Tibiotalocalcaneal Arthrodesis Utilizing a Titanium Intramedullary Nail With an Internal Pseudoelastic Nitinol Compression Element: A Retrospective Case Series of 33 Patients

Nitinol has been shown to generate durable compression under loading via pseudoelastic shape memory. The purpose of this study was to evaluate the effectiveness of a hindfoot arthrodesis nail with an internal pseudoelastic nitinol compression element. Patients who had undergone tibiotalocalcaneal arthrodesis from 2013 to 2016 were identified at 2 tertiary referral centers (12-week follow-up minimum). Patients managed with a tibiotalocalcaneal nail with an internal nitinol compression element were identified for review. Sagittal computed tomographic scan reformats were reviewed to calculate a percentage of joint surface bony union. Intraoperative and postoperative radiographs were compared to calculate postoperative screw position change generated by the nitinol element, a surrogate for postoperative unloading of compressive forces. Thirty-three patients were included in analysis and 81% of patients had successful union of both tibiotalar and subtalar joints. Overall, 90% of all arthrodesis surfaces united. The union rate of arthrodesis surfaces among patients without Charcot osteoarthropathy was 94%. A history of Charcot was identified as a risk factor for subtalar nonunion (p?=?.04) and was associated with less complete computed tomography-based tibiotalar union: 94% versus 71% (p < .01). The posterior-to-anterior screw translated an average of 3.9 mm proximally relative to the rigid portion of the nail from intraoperative to initial postoperative radiographs (p < .0001). High rates of computed tomography-confirmed union were demonstrated in the face of challenging clinical scenarios. Shortening of the pseudoelastic nitinol element occurs early in the postoperative period, indicating continued unloading of the nitinol compression element through the arthrodesis sites after initial implantation.     

Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BackgroundSubtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases.MethodsTwenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments.ResultsThe mean postoperative [TCH] [70.3 ± 1.9 mm] was statistically better than the preoperative value [64.7 ± 2.2 mm] [p < 0.001]. There was a statistically significant decrease in [HVA] [p < 0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p < 0.001].ConclusionsApplying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.     

Charcot Midfoot Reconstruction: Does Subtalar Arthrodesis or Medial Column Fixation Improve Outcomes?

Charcot neuroarthropathy is a complication of neuropathy often secondary to diabetes mellitus and most commonly affects the midfoot. In these patients, reconstruction of the foot may be required for limb salvage. A superconstruct technique has previously been described using intramedullary beaming fixation of the midfoot and hindfoot to span the zone of injury. Inclusion of the subtalar joint in the arthrodesis construct is not consistently performed among different surgeons. The aim of this study was to describe midfoot beaming constructs and postoperative complications after midfoot reconstruction with and without subtalar arthrodesis. We reviewed medical records of patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct. Patients included in the study had at least 3 months of follow-up and had Sanders-Frykberg II/III classification of Charcot neuroarthropathy. Postoperative radiographs were evaluated for evidence of hardware failure at the latest follow-up evaluation. The main variables of interest were: hardware failure or nonunion requiring revision operation, deep infection, and unplanned reoperation. Thirty patients who underwent midfoot reconstruction were included. The mean follow-up was 67.4 ± 25.9 weeks. Twenty-two (73.3%) patients had concomitant subtalar arthrodesis and midfoot beaming. Overall complications were lower in patients with subtalar arthrodesis (40.9%) than those without subtalar arthrodesis (75%) resulting in an odds ratio of 0.271 (0.042-1.338, p = .146). Furthermore, increased number of screws used in the midfoot construct was negatively correlated with complications (r = −0.44, p = .01). An intramedullary midfoot beaming superconstruct with subtalar arthrodesis has previously been proposed to provide better fixation after midfoot beaming Charcot neuroarthropathy reconstruction. Our results suggest including the subtalar joint as part of a superconstruct for the reconstruction of Sanders-Frykberg II/III Charcot results in an 80% lower complication rate than intramedullary beaming alone. We also found an increased number of screws used in the midfoot results in a lower complication rate.     

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

IntroductionThe management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures.PurposeAim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems.Patients and methodsThis was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5 mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial.ResultsMortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12–18 m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p < 0.05). There was significant shorter hospital stay in Group A (5.2 ± 3.1d) than in Group B (8.4 ± 5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9 ± 9.85 and 56.6 ± 9.3 respectively).ConclusionsWe believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.     

