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Dear collegues! Could I remove little (1x0,5 cm)dry plantar ulcer and close wound with sutures during reconstructive surgery of cold Sharcot foot (Shopart arthrodesis) or I have to wait complete ulcer healing?
Dear collegues! Could I remove little (1x0,5 cm)dry plantar ulcer and close wound with sutures during reconstructive surgery of cold Sharcot foot (Shopart arthrodesis) or I have to wait complete ulcer healing?
pahomovigor
You could excise and close the ulcer, but I would avoid doing an arthrodesis until it has healed.
Why not heal the ulcer first in a total contact cast or removable CAM walker, then do the arthrodesis later to lessen risk of infection?
Or how about removal of just the underlying exostosis and excision of the ulcer if the foot is relatively stable, before attempting arthrodesis?
Dear collegues! Could I remove little (1x0,5 cm)dry plantar ulcer and close wound with sutures during reconstructive surgery of cold Sharcot foot (Shopart arthrodesis) or I have to wait complete ulcer healing?
By not waiting for the ulcer to heal completely you probably increase the risk of infection at your operative site. However, if the ulcer is fairly clean and superficial, I am sure many surgeons would go ahead and close the ulcer primarily during the Charcot reconstructive surgery. Surgeon's choice.
__________________
Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
BACKGROUND: Charcot foot arthropathy negatively impacts the health-related quality of life (HRQL) of affected individuals. The disease process often is responsible for the development of significant deformity and disability, often progressing to lower extremity amputation. Many patients are morbidly obese, immunocompromised, and have complex wounds with underlying bony infection or poor bone quality, making operative correction and internal fixation problematic.
METHODS: Using a prospective clinical algorithm, 26 consecutive diabetic adults with multiple diabetic co-morbidities, including morbid obesity, had operative correction of nonplantigrade Charcot midfoot deformity at the midfoot level. Correction was maintained with a neutrally applied three-level ring external fixator. Average body mass index was 38.31 +/- 12.51. Nineteen patients used insulin. Fourteen had open wounds with underlying osteomyelitis. The altered relationship between the forefoot and hindfoot was measured as 14.04 +/- 31.09 degrees in the anteroposterior axis, and 16.70 +/- 17.47 degrees in the lateral axis before surgery. Surgery included Achilles tendon lengthening, excision of infected bone, correction of the multiplanar deformity, and culture-specific parenteral antibiotic therapy.
RESULTS: At a minimum 1-year followup, 24 of 26 patients were ulcer and infection free and able to ambulate with commercially-available depth-inlay shoes and custom accommodative foot orthoses. One patient died of unrelated causes, and one had transtibial amputation for persistent infection. Four developed recurrent plantar ulcers, which resolved with excision of underlying bony prominences. There were two stress fractures through olive wire pin sites, one requiring intramedullary nailing. The radiographic anteroposterior axis was corrected to 3.12 +/- 9.42 degrees, and lateral to 10.42 +/- 11.86 degrees after surgery.
CONCLUSIONS: Morbidly obese diabetic individuals with multiple co-morbidities complicating severe Charcot foot deformity can achieve correction of midfoot deformity after operative correction of the deformity and maintenance of that correction with a neutrally applied ring external fixator.
Between January 2000 and May 2003, 50 consecutive Charcot diabetic salvage procedures were performed on 44 patients (average age 55.1 years). Twenty-four women (26 feet) and 20 men (24 feet) underwent a reconstructive limb salvage procedure for diabetic Charcot neuroarthropathy using a systematic surgical approach involving internal and external fixation. A retrospective analysis of patient satisfaction and clinical outcome was evaluated over a 2- to 5-year postoperative period; 75% of patients completed the SF-36 health survey and a patient satisfaction survey. A reliability analysis found the SF-36 survey to be an adequate health measurement tool in this Charcot neuroarthropathy cohort. Analysis of variance and categorical data analysis showed that the patients improved statistically significantly in response to surgical intervention; however, none of the demographic variables was statistically significantly associated with patient outcomes as measured by the SF-36 and the patient satisfaction survey. Level of Clinical Evidence: 2.
Background: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique.
Methods: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction.
Results: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure.
Conclusions: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.
What "charcot reconstructive" procedure are you planning?
Where is the ulcer relative to the bony pathology?
