Split Anterior Tibial Tendon Transfer to Dorsal Lateral Foot for Cavovarus Deformities With Neuropathic Ulcerations: A Case Series.

Cavovarus deformity leads to increased peak pressure on the plantar lateral foot, which can lead to ulceration, and can potentially progress to amputation. Techniques have been suggested in the treatment of cavovarus deformity, such as peroneus brevis or longus tendon transfer, anterior tibial tendon lengthening, posterior tibial tendon transfer, or boney resection. This case series shows split anterior tibial tendon transfer as a surgical reconstruction of cavovarus pedal deformity. Our technique of split anterior tibial tendon in-phase transfer to the dorsal lateral foot, restores the eversion and dorsiflexory pull necessary to offset peroneal attenuation. The procedure can be performed primarily or staged, in order to achieve infection temporization prior to the transfer. A total of 14 patients underwent split anterior tibial tendon transfer, 57.14% (8/14) of which had preoperative ulcerations, and 42.86% (6/14) of which had preoperative hyperkeratotic pre-ulcerative lesions. The preoperative ulcerations were present for an average of 67.89 weeks (range 2-232), with an average area of 6.09 ± 7.44 cm2. The ulcerations healed in 75% (6/8) of the patients, at 19.67 weeks (range 1.57-76), with new ulceration occurrence in 7.14% (1/14) of patients, 7.14% (1/14) rate of ulceration recurrence. None of the patients went on to minor or major amputation. The goal of the tendon transfer is to decrease midfoot plantar pressures on the lateral foot and allow for resolution of pre-existing ulcerations and rebalancing the foot and ankle.

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.

Peripheral Vascular Disease Diagnostic Related Outcomes in Diabetic Charcot Reconstruction.

Postreconstructive outcomes were compared in diabetic patients with Charcot neuroarthropathy (CN) who had peripheral arterial disease (PAD) diagnosed with angiography versus patients who were diagnosed clinically. A retrospective review was performed of patients with diabetic CN requiring reconstruction secondary to ulceration and/or acute infection. Of the 284 patients in the CN osseous reconstruction cohort, after accounting for exclusion criteria, 59 (20.8%) patients with PAD were included in the analyses. Forty (67.8%) of these 59 patients were diagnosed with PAD clinically and 19 (32.2%) were diagnosed with the use of angiography. Bivariate analysis was used to compare outcomes between those diagnosed with PAD via angiography versus those diagnosed clinically for the following postreconstruction outcomes: wound healing, delayed healing, surgical site infection, pin tract infection, osteomyelitis, dehiscence, transfer ulcer, new site of Charcot collapse, contralateral Charcot event, nonunion, major lower extremity amputation, and return to ambulation. Bivariate analysis found return to ambulation postreconstruction (p = .0054) to be the only statistically significant factor. There was a trend toward significance for major lower extremity amputation, with higher rates of amputation in the clinically diagnosed PAD arm. Return to ambulation indicates improved functional outcomes. The main goal of limb salvage should be focused on improving the patient's functional performance. With significantly faster rates of return to ambulation and a trend toward decreased rates of major amputation, angiography was found to be a better assessor of PAD than clinical evaluations.