Combined Internal and External Fixation for Diabetic Charcot Reconstruction: A Retrospective Case Series.

Diabetic Charcot neuroarthropathy is a complex, limb-threatening disease process with major lifestyle-altering repercussions for patients. When Charcot neuroarthropathy leads to unstable deformity, ulceration, and potential infection despite conservative therapies, foot and ankle surgeons often consider reconstructive limb salvage procedures to restore function. The purpose of the present study was to evaluate the clinical and radiographic outcomes of diabetic Charcot reconstruction using combined internal and external fixation. A total of 22 patients were reviewed; 16 (72.73%) midfoot and 6 (27.27%) tibiotalocalcaneal arthrodesis procedures were consecutively performed from March 2009 to May 2013. All surgical procedures were performed in nonacute phases of the Charcot process in patients with diagnosed diabetes mellitus and documented peripheral neuropathy. Patients were excluded from the study if they were not diabetic despite having undergone Charcot reconstruction, regardless of the fixation method, or if they did not complete radiographic imaging. During a mean follow-up period of 58.60 ± 42.37 (range 16 to 164) weeks, limb salvage was achieved in 20 patients (90.91%), and 2 (9.09%) required below-the-knee amputation at a mean of 42 ± 14.14 weeks. Wound dehiscence occurred in 8 (36.36%), pin tract infection in 10 (45.45%), and superficial wound infection in 9 (40.91%) and peaked in bimodal fashion at 4 and 8 weeks postoperatively. Radiographic analysis of the pre- versus postoperative alignment showed statistically significant changes in the lateral talo-first metatarsal angle (p = .02) and lateral talar declination angle (p = .01). The limb salvage rates with diabetic Charcot reconstruction are improving in part because of the continued development of increasingly superior modalities for both internal and external fixation.

A biomechanical comparison of internal fixation techniques for ankle arthrodesis.

The purpose of the present study was to compare the primary bending stiffness characteristics of 5 different ankle arthrodesis fixation techniques: 3 compression screws, an anterior locking plate, a lateral locking plate, an anterior locking plate with a compression screw, and a lateral locking plate with a compression screw. A total of 25 full-scale anatomic models consisting of fourth-generation composite tibiae and tali were tested using an Instron 4505 Universal Testing System. We hypothesized that the use of a compression screw with a locking plate would add considerable stiffness to the fixation construct compared with the use of a locking plate alone. The data have shown that an anterior or lateral plate with a compression screw provides significantly greater stiffness than both a plate and 3 compression screws used individually. No significant difference was seen between the anterior plate with a compression screw and the lateral plate with a compression screw. No significant differences were found among the use of an anterior plate, a lateral plate, or 3 compression screws. We have concluded that when using a locking plate in an anterior or lateral configuration, the addition of a compression screw will considerably increase the primary bending stiffness of ankle arthrodesis.

Popliteal blocks for foot and ankle surgery: success rate and contributing factors.

The purpose of the present study was to evaluate the factors contributing to the success of popliteal nerve blocks performed by podiatric surgical residents in various stages of training. A retrospective review was conducted of 143 consecutively performed blocks during a 2-year period. A total of 29 blocks using a lateral approach and 114 blocks using a modified posterior approach were performed. The intrinsic and extrinsic variables contributing to block outcome were analyzed. A total of 109 successful blocks were performed, for an overall success rate of 76.2%. Significant differences (p < .002) were found between the success and failure groups with respect to the patients body mass index and age. No differences were observed between the success and failure groups with respect to the block approach or months of resident training. In conclusion, podiatric surgical residents in all stages of training can safely and effectively perform popliteal nerve blocks for peri- and postoperative analgesia. Surgeons should be aware of the potential influence of patients body mass index and age on the overall block success rates.

Circular Fixation in Charcot.

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.

Management of Osseous Defects in the Tibia: Utilization of External Fixation, Distraction Osteogenesis, and Bone Transport.

The use of external fixators for distraction osteogenesis has revolutionized treatment options for segmental bone defects in the tibia. Following corticotomy, the latency phase allows the biologic environment to initiate healing, and optimized distraction rates produce regenerate. Regenerate consolidation can be improved with local and systemic biologic optimization. Consolidation time is often considered to be 3 to 4 times longer than distraction in adults. Soft tissue considerations are important during external fixation and distraction. Additionally, slow regenerate can be benefited by various techniques discussed in this article. Distraction osteogenesis is a beneficial tool for segmental bone defects.

The kickstand technique for circular external fixator assembly.

