Search Results (29)

This study proposes a methodology for conducting computational simulations of pathological gait. The literature shows a consensus that biomechanical models for gait analysis should be formulated as control problems. To achieve this, it is common practice to guide the solution using kinematic or kinetic data to prevent temporal instability. The aim of this study is to implement a biomechanical model of the Charcot–Marie–Tooth disease in OpenSim software that enables more comprehensive simulations, which may in future involve the musculoskeletal system of patient and predictive studies. In this way, it will be possible to design specific active assistive devices tailored to each patient. Experimental gait data from six Charcot–Marie–Tooth patients were used. The dataset comprises three-dimensional trajectories of reflective markers placed according to the Davis-Heel protocol. The acquired data allowed a patient-specific adjustment of the biomechanical model. The inverse kinematic was solved, and the results were validated by comparing them with those obtained using the commercial BTS Bioengineering^® software. The results show a strong alignment in ankle kinematics between the OpenSim model and the data generated by BTS Bioengineering^®. Additionally, the kinematic results have been compared with normative curves, allowing the identification of potential areas for intervention using active assistive devices aimed at improving movement patterns of patients. Full article

Background: Flap-based and podoplastic limb salvage in the foot and ankle is difficult due to the presence of biomechanical forces that can impact flap healing and complication rates and, in turn, limb salvage rates. For this reason, external fixation is indicated to neutralize forces across the flap interface and allow for optimal flap take and healing. Although external fixation for flap immobilization is the current standard of care, not much is known about how duration and timing may impact complication and salvage rates. Methods: We retrospectively identified and analyzed complication and limb salvage rates in 18 patients who underwent flap-frame immobilization with a multiplanar external fixator during a 4.75-year period. Results: Patients ranged in age from 40 to 75 years (mean, 55.5 years). Sixteen patients (88.9%) had diabetes mellitus, and all had defects that were a mean of 110.9 cm² (range, 36–500 cm²) and required the use of a local or free flap. Thirteen defects (72.2%) were in the plantar region, with the remaining five (27.8%) in nonplantar regions. Eleven flaps (61.1%) were fasciocutaneous, and the remaining seven (38.9%) were vascularized muscle flaps. All of the flaps were immobilized with either a three- or four-ring circular external fixator. Overall, a 66.7% limb salvage rate (12 of 18) was observed with mean follow-up of 2.4 years, or 892.6 days (range, 222–1,555 days). Seven minor flap complications (38.9%) required a return to the operating room. Conclusions: External fixation is an essential tool in flap-based limb salvage. These findings hint that the “Goldilocks zone” of duration is approximately 28 to 35 days. Furthermore, we believe that risk factors such as open amputation, increased defect size, and presence of Charcot’s neuroarthropathy impact limb salvage rates regardless of duration and timing of flap-frame immobilization. Full article

Background: Whether a sequela of neuropathy or a result of infectious processes to dysvascular changes, talar degeneration in the Charcot ankle proves difficult to treat. Total resection followed by bone void filler or grafts is costly, with varying levels of success. Although tibiocalcaneal fusion allows stabilization, this approach remains a procedure of last resort before amputation. This series presents outcomes of partial talectomy with tibiotalocalcaneal arthrodesis. Methods: Nineteen patients with Charcot’s neuroarthropathy necessitating a tibiotalocalcaneal fusion were included in this study. Tibiotalocalcaneal arthrodesis was performed using a partial talectomy with a combination of internal with and without external fixation constructs. Results: Among this cohort of 19 patients followed up for a mean ± SD of 22.0 ± 14.8 months, 21% had osteomyelitis of the talus, and 32% presented with a wound at the time of surgery. Successful primary tibiotalocalcaneal arthrodesis with a partial talectomy was reached in 79% of patients. Of patients necessitating revision, two continued with a tibiotalocalcaneal arthrodesis, and the remaining two reverted to a tibiocalcaneal arthrodesis. No patients experienced a major amputation. Conclusions: Unstable ankle Charcot’s deformity with osseous degeneration poses a serious threat of limb loss without surgical reconstruction. Total talectomy allows complete resection of nonviable bone; however, this irreversible approach removes possibly viable native tissue. Partial talectomy proves an effective option by minimizing osseous resection, allowing primary arthrodesis between autogenous osseous segments. Moreover, in patients with failed partial talectomy, conversion to tibiocalcaneal arthrodesis proved viable. Before total removal of native bone, partial talectomy should be considered. Full article