Does Preparation of the Subtalar Joint for Primary Union Affect Clinical Outcome in Patients Undergoing Intramedullary Nail for Rheumatoid Arthritis of the Hindfoot and Ankle?

This study aimed to evaluate whether preparation of the subtalar joint affects the clinical outcomes after tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid ankle/hindfoot deformity. Fifty-three joints in 51 patients who underwent tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid arthritis at 2 institutions were included. Ten patients were male and 41 were female, with a mean age at surgery and follow-up period of 61.3 years and 71.6 months, respectively. Radiographic bone union was evaluated at the most recent visit. Univariate and multivariable analyses were performed to determine the risk factors associated with nonunion. The mean postoperative Japanese Society for Surgery of the Foot ankle/hindfoot scale was 65.3 (range, 5–84). The tibiotalar nonunion rate was 0%, whereas the subtalar nonunion rate was 43.3% (23 joints). Revision surgery was performed in 5, all of which were due to painful subtalar nonunion. Absence of subtalar curettage and earlier postoperative weightbearing were significantly associated with subtalar nonunion (p = .0451 and p = .0438, respectively). Subtalar nonunion after tibiotalocalcaneal arthrodesis for rheumatoid hindfoot is associated with higher revision rate. To decrease the risk of subtalar nonunion after tibiotalocalcaneal arthrodesis with an intramedullary nail in rheumatoid patients, curettage for the subtalar joint should be performed, and full weightbearing should be delayed until at least 26 days postoperatively.     

External versus internal fixation for arthrodesis of chronic ankle joint infections — A comparative retrospective study

BackgroundArthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard.We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.MethodsAll patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.ResultsSeventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p = 0.019), achieved full weightbearing significantly more often (p = 0.042) and faster and developed significantly fewer complications (p < 0.001). Forty-three patients showed bone fusion without significant differences between the groups.ConclusionsAnkle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.     

Tibiotalocalcaneal arthrodesis with distal tibial allograft for massive bone deficits in the ankle

BackgroundThe purpose of this study was to assess the outcomes of distal tibial structural allograft to obtain a stable TTC fusion.MethodsRetrospectively, ten patients were carried out with a minimum one year follow-up. The median age was 72 (33–81). The median BMI was 28 (24–33). Indications for TTC arthrodesis included failed total ankle arthroplasty (n = 7 patients), prior nonunion (n = 2 patients), and a trauma injury.ResultsUnion rate was 80%. The median initial height of the distal tibial allograft was 19 mm (14–24 mm). In seven cases the allograft did not lose height. The AOFAS score median was 69 (31–84). SF-12 median physical component was 39 (30–53), and 59 (23–62) for mental component. The VAS median was 2 (0–8).ConclusionsTTC using distal tibial allograft shows a lower rate of collapse than other structural grafts and provides a fusion rate higher or in accordance with the literature.Level of evidenceLevel IV, retrospective case series.     

How many screws are necessary for subtalar fusion? A retrospective study

BackgroundBiomechanical studies have shown a higher compressive force and higher torsional stiffness for fixation with three screws compared to two screws. However, clinical data to compare these fixation techniques is still lacking.MethodsA retrospective analysis of 113 patients was performed, who underwent isolated subtalar fusion between January 2006 and April 2018.ResultsRevision arthrodesis was required in 8% (n = 6/36) for 3-screw-fixation and 38% (n = 35/77) for 2-screw-fixation. For 3-screw-fixation, non-union, was observed in 14% (n = 5/36) compared to 35% (n = 27/77) in 2-screw fixation. Non-union (p = .025) and revision arthrodesis (p = .034) were significantly more frequent in patients with 2 screws. A body mass index ≥30 kg/m² (p = .04, OR = 2.6,95%CI:1.1–6.3), prior ankle-fusion (p = .017,OR = 4.4,95%CI:1.3–14.5) and diabetes mellitus (p = .04,OR = 4.9,95%CI:1.1–17.8) were associated with a higher rate of revision arthrodesis.ConclusionsOur findings suggest that successful subtalar fusion is more reliably achieved with use of three screws. However, future prospective studies will be necessary to further specify this recommendation.     

Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

BackgroundOver the last twenty years, minimally invasive ankle arthrodesis has evolved into a well-tolerated and safe procedure. It has grown in favor to open ankle arthrodesis due to shorter length of stay and fewer complications recorded. This paper aims to compare the clinical outcomes of arthroscopic vs open ankle arthrodesis at 24-months followup.MethodsFrom 2004 to 2015, we reviewed a prospectively collected database in a tertiary hospital foot and ankle registry. 28 feet that underwent arthroscopic ankle arthrodesis were matched to 56 feet that underwent open ankle arthrodesis for age, sex and body mass index (BMI). Visual analogue scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-hindfoot Scores and Short Form Health Survey (SF-36) were obtained to assess clinical outcomes. These parameters were collected before surgery, at 6 months and 24 months after surgery.ResultsThe arthroscopic group demonstrated significant less pain in the perioperative period (arthroscopic: 1.9 ± 1.2, open: 3.8 ± 1.1, p < 0.001) and shorter length of hospitalization stay (arthroscopic: 2.1 ± 0.7 open: 3.5 ± 1.7, p < 0.001). Patients who underwent arthroscopic ankle arthrodesis also reported a higher SF-36 score on physical functioning at 6 months (arthroscopic: 58.4 ± 27.1, open: 47.1 ± 24.0, p < 0.05) and higher AOFAS Ankle-hindfoot Scale score at 24-months (arthroscopic: 78.9 ± 18.9, open: 68.9 ± 24.7, p < 0.05). There were no postoperative complications in the arthroscopic group but 11 in the open group, including 9 which required followup operations. There was no significant difference in length of operative procedure between both groups.ConclusionsWe conclude that the arthroscopic group displayed better clinical outcomes compared to the open group at the 24 months followup. The advantages of arthroscopic ankle arthrodesis include significantly less perioperative pain, higher AOFAS Ankle-hindfoot scores at 24 months, shorter length of stay, fewer postoperative complications and followup operations.Level of evidenceLevel III, retrospective comparative series.     

Tibial torsion correlates with talar morphology

BackgroundThere is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles.MethodsPreoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs.ResultsMeasurements indicated mean external tibial torsion of 29.2 ± 9.1? and TNBA of 35.2 ± 7.5? medial. Tibiotalar tilt ranged from 48? varus to 23.5? valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ = ?0.576, p < .0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ = ?0.239, p = .014) and plantarflexion of the talo-first metatarsal angle (ρ = ?0.218, p < .025).ConclusionWe observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology.Level of evidenceLevel III.     

Modified Lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: A preliminary report

BackgroundTMT-1 arthrodesis is an established method in hallux valgus surgery, but it is technically demanding and typically calls for a period of postoperative immobilization.MethodsIn this cohort study, initial experience with a plantar plate is described. 58 patients (59 arthrodesis) were included.ResultsThe mean duration of protected full weight bearing was 7 weeks. 94.12% patients were satisfied with the results, bony union was achieved in 98.31%. The Foot Function Index improved by 33 to a mean of 8 (p < .001). The postoperative Mayo Clinic Forefoot Score was excellent in 47.04 and good in 47.04%. The mean hallux valgus angle improved by 24.4–13.2° (p < .001). The mean first intermetatarsal angle improved by 11.2–5.2° (p < .001).ConclusionInitial experience with this form of fixation appears to provide suitable stability, allow early-protected weight bearing, with an acceptable level of complications.     

Optimising use of the mini C-arm in foot and ankle surgery

BackgroundThe mini C-arm reduces exposure to ionising radiation compared to the conventional C-arm. Optimising radiation exposure is not only desirable, but also a legal requirement and protocols should be in place to achieve this.MethodsSince 2004, all elective foot surgery requiring intraoperative imaging was performed using the mini C-arm. Screening times and radiation doses were recorded for each procedure.ResultsFollowing a learning curve, the screening times stabilised around the median value for the individual procedures. For subtalar or triple arthrodesis this was less than 60 s, for ankle arthrodesis, less than 90 s, for hindfoot arthrodesis using a nail, less than 100 s and for joint injections less than 12 s.ConclusionScreening time can be used as an audit tool to measure optimum use of the mini C-arm. A protocol is presented including an audit form for every operation where the mini C-arm is used. Radiation protection issues are addressed.     