External fixation has been shown to be an extremely versatile tool for surgical reconstruction of the lower extremity. Modern circular-ring fixators, based on original Ilizarov design, are widely used for their stiffness, utility, adjustability, and effectiveness. Because of the full-radius enclosure of the limb, however, it can be difficult to place the fixator on a supine patient. Our institutions have used a useful technique to aid application of the fixator by suspending the limb several centimeters above the operating table.

Revision Surgery for Failed Total Ankle Replacement.

Revision surgery for failed total ankle replacement is a challenge to the revision surgeon. Deformity, presence of infection, segmental bone defects, patient comorbidities, and soft tissue compromise all are significant considerations when determining appropriate procedures. Revision total ankle replacement, explant and fusion with or without lengthening, use of a trabecular metal cage, placement of an antibiotic cement spacer, grafting, and amputation all are viable options to treat patients with failed ankle arthroplasty.

Distal tibial distraction osteogenesis-an alternative approach to addressing limb length discrepancy with concurrent hindfoot and ankle reconstruction.

BACKGROUND: Limb length discrepancy (LLD) in the setting of concurrent hindfoot and ankle deformity poses an added level of complexity to the reconstructive surgeon. Regardless of etiology, a clinically significant LLD poses additional challenges without a forthright and validated solution. The purpose of the current study is to determine whether reconstructive hindfoot and ankle surgery with concurrent lengthening through a distal tibial corticotomy is comparable to other treatment alternatives in the literature. PATIENTS AND METHODS: A retrospective review of hindfoot and ankle deformity correction utilizing Ilizarov circular external fixation with concurrent distal tibial distraction osteogenesis from July 2009 to September 2014 was conducted. RESULTS: This study included 19 patients with a mean age of 47.47 ± 13.36 years with a mean follow up of 576.13 ± 341.89 days. The mean preoperative LLD was 2.70 ± 1.22 cm and the mean operatively induced LLD was 2.53 ± 0.59 cm. The mean latency period was 9.33 ± 3.47 days and distraction rate was 0.55 ± 0.16 mm/day. The mean distraction length was 2.14 ± 0.83 cm and mean duration of external fixation was 146.42 ± 58.69 days. The time to union of all hindfoot and ankle fusions was 121.00 ± 25.66 days with an overall fusion rate of 85.71%. CONCLUSIONS: The successful treatment of hindfoot and ankle deformity correction in the setting of LLD using the technique of a distal tibial corticotomy and distraction osteogenesis is reported and illustrates an additional treatment technique with comparable measured outcomes to those previously described. We urge that each patient presentation be evaluated with consideration of all described approaches and associated literature to determine the current best reconstructive approach as future studies may validate or replace the accepted options at present.

Biomechanical Considerations in Foot and Ankle Circular External Fixation: Maintenance of Wire Tension.

Initial tensioning of the forefoot wires to 130 kg followed by simultaneous tensioning of the calcaneal wires to 90 kg and using the rigid double-row foot plate closed anteriorly via threaded rods produce maximum preservation of the initial wire tension during foot circular external fixation.

Arthroscopic Ankle Arthrodesis.

Arthroscopic ankle arthrodesis is a cost-effective option for many patients with posttraumatic arthritis of the ankle joint. Rehabilitation is generally quicker than conventional open techniques, and rates of fusion are comparable or better than traditional open techniques. Unless the arthroscopic surgeon has considerable experience, the best results are seen in patients with very little deformity in the ankle joint.

Arthroscopic treatment of ankle osteochondral lesions.

Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. The diverse treatment modalities available via arthroscopy offer simplistic and straightforward solutions for biologically and mechanically complicated pathology. Marrow-stimulating techniques, particularly microfracture, have shown good to excellent results in most patients with small (<15 mm) acute lesions, and have a low complication rate.

Pediatric metatarsus adductus and skewfoot deformity.

Skewfoot is a rare condition that is often missed early in a child's development. Mild and flexible forms can be successfully treated with cast immobilization and shoe therapy. In more severe forms, surgical intervention is indicated if there are underlying neuromuscular conditions or the individual is affected on a daily basis because of the deformity. Careful evaluation and proper surgical procedures selection can realign the foot, resulting in favorable long-term outcomes. This article presents clinical and radiographic evaluation techniques and treatment options.

Pedal plexiform neurofibroma: review of the literature and case report.

Plexiform neurofibroma typically occurs in the setting of neurofibromatosis type 1, and is included in the diagnostic criteria for neurofibromatosis. Plexiform neurofibromas generally affect larger peripheral nerves and are uncommon in the foot and ankle. While there are several reports of large neurofibromas involving the foot, they have been described on the plantar aspect. We report the first known case of plexiform neurofibroma involving the deep peroneal nerve of the foot. A review of the literature is also presented.