Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction – Results from a multi-centre study

Abstract

Realignment and fixation with MFB in severe CN result in adequate correction with minimal loss of correction in the observed clinical course. The non-union rate was lower than previously reported. Stable fixation with MFB is a valuable treatment option for CN with minimal loss of correction and high union rates. The use of a minimum of two bolts is recommended to avoid recurrent deformity. Clinical Trials.gov: NCT01770639.

Treading on tricky ground: reconstructive approaches to Charcot neuropathic arthropathy of the foot

“…The Eichenholtz (Table 1) [7], Schon (Table 2) [8], Brosdky (Table 3) [9] classifications are currently used, but those of Sanders and Frykberg (Table 4) [10], Sella and Barrette [11] are also mentioned. The tarsometatarsal joint and midtarsal joints are most commonly involved [29], the talus often collapses due to avascular necrosis or neuropathic fracture resulting in prominent malleoli [12], varus hindfoot, valgus forefoot and the classically described rocker-bottom deformity accompanied by dorsiflexion of the midfoot onto the hindfoot ("bayonet" effect) [13]. Lateral column involvement (calcaneocuboid luxation) is rarer, but associated with a worse prognosis than medial column involvement (peritalar dislocation of the navicular-cuneiform joint) [14][15][16] and as the apex of deformity moves more proximally, the deforming forces increase, stressing the affected area and any fixation construct applied [17].…”

“…Removing a major deforming force also allows improved intraoperatory mobility and plantigrade positioning. Options include: the Hoke triple hemisection or open Z-plasty for Achilles tendon lengthening, gastrocsoleus release (Strayer technique), transection of gastrocnemius aponeurosis and soleus fascia, occasionally a peroneal longus or tibialis posterior tendon lengthening; postoperative concerns are overcorrection, rupture and poor blood supply [12,17,[26][27][28]. Claw and hammer toes require percutaneous flexor (long ± short) tenotomy procedures [29,30] extensor hallucis longus tendon Z-lengthening or metatarsophalangeal arthrodesis in the opportunity of immobile joints [14,17].…”

“…Bone resections are indispensable, either for preparing fusion surfaces (accompanied by subchondral bone plate, cartilage and synovium removal) [12] relaxing the soft tissues [27] eliminating pressure points or osteomyelitis. Aggressive resections termed "internal amputations" [18] are sometimes necessary, but simple ostectomies can be performed even percutaneously (using a Gigli saw [31] or bone shaving [17]); they are never enough to prevent deformity progress [28], but allow subtle adjustments even after final fixation.…”

“…Intramedullary anterograde or retrograde fixation through axial screws or midfoot fusion bolts (MFB) serves to reestablish the medial (talus-navicular-medial cuneiform-1st metatarsal) and lateral (calcaneus-cuboid-4th/ 5th metatarsal base/ head) columns. No stress is placed on the cortical bone, especially with 6.5 to 8.0 mm diameters (larger medially) and yet the devices accept pressure on both the plantar and dorsal surfaces; limited incisions and deperiostation, unexposed hardware in case of soft tissue wounds and easy reduction by the aid of guidewires and cannulated screws (under fluoroscopy; definitive devices are placed last because they impede proper visibility) strongly advise the use of these methods, but at least 2 diverging implants must be used to avoid creating centers of rotation [12,14,36]. Complications include cannulated screw failure (5,6% to 36,4%) and implant migration, avoidable by fully/ longer threaded or hydroxyapatite coated implants.…”

“…The following complications may arise: loss of correction, infection, and amputation, nonunion, implant break or migration, with the need for symptomatic hardware removal, fractures, damage to tendons and joints, swelling and lymphedema, burred bone or bone graft substitute leakage through the incision sites, transfer ulcers developing on adjacent areas because of shifted pressure [12,14,17,29,37]. External fixation constructs might additionally develop pin tract infections (at 4 and 8 weeks, due to a loss of wire tension over time owing to premature or excessive frame loading) [33], pin breakage, tibia fracture after device removal [15].…”