The relationship of Interleukin-6 -174 G > C gene polymorphism in type 2 diabetic patients with and without diabetic foot ulcers in Turkish population

ObjectiveWe aims investigate Turkish type 2 diabetic patients with/without diabetic foot ulcers and healthy group and examined the contribution of Interleukin (IL)-6 -174 G > C gene polymorphism to the development of diabetic foot ulcers.Design and patientsThe Interleukin (IL)-6 -174 G > C genotypes were determined prospectively in 50 patients with diabetic foot ulcers and 35 without diabetic foot ulcers and a control group of 119 healthy individuals. Genotyping of the Interleukin (IL)-6 -174 G > C gene polymorphisms for all individuals was performed by PCR-RFLP method.ResultsThe genotype IL6 distribution did differ between the control group (CC 13.3%, GC 66.7%, GG 20%) and type 2 diabetic patients (CC 2.4%, GC 47.1%, GG 50.6%) (P < 0.001). The genotype IL6 distribution did not differ between type 2 diabetic patients group (CC 0%, GC 45.7%, GG 54.3%) and diabetic foot ulcers (CC 4%, GC 48%, 48%) (P > 0.05). The frequency of the polymorphic G allele in between the control group and type 2 diabetic patients was no similar for the groups (58.4% and 74.1%, respectively) (p < 0.05). The frequency of the polymorphic G allele in between the type 2 diabetic patients and diabetic foot ulcers was similar for the groups (77.1% and 72%, respectively) (p > 0.05).ConclusionThe gene polymorphism of Interleukin-6 -174 G > C and G allele are an risk factor for diabetes, but gene polymorphism of Interleukin-6 -174 G > C is not an independent risk factor for diabetic foot. Genetic factors in the pathogenesis of diabetic foot may also show any changes in different populations.     

Arthroscopic ankle arthrodesis: Are results reproducible irrespective of pre-operative deformity?

BackgroundArthroscopic ankle arthrodesis is gaining in popularity. It has been shown to have a shorter time to union and less morbidity than traditional open procedures. The arthroscopic technique has been mainly used for ankles with minimal deformity. Our aim was to find out whether we could reproduce the good results of arthroscopic ankle arthrodesis in both minimally and markedly deformed ankles.MethodsWe reviewed 62 patients who underwent an arthroscopic ankle arthrodesis for end stage arthritis. The average follow up was 63 months (range 21–92 months). Patients were evaluated subjectively and objectively using the Mazur grading system. 4 patients died before final review and 3 were lost to follow-up leaving 55 patients for evaluation.The pre-operative tibiotalar angle in the coronal plane was between 26° valgus and 24° varus. We divided our patients into 2 groups based on the tibiotalar angle. Group A (n = 31) had a varus or valgus deformity of less than 15? and Group B (n = 24) had a deformity equal to or more than 15°.ResultsThe overall fusion rate was 91%. Fusion occurred in 29 of 31 (94%) ankles in Group A compared to 21 of 24 (88%) in Group B (p = 0.64).The overall mean time to union was 10.4 weeks. The time to union in Group A was 8.8 weeks compared to 12.7 weeks for Group B (p = 0.001). Using the Mazur ankle grading system, 84% of the cases in Group A had a good to excellent result compared to 79% in Group B (p = 0.73). There were 2 superficial infections, 2 cases of deep vein thrombosis and 3 patients required removal of prominent screws.ConclusionsWe have shown that arthroscopic ankle arthrodesis yields reliable and reproducible results in a District General Hospital setting with high union rates, short time to union and low complication rates. It can be satisfactorily employed for ankles with significant deformity, although this resulted in a longer time to union. The end results remain uniformly good to excellent.     

