Surgical Considerations for the Acute and Chronic Charcot Neuroarthropathy of the Foot and Ankle.

Charcot neuroarthropathy (CN) of the foot/ankle is a devastating complication that can occur in neuropathic patients. It is a progressive and destructive process that is characterized by acute fractures, dislocations, and joint destruction that will lead to foot and/or ankle deformities. Early diagnosis is imperative, and early treatment may be advantageous, but the condition is not reversible.

Operative Fixation Options for Elective and Diabetic Ankle Arthrodesis.

Ankle arthrodesis remains one of the most definitive treatment options for end-stage arthritis, paralysis, posttraumatic and postinfectious conditions, failed total ankle arthroplasty, and severe deformities. The general aims of ankle arthrodesis are to decrease pain and instability, correct the accompanying deformity, and create a stable plantigrade foot. Several surgical approaches have been reported for ankle arthrodesis with internal fixation options.

Hindfoot Arthrodesis for the Elective and Posttraumatic Foot Deformity.

Triple (talonavicular, subtalar, and calcaneocuboid) joint arthrodesis and most recently double (talonavicular and subtalar) joint arthrodesis have been well proposed in the literature for surgical repair of the elective, posttraumatic, and/or neuropathic hindfoot deformities. The articulation of the hindfoot with the ankle and midfoot is multiaxial, and arthrodesis of these joints can significantly alter the lower extremity biomechanical manifestations by providing anatomic correction and alignment. This article reviews the indications and preoperative planning for some of the most common procedures to address the hindfoot deformity.

Tibialis Anterior Tendon Transfer for Posterior Tibial Tendon Insufficiency.

The Cobb procedure is useful for addressing stage 2 posterior tibial tendon dysfunction and is often accompanied by a medial displacement calcaneal osteotomy and/or lateral column lengthening. The Cobb procedure can also be combined with selected medial column arthrodesis and realignment osteotomies along with equinus correction when indicated.

Supramalleolar osteotomy and ankle arthrodiastasis for juvenile posttraumatic ankle arthritis.

Numerous techniques have been described for posttraumatic ankle arthritis with or without an associated lower extremity deformity in the adult population. These surgical procedures may include, but are not limited to, ankle exostectomy with joint resurfacing, ankle arthrodiastasis, ankle arthroplasty, and ankle arthrodesis. Associated deformities may also be addressed with supramalleolar osteotomies, tibia or fibular lengthening, and calcaneal osteotomies.

Surgical treatment of tibial plafond fractures.

Intra-articular fractures of the tibial plafond are typically the result of rotational or axial loading forces, and both mechanisms of injuries can result in an associated fibula fracture. Rotational distal tibial plafond fractures are typically of lower energy and are associated with less articular injury and chondral impaction, whereas axial load injuries of the distal tibial plafond are associated with a higher incidence of intra-articular and soft tissue injury. The goal of this article is to review the mechanisms of injury, fracture patterns, and potential complications associated with the most common presentations of tibial plafond fractures.

Surgical treatment of intra-articular calcaneal fractures.

Most intra-articular calcaneal fractures are a result of high-energy trauma. The operative management of calcaneal fractures has been based on achieving anatomic reduction and minimizing complications of the compromised soft tissue envelope. The traditional extensile lateral approach offers advantages of achieving adequate fracture reduction with the risk of wound-healing complications and infection.

Diabetic charcot neuroarthropathy of the foot and ankle with osteomyelitis.

One of the most devastating foot and/or ankle complications in the diabetic population with peripheral neuropathy is the presence of Charcot neuroarthropathy (CN). In recent years, diabetic limb salvage has been attempted more frequently as opposed to major lower extremity amputation for CN of the foot and ankle with ulceration and/or deep infection. Treatment strategies for osteomyelitis in the diabetic population have evolved.

Simultaneous surgical repair of a tibialis anterior tendon rupture and diabetic charcot neuroarthropathy of the midfoot: a case report.

The combination of simultaneous rupture of a tibialis anterior tendon and Charcot neuroarthropathy of the midfoot in a diabetic patient is a rare and challenging condition that can lead to major complications if not addressed appropriately. This article discusses a tibialis anterior tendon rupture that may have developed before or after the incidence of the diabetic Charcot neuroarthropathy midfoot deformity and raises awareness to potential spontaneous tendon ruptures that may be associated with the diabetic Charcot foot.

Negative-pressure wound therapy in the management of diabetic Charcot foot and ankle wounds.

As the prevalence of diabetes mellitus continues to rise, innovative medical and surgical treatment options have increased dramatically to address diabetic-related foot and ankle complications. Among the most challenging clinical case scenarios is Charcot neuroarthropathy associated with soft tissue loss and/or osteomyelitis. In this review article, the authors present a review of the most common utilizations of negative-pressure wound therapy as an adjunctive therapy or combined with plastic surgery as it relates to the surgical management of diabetic Charcot foot and ankle wounds.

Diabetic Lisfranc fracture-dislocations and Charcot neuroarthropathy.

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot.

Concomitant osteomyelitis and avascular necrosis of the talus treated with talectomy and tibiocalcaneal arthrodesis.

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot.

Diabetic calcaneal fractures.

