The role of ring external fixation in Charcot foot arthropathy

These two morbidly obese patients with severe Charcot foot arthropathy were treated successfully with percutaneous correction of their deformity followed by a stepwise application of a pre-assembled neutrally aligned multiplane ring external fixator. This technique transfers well to the trauma environment in which alignment can be maintained without further violation within the zone of injury. The application of the fine wire ring external fixation has been used for many years to accomplished leg lengthening and correction of deformity. Historically it has required a great deal of experience to apply to complex frames and implement the required daily adjustments. The patient experience often has been an unpleasant ordeal with a high potential for associated morbidity. This negative exposure has prompted practicing orthopedic surgeons to avoid this technique, feeling that it best be left to those in tertiary care setting who are equipped to handle the morbidity and complications. Taking this technology from the domain of the deformity surgeon to the general orthopedic community will require the suppression of bad memories from residency. Using the device solely as a method of maintaining alignment eliminates many of the dynamic attributes that contributes to pain and morbidity. The bone and soft tissues are not stretched, eliminating much of the pain and decreasing the rate of traction-associated pin tract morbidity. Because there is no dynamic of the treatment, the simplified frame can be pre-assembled and have no adjustable components. The experience derived from this application has the potential of expanding the role of ring external fixation. Where the ring has been used previously as method of both obtaining and maintaining alignment, this application uses a simplified neutral version of a complex device to simply maintain alignment in a high risk patient population. Correction of deformity and achieving alignment/reduction of fractures is well within the domain of practicing orthopedic surgeon. Once that correction has been achieved, this application simply maintains that correction. It helps avoid extensive surgical dissection in a poor host and eliminates the need for bone that is mechanically capable of holding internal fixation devices during the bony and soft tissue healing period.     

Spinal Charcot arthropathy

Charcot joints of the spine are well-documented clinical entities most commonly associated with tabes dorsalis. Spinal neuropathic joints, however, may be produced by other disease processes including syringomyelia. In this review, the authors discuss the cause and treatment of spinal Charcot arthropathy with emphasis on surgical therapy and results.     

External fixation in the management of Charcot neuroarthropathy

Charcot neuroarthropathy is a complex sequela of neuropathies associated with diabetes mellitus, syringomyelia, alcoholism, and other disorders. The treatment of deformities associated with Charcot neuroarthropathy is evolving from a passive approach to one in which an earlier recognition of the emergence of the event permits an avoidance of deformity. As the understanding of the etiology and natural history of Charcot neuroarthropathy deepens, it has become apparent that many of the deformities that do develop may be reconstructed expeditiously by the surgeon with a thorough understanding of the diabetic foot and experience in the use of external fixation.     

夏克氏膝关节病的研究进展

夏克氏关节病是一种临床少见病,可由多种致病因素引起,易发于大关节,尤其是膝关节,造成关节的骨质破坏,严重影响患者生活质量。随着社会的进步,其主要致病因素也由梅毒逐步被糖尿病取代,并呈现增多趋势。本文根据目前对此病的认识,从致病因素、发病机理、诊断和治疗等多方面对此作一系统综述。     

Charcot arthropathy in spina bifida

This multicenter study was undertaken to identify the prevalence of Charcot arthropathy in the spina bifida population; to evaluate the relationship of neurosegmental level, ambulatory level, and distribution of joint involvement; and to assess treatment results and make treatment recommendations. Sixteen patients were identified with Charcot arthropathy based on clinical and radiographic criteria ranging in age from 9 to 42 years. There were 15 ankles, seven knees, and four hips identified with Charcot arthropathy. Six patients underwent surgery and modification of orthoses, eight had a modification of orthoses only, one had no modification, and one was lost to follow-up. Mean follow-up was 4 years and 9 months (with four good, 17 fair, and five poor results). The best results were seen in 13 compliant patients with a brace modification, whereas poor results were seen in three patients with poor brace compliance. Based on our study, we have noted the prevalence of Charcot arthropathy in spina bifida to be one in 100 cases.     

脊柱夏科氏关节病的诊断与治疗

脊柱夏科氏关节病是一种罕见的具有进展性的严重的退行性脊柱疾病。其临床表现隐匿且不典型,容易导致漏诊、误诊,延误病情,影响预后。目前国内尚无系统性分析脊柱夏科氏关节病的文献。脊柱夏科氏关节病的病因主要分为脊髓损伤及非损伤性神经病变两类,其中脊髓损伤引发脊柱夏科氏关节病的危险因素包括长节段固定、脊柱侧凸、椎板切除、脊柱负荷过大的运动和肥胖。脊柱夏科氏关节病好发于下胸椎或腰椎,常见症状是脊柱畸形、坐姿不平衡和局部疼痛。根据潜在疾病引起本体感觉及痛温觉损害,影像学上大量的骨破坏和吸收以及大量新骨形成,组织学提示非特异性慢性炎症,并排除其他炎性和肿瘤性疾病,可以作出诊断。对稳定性好、未合并感染、神经功能平稳、未出现皮肤瘘口、坐姿不平衡或自主神经功能紊乱的脊柱夏科氏关节病患者,可以考虑保守治疗。对症状持续大于6个月、脊柱不稳定、皮肤出现瘘口或并发感染的患者建议优先选择手术。术前应评估髋关节的异位骨化或强直,术中重视病灶内坏死组织、炎症组织的充分清除以及足量的植骨,建议融合至骶骨或骨盆。术后并发症包括内固定失败、新的夏科氏关节形成、伤口愈合困难、感染等。对脊髓损伤合并截瘫的术后患者,建议定期、系统、长期随访,观察整体胸腰椎而非仅仅手术部位的影像。熟知脊柱夏科氏关节病的危险因素及典型症状,有助于早期发现和诊断,并选择适当的治疗方案。     

