SLR - January 2019 - David Cheskis
Reference: Vasukutty N, Jawalkar H, Anugraha A, Chekuri R, Ahluwalia R, Kavarthapu V. Correction of Ankle And Hind Foot Deformity in Charcot Neuroarthropathy Using A Retrograde Hind Foot Nail—The Kings’ Experience. Foot and Ankle Surgery: Official Journal of the European Society of Foot and Ankle Surgeons. 2018 Oct; 24(5): 406–410.Scientific Literature Review
Reviewed By: David Cheskis, DPM
Residency Program: NYU Langone Hospital Systems, Brooklyn, NY
Podiatric Relevance: Charcot Neuroathropathy (CN) changes to the foot are a dreaded complication of Diabetes Mellitus. Consequences may include hindfoot and midfoot collapse, which can lead to ulceration, osteomyelitis and subsequent major limb amputations. Managing this condition as a podiatric surgeon remains challenging due to high rate of complication and concurrent patient comorbidities that make them high-risk surgical candidates. Due to these challenges, it has been found that these patients are better managed in a tertiary center under a multidisciplinary team of physicians. The aim of all Charcot reconstruction is to create a stable plantigrade foot, healing of ulceration and to provide ability for ambulation that will allow the patient to perform daily activities independently. Reconstruction often includes internal fixation using intramedullary hindfoot nail, plate fixation and external fixation. This study reports outcomes of hind foot fusion using intramedullary nail from a busy tertiary diabetic unit in the United Kingdom that manages more than 13,000 patient episodes a year.
Methods: A retrospective study presenting 42 feet in 40 consecutive patients who underwent Charcot hindfoot and ankle reconstruction between 2008 and 2015 with a minimum of one year follow-up. Twenty-three feet had ulceration at the time of surgery and included patients who were recommended to undergo below-knee amputation due to the degree of deformity and presence of nonhealing ulceration. If patient ulcerations were infected, they underwent debridement and were placed on antibiotics if necessary. Patients with vascular disease underwent angioplasty or bypass prior to their reconstructive procedure. All patients had hind foot fusion done using a hind foot arthrodesis nail. The procedure was performed by the senior author (VK) using a standard surgical technique. Main outcome measures included deformity correction, radiological fusion, ulcer healing, ability to wear lace-up shoes and ability to carry out activities of daily living.
Results: At a mean follow-up of 42 months, the study achieved 100 percent limb salvage initially and a 97 percent fusion rate. They achieved deformity correction in 100 percent and ulcer healing in 83 percent of feet. Eighty-three percent of patients reported ability to ambulate effectively and to carry out their activities of daily living. There were 11 patients with one or more complications, including metal work failure, infection and ulcer reactivation. There have been nine repeat procedures, including one revision fixation and one vascular procedure.
Conclusion: Outcome studies for hindfoot Charcot deformity are much fewer compared to midfoot collapse. Hindfoot reconstruction is important as it has been proven that even mild instability is poorly tolerated and could lead to potential amputation. This study proves IM nail alone can produce good results while avoiding complications of external fixation. The main drawback of the study is it lacks a comparative group. However, in conclusion, the results show satisfactory results in using intramedullary nail to treat severe cases of hind foot and ankle CN.