Background: Minority disparities have been documented in the diabetic community since the late 1990s. Historically, the literature acknowledges that higher rates of diabetes-related complications occur in this subgroup. Despite this, disparities among patients with Charcot’s neuroarthropathy have yet to be explored. We compared incidence and management among patients with Charcot’s neuroarthropathy with emphasis on racial and geographic differences. Methods: We retrospectively reviewed patients from two hospitals, an inner-city tertiary center and a suburban facility, between 2013 and 2022. Patients were managed by the same attending physician as either referrals or initial consultations for a diagnosis of Charcot’s neuroarthropathy of the foot and ankle. Patient selection was performed via International Classification of Diseases, 10th Revision codes associated with Charcot’s joint of the foot. Results: Of 120 patients identified, 87.5% were nonminority white individuals. The minority community had an increased frequency of medical comorbidities. Minorities were two times more likely to undergo a staged reconstruction. Compared with suburban patients, inner-city patients, on average, had higher hemoglobin A1c levels and more ulceration and osteomyelitis. Similarly, this cohort was more apt to undergo reconstructive surgery and had a reduced mortality rate. Conclusions: Although there may be a correlation with medical comorbidities in minority communities, there does not seem to be a difference in the management of Charcot’s neuroarthropathy. Location has the potential to play a role in diagnosis, management, and potential outcomes, likely due to access to health care and community education. More prospective studies are warranted to better understand the influence of racial and geographic differences on management of the Charcot foot. Full article

Surgical reconstruction of the foot and ankle following degenerative changes secondary to Charcot neuroarthropathy poses a challenge due to both soft-tissue and osseous deformity. As a limb salvage procedure, this article aims to address such deformity with the goal of returning to a braceable limb without subsequent ulceration and infection. As this disease process affects both bone and soft tissue, surgical reconstruction should be directed to address osseous and ligamentous deformities that may contribute to postoperative failure. We present an algorithm to eliminate deforming forces, identify and stabilize at-risk and damaged anatomy, and stabilize the ankle joint to reduce the risk of postoperative progression to Charcot collapse of the ankle joint in individuals with midfoot Charcot neuroarthropathy. In conjunction with a multidisciplinary infection, perfusion, and bone metabolism assessment, this algorithm serves as comprehensive tool to evaluate and reconstruct midfoot Charcot collapse. Full article

Background/Objectives: Advanced destruction of the ankle and subtalar joints due to neuropathy, chronic infection, or inflammatory conditions presents a major surgical challenge, often resulting in limb amputation. This descriptive retrospective study aims to evaluate outcomes of reconstructive surgery in patients, in whom limb preservation was prioritized over amputation despite significant soft tissue and osseous involvement. Methods: Between January 2013 and December 2022, 31 reconstructive procedures were performed on 29 patients (16 women and 13 men) with severe hindfoot deformities. Etiologies included Charcot arthropathy (55%), osteomyelitis (25%), combined pathology (10%), and rheumatoid deformity with skin defect (10%). Surgical procedures included tibiotalocalcaneal arthrodesis (39%), astragalectomy with tibiocalcaneal arthrodesis (32%), tibiotalar arthrodesis (23%), and multistage procedures (6%). Fixation methods varied based on the extent of deformity and infection. The union was assessed via radiographs and CT imaging, and outcomes were statistically analyzed using Fisher’s exact test. Results: Successful arthrodesis was achieved in 74% of cases (23/31). The union rate was significantly influenced by the type and level of fixation (p = 0.0199), with the lowest rate observed in tibiotalocalcaneal arthrodesis using external fixation (17%). Complications included surgical site infection or abscess in 42% of cases, requiring reoperation in 35%. Limb amputation was ultimately necessary in five patients (16%). Conclusions: Despite high complication rates, limb-preserving reconstructive surgery remains a viable alternative to amputation in selected high-risk patients with severe hindfoot pathology. Appropriate preoperative planning, tailored surgical strategy, and patient compliance are essential to achieving functional limb salvage and restoring weight-bearing capacity. Full article

