited clear consensus on the best approach for preoperative optimization. The primary aim of Charcot reconstructions is to limit the risk of ulceration by providing a stable plantigrade foot allowing ambulation. The focus of this article is the discussion of modifiable risk factors associated with Charcot reconstruction for preoperative optimization.
Assuntos
Artropatia Neurogênica , Pé Diabético , Amputação Cirúrgica , Tornozelo/cirurgia , Articulação do Tornozelo/cirurgia , Artropatia Neurogênica/complicações , Artropatia Neurogênica/cirurgia , Pé Diabético/complicações , Pé Diabético/cirurgia , HumanosRESUMO
Charcot neuroarthropathy (CN) and its sequela is a disabling pathology in the foot and ankle. The 2-stage computer hexapod-assisted technique is an effective tool to address midfoot Charcot and ankle-hindfoot deformities to restore function and decrease the risk of amputation secondary to ulceration and infection. Although this is not the only technique available, it is an excellent option in cases with significant angular deformity or subluxation, need to reduce shortening of the foot, and in the presence of soft tissue defects, with or without concurrent soft tissue or bone infection.
Assuntos
Artropatia Neurogênica , Pé Diabético , Tornozelo , Artropatia Neurogênica/complicações , Artropatia Neurogênica/diagnóstico por imagem , Artropatia Neurogênica/cirurgia , Pé Diabético/cirurgia , Fixadores Externos , Fixação de Fratura , HumanosRESUMO
Static circular fixation is a valuable tool for patients with Charcot foot and ankle deformities. The versatility of circular fixators allows for dynamic adjustments over time and can allow for off-loading of flaps or ulcers. The circular fixator can be used as a primary fixation device in cases of osteomyelitis or to facilitate lengthening when a segmental bone defect exists such as loss of the talus. As a secondary fixation device it can protect the internal fixation or be used when there is a compromised soft tissue envelope.