Charcot arthropathy presenting with primary bone resorption

BackgroundThe clinical presentation of acute Charcot arthropathy in the diabetic population usually follows the Eichenholtz classification. We present three usual cases of Charcot arthropathy presenting with rapid primary bone resorption in the absence of subluxation, dislocation and/or fracture.MethodsA review of the literature was performed. To our knowledge Charcot arthropathy has not been previously described as primary bone resorption.Case reportsThree cases encountered at our specialist multidisciplinary High Risk Foot Clinic (HRFC) presented with primary bony resorption without features of subluxation, dislocation and/or fracture.DiscussionAggressive primary bone resorption was initially thought due to infection; a diagnostic dilemma that delayed optimal treatment. Late bone resorption in typical Charcot is linked to unregulated proinflammatory cytokines (IL-1β, IL-6 and TNFα) that lead to increased osteoclastic activity. The pathophysiology of osteolysis in aggressive primary bony resorption may relate to a disturbance in the balance between RANK-L and OPG.ConclusionPrimary resorption of bone without subluxation, dislocation and/or fracture can represent an active Charcot process. Prudent use of serial radiography and early MRI to look for the widespread bone and soft tissue oedema is recommended.     

Charcot arthropathy of the spine in long-standing paraplegia

Three cases of Charcot spinal arthropathy in long-standing (greater than 20 years) paraplegia are presented. In this group of patients with other known chronic infections, the differential diagnosis strongly favored osteomyelitis. Scanning techniques including technetium 99, indium 111, and computed tomography (CT) were used in the extensive work-up and were helpful, although not diagnostic. Closed needle and, in two cases, open biopsies eventually confirmed the diagnosis. The possible occurrence of this neuroarthropathy long after the onset of nonprogressive paraplegia should be kept in mind by those treating spinal cord injured patients.     

Charcot arthropathy of the first metatarsophalangeal joint.

The authors present an unusual case study of a Charcot joint of the first metatarsophalangeal articulation as well as a successful tibial sesamoidectomy for an associated chronic ulceration. Serial radiographs document the destructive disease process. The authors also address the etiologies of peripheral neuropathy, diagnostic tests to differentiate between Charcot joint and osteomyelitis, and both conservative and surgical management of Charcot joints.     

Surgical stabilization of nonplantigrade Charcot arthropathy of the midfoot

Fifty-one adults (28 men, 23 women) with Charcot arthropathy of the midfoot underwent surgical correction. Mean patient age was 58 years (SD, 9.9 years). All affected feet were nonplantigrade and at high risk for ulcers. Before surgery, mean lateral talar-first metatarsal angle was 27.6 degrees (SD, 12.8 degrees). Corrective osteotomy was performed to achieve plantigrade alignment. At minimum 1-year follow-up, 44 of 51 patients had the desired outcome. Mean lateral talar-first metatarsal angle had decreased to 6.4 degrees (SD, 7.7 degrees). Despite its associated high complication rate, corrective osteotomy can help patients become ulcer- and infection-free and maintain their ability to walk with commercially available therapeutic footwear. A treatment algorithm is presented.     

Treatment of Charcot spinal arthropathy following traumatic paraplegia.

Four cases of Charcot's spinal arthropathy in patients with complete traumatic paraplegia were diagnosed an average of 12 years (range, 4-22 years) postinjury. Each patient had previous posterior spinal fusion with Harrington instrumentation. The Charcot joint occurred just below the fusion near the thoracolumbar junction and well below the level of spinal cord injury. All four patients experienced progressive kyphosis, flexion instability, and loss of height. Each underwent a treatment protocol that included anterior fusion with partial resection of the Charcot joint and staged posterior spinal fusion and stabilization with Cotrel-Dubousset (CD) rods. At follow-up evaluation 18-30 months postoperatively, three of four patients showed complete healing with kyphosis correction. One patient developed loosening of his lower hooks at 6 months postoperatively and required posterior revision with ultimate healing. Resection of the involved segments along with two-stage fusion with segmental instrumentation provides excellent management of this difficult problem.     

Midfoot and hindfoot arthrodeses in diabetic Charcot arthropathy.

OBJECTIVES: To review the clinical outcome of arthrodesis of the foot in patients with diabetic Charcot arthropathy and to review the pathophysiology, clinical and radiographic features of Charcot arthropathy. DESIGN: A retrospective review and clinical follow-up of a series of patients. SETTING: St. Michael's Hospital, Toronto, a tertiary care teaching hospital. PATIENTS: Ten diabetic patients treated between 1996 and 1998 who required an arthrodesis of the midfoot or hindfoot secondary to deformity of diabetic neuropathic joints. INTERVENTIONS: Three midfoot (Lisfranc) and 7 hindfoot arthrodeses with autogenous iliac-crest bone grafting and internal fixation. OUTCOME MEASURES: Patient satisfaction, maintenance of the correction of the deformity and avoidance of amputation. Western Ontario/McMaster University score and midfoot/hindfoot American Orthopaedic Foot and Ankle Society foot ratios. Clinical examination including E-MED pedographic examination. Correction and evidence of bony or fibrous union assessed radiologically. RESULTS: The postoperative correction was maintained, no further skin ulceration occurred and amputation was avoided in 9 of 10 patients. Because this is a salvage procedure and there was often significant concomitant illness, the results of clinical rating systems were poor. Five of 9 patients had clinical and radiographic evidence of a solid bony arthrodesis; 4 had a stable fibrous union. CONCLUSIONS: With careful surgical technique, a reasonable number of feet can be salvaged by an arthrodesis of a diabetic neuropathic joint when nonoperative measures fail. Patient selection is important because there is a significant complication rate.