Charcot Neuro-Osteoarthropathy (CNO) is a debilitating complication predominantly affecting individuals with diabetes and peripheral neuropathy. Radiological assessment plays a central role in the diagnosis, staging, and management of CNO. While plain radiographs remain the cornerstone of initial imaging, advanced modalities such as Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) have significantly enhanced diagnostic accuracy. Nuclear imaging, including bone scintigraphy, radiolabeled leukocyte scans, and FDG-PET/CT, offers additional diagnostic precision in complex cases, especially when differentiating CNO from infections or evaluating patients with metal implants. This review underscores the importance of a multimodal imaging approach suited to the clinical stage and specific diagnostic challenges of CNO. It highlights the critical need for standardized imaging protocols and integrated diagnostic algorithms that combine radiological, clinical, and laboratory findings. Advances in imaging biomarkers and novel techniques such as diffusion-weighted MRI hold promise for improving early detection and monitoring treatment efficacy. In conclusion, the effective management of CNO in diabetic foot patients requires a multidisciplinary approach that integrates advanced imaging technologies with clinical expertise. Timely and accurate diagnosis not only prevents debilitating complications but also facilitates the development of personalized therapeutic strategies, ultimately improving patient outcomes. Full article

Background/Objectives: International guidelines recommend the use of orthoses in subjects with cerebral palsy (CP), even though there is limited evidence of their effectiveness. Little is known about their effectiveness in children and adolescents with other types of neuromotor disability. Methods: The review protocol was recorded on the PROSPERO register (CRD42024509165) and conformed to the PRISMA guidelines. The inclusion criteria were any type of ankle–foot orthoses (AFOs); pediatric subjects with any non-acquired neuromotor disease; any type of outcome measure regarding gait performance; controlled studies; and those in the English language. Screening, selection, risk of bias assessment, and data extraction were performed by a group of independent researchers. Results: Fifty-seven reports were included, with most regarding CP; three involved subjects with Charcot–Marie–Tooth disease or Duchenne dystrophy. Nine were RCTs. A meta-analysis was performed for studies including subjects with CP. The meta-analysis demonstrated the effectiveness of AFOs in increasing stride length (MD −10.21 [−13.92, −6.51]), ankle dorsiflexion at IC (MD 9.66 [7.05, 12.27]), and peak ankle DF in stance (MD 5.72 [2.34, 9.09]) while reducing cadence (MD 0.13 [0.06, 0.17]) and the energy cost of walking (MD −0.02 [−0.03, −0.00]). The peak ankle power generated at push-off was significantly increased with flexible AFOs compared to rigid AFOs (MD 0.38 [0.30, 0.46]), but it decreased with both compared to walking barefoot or with shoes (MD −0.35 [−0.49, −0.22]). Evidence regarding DMD and CMT was limited but suggested opting for individualized flexible AFOs, which preserved peak ankle power generation. Conclusions: AFOs improve gait performance in CP. Flexible AFOs are preferable because they preserve the peak ankle power generated at push-off compared to rigid AFOs. Full article