Surgical site infection in tibial plateau fractures with ipsilateral compartment syndrome

AimThe aim of this study was to investigate the effects of compartment syndrome and timing of fasciotomy wound closure on surgical site infection (SSI) after surgical fixation of tibial plateau fractures. Our primary hypothesis was that SSI rate is increased for fractures with compartment syndrome versus those without, even accounting for confounders associated with infection. Our secondary hypothesis was that infection rates are unrelated to timing of fasciotomy closure or fixation.Materials and methodsWe conducted a retrospective cohort study of operative tibial plateau fractures with ipsilateral compartment syndrome (n = 71) treated with fasciotomy at our level I trauma center from 2003 through 2011. A control group consisted of 602 patients with 625 operatively treated tibial plateau fractures without diagnosis of compartment syndrome. The primary outcome measure was deep SSI after ORIF.ResultsFractures with compartment syndrome had a higher rate of SSI (25% versus 8%, p < 0.001). The difference remained significant in our multivariate model (odds ratio, 7.27; 95% confidence interval, 3.8–13.9). Delay in timing of fasciotomy closure was associated with a 7% increase per day in odds of infection (95% confidence interval, 0.2–13; p < 0.05).ConclusionsTibial plateau fractures with ipsilateral compartment syndrome have a significant increase in rates of SSI compared with those without compartment syndrome (p < 0.001). Delays in fasciotomy wound closure were also associated with increased odds of SSI (p < 0.05).     

Primary stability and stiffness in ankle arthrodes—Crossed screws versus anterior plating

BackgroundAnkle arthrodesis is commonly used for the treatment of osteoarthritis or failed arthroplasty. Screw fixation is the predominant technique to perform ankle arthrodesis. Due to a considerable frequency of failures research suggests the use of an anatomically shaped anterior double plate system as a reliable method for isolated tibiotalar arthrodesis. The purpose of the present biomechanical study was to compare two groups of ankle fusion constructs – three screw fixation and an anterior double plate system – in terms of primary stability and stiffness.MethodsSix matched-pairs human cadaveric lower legs (Thiel fixated) were used in this study. One specimen from each pair was randomly assigned to be stabilized with the anterior double plate system and the other with the three-screw technique. The different arthrodesis methods were tested by dorsiflexing the foot until failure of the system, defined as rotation of the talus relative to the tibia in the sagittal plane. Experiments were performed on a universal materials testing machine. The force required to make arthrodesis fail was documented. For calculation of the stiffness, a linear regression was fitted to the force–displacement curve in the linear portion of the curve and its slope taken as the stiffness.ResultsFor the anatomically shaped double-plate system a mean load of 967 N was needed (range from 570 N to 1400 N) to make arthrodesis fail. The three-screw fixation method resisted a mean load of 190 N (range from 100 N to 280 N) (p = 0.005). In terms of stiffness a mean of 56 N/mm (range from 35 N/mm to 79 N/mm) was achieved for the anatomically shaped double-plate system whereas a mean of 10 N/mm (range from 6 N/mm to 18 N/mm) was achieved for the three-screw fixation method (p = 0.004).ConclusionsOur biomechanical data demonstrates that the anterior double-plate system is significantly superior to the three-screw fixation technique for ankle arthrodesis in terms of primary stability and stiffness.     

Long-term outcome and quality of life in patients with Charcot foot

BackgroundThere is only sparse scientific data about the long-term effects of the Charcot foot on patients’ lives and the clinical outcome. This study evaluates the long-term effects of diabetic Charcot foot.MethodsA cross-sectional follow-up study of consecutive series of patients with Charcot foot referred to the University Hospital Diabetic Foot and Ankle Clinic between 1991 and 2002.ResultsForty-one patients were referred with Charcot foot between 1991 and 2002. After an average follow-up of 8 years their overall mortality rate was 29% (12/41) and 29 patients (30 Charcot feet) have been followed more than 5 years. Sixty-seven percent of Charcot feet suffered at least one episode of ulceration and 50% (15/30) of affected feet had surgical treatment resulting in 29 operations. Simple exostectomy was successful in 62% of cases. The need for surgical management increased markedly 4 years after the diagnosis. Correct diagnosis within 3 months resulted in better functional outcome (AOFAS) and walking distance (p = 0.006 and p = 0.008, respectively). Lower SF-36 component scores in physical functioning, social functioning and general health perceptions were found when the study population was compared to the general population and chronically ill control subjects.ConclusionsDiabetic Charcot foot decreases patient's physical functioning and general health but does not usually affect mental health. Surgical management is often required with an increase 4 years post-diagnosis. A delay of diagnosis of more than 3 months was found to adversely affect the quality of life and functional outcome.     