Calcaneal fractures among the diabetic population are severe and complex injuries that warrant careful evaluation in an effort to carry out adequate conservative or surgical management. The complication rates associated with diabetic fracture management are increased and may include poor wound healing, deep infection, malunion, and Charcot neuroarthropathy, each of which can pose a risk for limb loss. The significant surgery-associated morbidity accompanying diabetic calcaneal fractures has led to improved methods of calcaneal fracture management.

Surgical reconstruction of the diabetic Charcot foot: internal, external or combined fixation?

Charcot neuroarthropathy of the foot and ankle is a devastating neuropathic complication that can eventually lead to a lower extremity amputation in the presence of an ulceration or infection. Current surgical approaches for the management of the diabetic Charcot foot and ankle deformities are largely based on expert opinions in various fixation methods attempting to avoid major postoperative complications. The goal of this article is to discuss the advantages and disadvantages of various internal, external, or combined fixation methods as they relate to the inherent challenges in the management of the diabetic Charcot foot.

Total extrusion of the cuboid: a case report.

The incidence of total extrusion of the cuboid is rare, without any known published data or surgical guidelines. This case report describes the management of an open extruded cuboid by staged surgical interventions. Arthrodesis of the lateral column with a structural bone graft is a viable option to address the shortening, instability, and severe bone loss caused by the total cuboid extrusion.

Advanced foot and ankle fixation techniques in patients with diabetes.

This article presents advanced techniques and current fixation constructs that are advantageous for the management of diabetic foot and ankle trauma and Charcot neuroarthropathy. Both these pathologies are often intimately related, and the fixation constructs that are required often require sound biomechanical concepts coupled with innovative approaches to achieve bone healing and limb salvage.

Management of diabetic neuropathic foot and ankle malunions and nonunions.

The management of diabetic neuropathic foot and ankle malunions and/or nonunions is often complicated by the presence of broken or loosened hardware, Charcot joints, infection, osteomyelitis, avascular bone necrosis, unstable deformities, bone loss, disuse and pathologic osteopenia, and ulcerations. The author discusses a rational approach to functional limb salvage with various surgical techniques that are aimed at achieving anatomic alignment, long-term osseous stability, and adequate soft tissue coverage. Emphasis is placed on techniques to overcome the inherent challenges that are encountered when surgically managing a diabetic nonunion and/or malunion.

Surgical management of diabetic foot and ankle infections.

Delayed treatment of any diabetic foot infection can lead to a limb- or life-threatening scenario. Urgent and/or emergent surgery may be necessary in the early diagnosis of a severe diabetic foot infection that is followed by staged reconstructive procedures. This article provides the reader with a thorough understanding of the surgical management of severe diabetic foot infections and describes and guides treatment based on a rational schematic approach that identifies the anatomic location of the diabetic foot infection.

Internal and external fixation approaches to the surgical management of calcaneal fractures.

Calcaneal fractures are one of the most difficult fractures to surgically manage and often require a steep learning curve to achieve consistent results. They usually occur in young individuals with labor intensive occupations and are associated with major complications. Conservative treatment of intraarticular calcaneal fractures with displacement often results in significant deformity, bone loss, and posttraumatic arthrosis.

Split-thickness skin grafts for closure of diabetic foot and ankle wounds: a retrospective review of 83 patients.

The aim of this study was to determine if split-thickness skin grafts could be successfully used for closure of foot and ankle wounds in diabetic patients. The authors retrospectively reviewed the charts of 100 consecutive patients who underwent a soft tissue surgical reconstruction with split-thickness skin grafts to their foot and/or ankle in our institution from 2005 to 2008. After application of inclusion criteria, 83 eligible charts remained.

Soft tissue reconstruction pyramid in the diabetic foot.

Foot complications and ulceration are well-known sequelae to uncontrolled diabetes. Patients with chronic foot ulcers or wounds resulting from surgical debridement of deep-space infections are at continued risk for development of osteomyelitis and potential amputation. Moreover, these wounds often necessitate multiple outpatient clinic visits, daily dressing care, and prolonged periods of non-weight bearing, all of which have been shown to adversely affect the patient's quality of life.

Combined circular external fixation and open reduction internal fixation with pro-syndesmotic screws for repair of a diabetic ankle fracture.

The surgical management of ankle fractures among the diabetic population is associated with higher complication rates compared to the general population. Efforts toward development of better methods in prevention and treatment are continuously evolving for these injuries. The presence of peripheral neuropathy and the possible development of Charcot neuroarthropathy in this high risk patient population have stimulated much surgical interest to create more stable osseous constructs when open reduction of an ankle fracture/dislocation is required.

The role of an extended medial column arthrodesis for Charcot midfoot neuroarthropathy.

The etiology of diabetic Charcot neuroarthropathy involving the midfoot often includes an inciting traumatic event or repetitive micro-trauma from an uncompensated biomechanical imbalance that potentiates an incompletely understood pathway leading to a rocker-bottom foot deformity and ulceration. In the setting of a severe Charcot foot fracture and/or dislocation with obvious osseous instability, diagnostic delay can potentiate the limb-threatening sequelae of infected midfoot ulcerations in this patient population. In this article, the authors discuss the thought process as well as the advantages of performing an extended medial column arthrodesis for selected Charcot midfoot deformities.