SLR - March 2022 - Jacqueline Babayev
Reference: Moonot P, Sharma G, Kadakia A. Functional Outcome in Patients with Charcot Neuropathy with Almost Complete Loss of Talus Treated by Tibio-Talo Calcaneal Nail: A Cross-Sectional Study. Foot. 2021 Dec;49:101833. doi: 10.1016/j.foot.2021.101833. Epub 2021 Oct 20. PMID: 34687980.Level of Evidence: IV
Scientific Literature Review
Reviewed By: Jacqueline Babayev, DPM
Residency Program: New York Presbyterian, Queens – Flushing, NY
Podiatric Relevance: One of the more challenging surgical pathologies which podiatric surgeons are increasingly treating is Charcot neuroarthropathy: a progressive debilitating condition with historically high rates of limb loss. Surgically, the goal of limb salvage is to achieve a plantigrade and ulcer-free, deformity-free foot. Currently, foot and ankle surgeons utilize a combination of internal and external fixation across affected and adjacent joints as super constructs to give the patient’s foot and ankle the most support and prevent further bony breakdown. Intramedullary fixation with a nail is being used for patients who have deformity and breakdown affecting the hindfoot and ankle. This study aims to assess clinical and functional outcomes in Charcot patients who have hindfoot deformity specifically with significant loss of talar height who were treated with retrograde tibio-talo-calcaneal nailing.
Methods: Included in this study were seven patients with Charcot affecting the hindfoot who had different degrees of talar loss. All were classified as Brodsky 3A, Sanders & Frykberg IV, and Eichenholtz III. Patients with infections, history of fracture/surgery, or avascular necrosis of the talus were excluded.
These patients underwent TTC nailing by one surgeon between January 2014 and February 2016. Surgery entailed open preparation of ankle and subtalar joints via anterior or lateral approach, and tricortical autograft from iliac crest or fibula for talar height restoration. Retrograde nail was inserted and back hammered once distally locked to achieve compression. Outcome was measured with the AOFAS (physician assessed) and FADI (patient reported) scores after a follow up of 2 years.
Results: Of the seven patients included, two had total and five had subtotal loss of talus. All seven patients went on to osseous fusion by the two-year follow up. Only one patient had a deep infection, which was treated and the nail subsequently removed. At this point osseous fusion was already complete, so the outcome was satisfactory. Patients’ AOFAS scores improved from 32.2 ± 2.58 to 73.4 ± 3.36 and FADI scores improved from 31.74 ± 1.98 to 65.94 ± 3.68 at 2y follow up.
Conclusions: This described TTC arthrodesis utilizing a retrograde IM nail is a recommended option as a limb salvage fusion technique for patients suffering from severe Charcot neuroarthropathy with hindfoot deformity and talar height loss. This is a strong construct with load sharing ability, resistance of torsional forces, and adequate compression across the fusion site with added stability in patients who have poor bone quality. This is especially important due to the graft utilized for talar height restoration. One hundred (100) percent of patients in this study had osseous union and successful limb salvage. Although Ilizarov external fixation has been used more in this patient population, especially in Charcot patients with ongoing infections and soft tissue compromise, that comes with higher risk of complications such as pin tract infections and patient compliance issues, as well as need for subsequent surgery. Retrograde TTC IM nailing is a comparable, better option in the correct patient, resulting in satisfactory clinical and functional outcomes.