Foot care practice – The key to prevent diabetic foot ulcers in India

BackgroundThe magnitude of diabetic foot ulcers (DFUs) and the amputation rates due to DFUs remain high even in developing and developed countries. Yet, the influence of knowledge, attitude, and practice (KAP) of diabetic foot care (DFC) on DFU incidence is not studied much.ObjectiveTo study causal relationship between knowledge, attitude and practice (KAP) on DFC between diabetic patients with and without DFUs; and the risk factors associated with DFUs.MethodsA consecutive of 203 diabetic patients (103 with DFU and 100 without DFU) were included in the study. Their demographic details, medical history, and personal habits were recorded. KAP on DFC was assessed using a questionnaire. Responses were recorded, scored, and analyzed.ResultsOf the cohort, 67.5% were males, mean age: 59.9 ± 11.4 years. Patients without DFU had good knowledge on DFC compared to those with DFU (86% versus 69.9%) (p < 0.001). Incidence of DFU was 9% and 39.8% (p < 0.001) among patients who practiced and not practiced DFC respectively. 88% patients with and without DFUs; showed favorable attitude toward adopting DFC. Risk factors – diabetic peripheral neuropathy, peripheral vascular disease, retinopathy, nephropathy, smoking, tobacco chewing and alcohol consumption were significantly (p < 0.001) associated with DFUs.ConclusionsAn inverse relationship between DFU and foot care knowledge as well as practice was observed. Apart from tight glycemic control, diabetic patients must be educated and motivated on proper foot care practice and life style modifications for preventing DFUs.     

Is there a role for low intensity pulsed ultrasound (LIPUS) in delayed or nonunion following arthrodesis in foot and ankle surgery?

BackgroundDelayed union and nonunion following foot and ankle arthrodesis is a disabling complication for patients. There are no clinical studies looking at whether there is a role for use of low-intensity pulsed ultrasound (LIPUS) following this. The aim of this study is to investigate the efficacy of LIPUS in this cohort of patients in our centre.MethodsThis was a retrospective observational study reviewing the use of LIPUS in patients who had arthrodesis of a number of different foot and ankle joints diagnosed with delayed or non-union.ResultsOver a 5 year period, 18 patients (71st MTPJ fusion, 2 subtalar joints, 2 triple fusion, 4 ankle fusions and 3 isolated midfoot joint) with radiologically confirmed delayed union, were treated with a standardised LIPUS therapy. Twelve patients (67%) were treated successfully with full radiological union confirmed. 4 patients required further surgical revision surgery while 2 were treated conservatively. Isolated small foot joints demonstrated a higher incidence of fusion (9/10; 90%) after LIPUS in comparison to larger or multiple joint arthrodesis (3/8; 38%).ConclusionsThere may be a role for the use of LIPUS as a treatment option in delayed union of isolated, small foot joint arthrodesis. However, we would not recommend its use in large or multiple F&A joint arthrodesis. Large multicentre series are required to confirm our findings.     

The treatment strategies of intertrochanteric fractures nonunion: An experience of 23 nonunion patients

BackgroundIntertrochanteric femoral fractures are common, but the nonunion of intertrochanteric fractures is not. The purpose of this study was to divide intertrochanteric fracture nonunion into different types and give corresponding treatment strategies.MethodsWe retrospectively evaluated 23 patients with intertrochanteric fracture nonunion. The patients were divided into five groups and each group was treated with a different strategy. All patients had staged clinical and radiographic follow-ups and the mean follow-up was 16.0 ± 4.6 months.ResultsExcept for the patients treated with total hip arthroplasty, all patients achieved fracture union. The mean union time was 4.7 ± 1.2 months. The Harris hip function score differed significantly from preoperative (28.9 ± 6.8) to postoperative (83.8 ± 6.3; p < 0.05). For the three patients who were classified as type III, the femoral neck shaft angle was corrected to a significant degree, from 97.3 ± 6.4 to 127.3 ± 2.5 (p < 0.05). For the four patients who were classified as type V, the mean time from debridement to re-internal fixation was 3.7 ± 1.5 months.ConclusionsThere are several factors associated with the failure of intertrochanteric fracture treatments. We need to analyze the causes of fracture treatment failure carefully. Based on our five classifications and corresponding treatment strategies, the radiographic and functional treatment outcomes were satisfactory. Future larger comparative studies are needed to confirm our results.