Deformity, Foot Clinical Trial
Official title:
Assessment of Surgical Correction of Deformity in Diabetic Charcot Arthropathy of the Foot and Ankle
The surgical techniques described in the literature for surgical management of diabetic charcot arthropathy of the foot and ankle include simple exostectomy, open reduction and internal fixation of neuropathic fractures, external fixation, arthrodesis, Achilles tendon lengthening. Patients are followed up at 1 year postoperative by an x-ray of the foot and ankle anteroposterior , lateral and oblique views to assess rate of union ,the correction of deformity by measuring the foot angles . The functional outcome is assessed by the AOFAS scoring system and the diabetic foot ulcer scaoeuulcer scale(18).
Diabetes mellitus affected approximately 422 million people worldwide in 2016 . Diabetic
complications including diabetic peripheral neuropathy and peripheral arterial disease remain
prevalent in the USA and worldwide and challenging to treat. Due to loss of protective
sensation and impaired vascular supply, these can lead to serious foot complications
including deformity, diabetic foot ulceration, Charcot neuroarthropathy and infection .
Charcot neuroarthropathy is a devastating orthopedic condition that afflicts patients with
diabetes. It is an inflammatory condition that affects the foot and ankle with varying
degrees of bone destruction and deformity. The true incidence or prevalence of this condition
is not known.
However, estimates demonstrate incidence to be between 0.1 and 0.9%
. Two principal pathways for the disease have been proposed. The neurotraumatic theory
suggests that the loss of neuroprotection causes repetitive microtrauma. The opposing
hypothesis, the neurovascular, is that sympathetic neuropathy results in hyperaemia. This
leads to increased osteoclastic activity resulting in bone resorption and fragmentation.
The active form of charcot foot arthropahy is often misdiagnosed as tenosynovitis,
cellulitis, or gout. The majority of these patients endure a short period of disability that
is treated by some form of immobilization for a variable period of time with minimal
resultant long-term disability. The diagnosis is not often clear until resolution of the
swelling when a resultant residual deformity is appreciated.
Eichenholtz classification is used to define Charcot foot clinical stages. Brodsky the
classification, in the other hand, allows us to locate the lesion anatomically.
The incidence of diabetic neuroarthropathy varies among the anatomical regions of the foot
and ankle according to Brodsky classification. Approximately 70% of cases affect the
tarsometatarsal joint (type 1). Type-1 disease is the least likely to require surgical
stabilization, although the most common type to cause plantar ulceration. Type-2 disease
involves the midtarsal and subtalar joints and accounts for approximately 20% of cases.
Type-3 disease affects approximately 10% of patients, and occurs mainly in the ankle. Type 2
and type 3 are the most likely to progress to instability and often require long-term bracing
or surgical reconstruction.
The surgical techniques described in the literature include simple exostectomy, open
reduction and internal fixation of neuropathic fractures, external fixation, arthrodesis,
Achilles tendon lengthening and, eventually, amputation.The goal of Charcot neuroarthropathy
treatment, both orthopedic and surgical is to obtain an ulcer free, stable plantigrade foot,
without osteomyelitis and able to ambulate. Achieving these goals notably reduces the rate of
amputations.
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