Background: Charcot’s neuroarthropathy (CN) is a destructive inflammatory process that affects patients with peripheral neuropathy, most commonly those with uncontrolled diabetes mellitus. The disease progresses through an active hyperemic phase that eventually becomes inactive, and the affected bone consolidates. The period in which the disease progresses from active to inactive is when instability, deformity, dislocation, and ulceration may occur depending on what deforming forces are stressing the affected pathologic area. There is a paucity of literature to support early primary surgical intervention, either single or staged, for active CN. Methods: The purpose of this case series was to retrospectively review 30 reconstructions in 30 patients who underwent primary surgical intervention for active midfoot and ankle CN. All of the 30 patients underwent staged deformity correction with temporary circular ring external fixation followed by definitive internal fixation. Results: Twenty-seven of the staged reconstructions (90%) at final follow-up resulted in limb salvage with no minor amputations after reconstruction. Mean final follow-up was 24.4 months. Nine of the 30 patients (30%) did not remain ulcer-free; however, 50% of the patients had a preexiting ulceration before surgical intervention, and the cohort exhibited a 40% healing rate of ulcers. Conclusions: We achieved a 90% limb salvage rate in patients with active midfoot and ankle CN with a staged surgical intervention protocol. Surgical intervention in the active stage of CN may be beneficial for patients who have gross instability with ulceration, significant midfoot collapse, and frank dislocation. Full article

Background: If unrecognized, Charcot neuro-osteoarthropathy (CNO) can be a devastating complication of diabetes. Methods: The aim of this retrospective study was to evaluate the outcomes in a cohort of diabetic patients diagnosed with active CNO managed in a tertiary level diabetic foot clinic (DFC). We included consecutive patients with active CNO, stage 0–1, according to the Eichenholtz–Shibata classification, who were referred from 1 January 2019 to 27 September 2022. Diagnosis of CNO was based on clinical signs and imaging (X-rays and magnetic resonance). All patients were completely offloaded by a total-contact cast (TCC) or removable knee-high device. Each patient was closely monitored monthly until CNO remission or another outcome. At 12 months of follow-up, the following outcomes were analyzed: remission, time to remission, major amputations (any above the ankle), and surgical indication. Results: Forty-three patients were included. The mean age was 57.6 ± 10.8 years; 65% were males and 88.4% had type 2 diabetes, with a mean duration of 20.6 ± 9.9 years. At baseline, 32.6% was affected by peripheral artery disease. Complete remission was recorded in 40/43 patients (93%), with a mean time to remission of 5.6 ± 1.5 months; major amputation and surgical indication occurred, respectively in 1/43 patients (2.3%) and 3/43 patients (7%). Conclusions: Early treatment of active Stage 0/1 CNO leads to high rates of remission and limb salvage. Full article

The aim of this study was to evaluate the characteristics of gait patterns in Charcot-Marie-Tooth disease type 1A (CMT1A) patients according to disease severity. Twenty-two CMT1A patients were enrolled and classified into two groups, according to the disease severity. The healthy control group consisted of 22 subjects with no gait impairment. Full barefoot three-dimensional gait analysis with temporospatial, kinematic, and kinetic data was performed among the mild and moderate CMT1A group and the control group. Minimal hip abduction, maximal hip extension generation, peak knee flexion moment at stance, ankle dorsiflexion at initial contact, maximal ankle plantarflexion at push-off and maximal ankle rotation moment at stance in the CMT1A group showed a significant difference compared to the control group (p < 0.05). In the moderate group, there were greater maximal hip flexion angles in swing, and smaller dorsiflexion angles at initial contact compared to the control group and mild group. CMT patients had typical gait characteristics and their gait patterns were different according to severity. The analysis of gait patterns in patients with CMT1A will help to understand gait function and provide important information for the treatment of patients with CMT in the future. Full article

(1) Background: Preservation surgery of the diabetic foot aims at tissue sparing to avoid further pathological changes from developing, while ultimately preserving the limb. For this purpose, osteoregenerative, antimicrobial, and osteostimulative materials are now available. The aim of this case series is to demonstrate several clinical situations in which the use of bioactive glass, a third-generation biomaterial, can potentially be of benefit. (2) Methods: In this retrospective case series, we present patients with a diabetic foot complication with septic osteoarthritis, treated at the University Medical Centre Ljubljana, in the years 2020–2022. Patients received surgical care with resection of the affected joint and bone and placement of bioactive glass material. We observed patient characteristics, recurrence of septic osteoarthritis or osteomyelitis, and the need for amputation in the follow-up period. (3) Results: Of the 16 included patients, 8 received treatment of the metatarsophalangeal joints, 4 of the midfoot joints, and 4 of the ankle joints. Ten suffered from Charcot neuroarthropathy. None required readmission within 30 days or suffered early complications. One complication with recidivant septic osteoarthritis and osteomyelitis was observed. (4) Conclusions: Our case series presents possible applications for treatment with bioactive glass in various joints and bones affected by septic osteoarthritis of the diabetic foot. Full article

Lateral column arthrodesis of the tarsometatarsal joints is a highly controversial topic in foot and ankle surgery, with minimal prospective research and reproducible findings in the current literature. Arthrodesis of the lateral fourth and fifth tarsometatarsal joints, when performed, is most often done secondary to post-traumatic osteoarthritis or Charcot’s neuroarthropathy deformity. This case report focuses on arthrodesis of the lateral column in a patient with post-traumatic osteoarthritis from a previously sustained Lisfranc fracture-dislocation. The patient also experienced a cavus foot deformity that was addressed with a lateral displacement calcaneal osteotomy. Arthrodesis of the fourth and fifth tarsometatarsal joints was found to be successful on this patient, with bony union noted to occur radiographically 12 weeks postoperatively. In addition, the patient experienced significant reduction in her preoperative pain and an ability to return to activities of daily living. Regular visits during an 18-month postoperative period occurred, with the patient continuing to have satisfactory results and a significant reduction in preoperative pain levels. One postoperative complication was encountered 15 months postoperatively: painful hardware, which resulted in the removal of both calcaneal screws and one screw from the fourth tarsometatarsal arthrodesis site. This case report proposes that lateral column arthrodesis may be performed successfully in select patients where other joint-preserving procedures may not be applicable. Herein we outline a suggested surgical technique with hardware that can be used to reproduce these findings and assist surgeons who are unfamiliar with performing this procedure. (J Am Podiatr Med Assoc 113(2), 2023) Full article

Bone in diabetes mellitus is characterized by an altered microarchitecture caused by abnormal metabolism of bone cells. Together with diabetic neuropathy, this is associated with serious complications including impaired bone healing culminating in complicated fractures and dislocations, especially in the lower extremities, so-called Charcot neuroarthropathy (CN). The underlying mechanisms are not yet fully understood, and treatment of CN is challenging. Several in vitro and in vivo investigations have suggested positive effects on bone regeneration by modifying biomaterials with sulfated glycosaminoglycans (sGAG). Recent findings described a beneficial effect of sGAG for bone healing in diabetic animal models compared to healthy animals. We therefore aimed at studying the effects of low- and high-sulfated hyaluronan derivatives on osteoclast markers as well as gene expression patterns of osteoclasts and osteoblasts from patients with diabetic CN compared to non-diabetic patients with arthritis at the foot and ankle. Exposure to sulfated hyaluronan (sHA) derivatives reduced the exaggerated calcium phosphate resorption as well as the expression of genes associated with bone resorption in both groups, but more pronounced in patients with CN. Moreover, sHA derivatives reduced the release of pro-inflammatory cytokines in osteoclasts of patients with CN. The effects of sHA on osteoblasts differed only marginally between patients with CN and non-diabetic patients with arthritis. These results suggest balancing effects of sHA on osteoclastic bone resorption parameters in diabetes. Full article