I would agree with LL and Dr. Kirby that it may be of value to the outcome of your reconstruction to go ahead and heal the ulcer first. The only point I might add is that if the ulcer is caused by, say, a subluxed Calcaneal Cuboid or other area that you are planning on fusing, then it may make more sense to correlate the fusion with a closure of the small ulcer (or just pack it if you are going apply a NWB cast anyway).
Steve
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DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
It depends on variables such as (1) where ulcer is in relation to reconstruction, (2) what type of "reconstruction" is proposed- an arthrodesis, I assume, (3) post-operative plans (immobilization)
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Dr. John G. Fasick II
Clinical Insructor, LSU School of Medicine
Advanced Foot & Ankle Center of East Jefferson footankledoc2@gmail.com
it is much better to leave the ulcer unclosed but after good deridment and removal of all callus areas followed by total contact cast ,, we have much data regarding this work in correcting the charcot's foot.
thank you very much
abdulhakim Al-tamimi
General surgeon, diabetic foot interest
university of Aden , Yemen
Can we predict outcome of surgical reconstruction of Charcot neuroarthropathy by dynamic plantar pressure assessment?-A proof of concept study.
Najafi B, Crews RT, Armstrong DG, Rogers LC, Aminian K, Wrobel J. Gait Posture. 2009 Oct 15. [Epub ahead of print]
Quote:
The joint deformity that arises as a result of Charcot neuroarthropathy, leads to gait modification. Ulceration risk associated with the deformity is generally assessed by measuring plantar pressure magnitude (PPM). However, as PPM is partially dependent on gait speed and treatment interventions may impact speed, the use of PPM to validate treatment is not ideal. This study suggests a novel assessment protocol, which is speed independent and can objectively (1) characterize abnormality in dynamic plantar loading in patients with foot Charcot neuroarthropathy and (2) screen improvement in dynamic plantar loading after foot reconstruction surgery. To examine whether the plantar pressure distribution (PPD) measured using EMED platform, was normal, a customized normal distribution curve was created for each trial. Then the original PPD was fitted to the customized normal distribution curve. This technique yields a regression factor (RF), which represents the similarity of the actual pressure distribution with a normal distribution. RF values may range from negative 1 to positive 1 and as the value increases positively so does the similarity between the actual and normalized pressure distributions. We tested this novel score on the plantar pressure pattern of healthy subjects (N=15), Charcot patients pre-operation (N=4) and a Charcot patient post-foot reconstruction (N=1). In healthy subjects, the RF was 0.46+/-0.1. When subjects increased their gait speed by 29%, PPM was increased by 8% (p<10(-5)), while RF was not changed (p=0.55), suggesting that RF value is independent of gait speed. In preoperative Charcot patients, the RF<0, however, RF increased post-surgery (RF=0.42), indicating a transition to normal plantar distribution after Charcot reconstruction.
INTRODUCTION: Diabetic neuropathic osteoarthropathy (DNOAP) often leads to progressive malpositioning of the foot with subsequent ulcers and a high risk of amputation. There are very few reliable studies on long-term outcome. This study includes the largest follow- up collective ever carried out. METHODS: In a retrospective study 205 surgical procedures (195 patients) for complex malpositioning of the foot and/or chronic ulcers using a fixateur externe (188 cases) or Steinmann pins (17 cases) in patients with NOAP were included. The average follow-up time was 21 months. The goal was walking without pain in customized orthopedic shoes and avoiding amputation. RESULTS: No primary amputations were necessary. Patient activity improved by more than 1 level according to the classification for lower limb amputees following the Hofer activity score. The most common minor complication was persistence or recurrence of ulcers in 48 patients. Only 7 new recurrences of NOAP were observed. In 15 patients secondary amputation was necessary. Approximately 50% of the patients could be mobilized with the help of customized orthopedic shoes 18 months after surgery. CONCLUSION: By using a fixateur externe many amputations could be avoided and patient's activity could be improved. The interdisciplinary teamwork between an orthopedic surgeon, orthopedic shoemaker and orthopedic technician is essential for long term success.
BACKGROUND: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique.
METHODS: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction.
RESULTS: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure.
CONCLUSIONS: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.
The goals of Charcot deformity correction are to restore osseous alignment, regain pedal stability, and prevent ulceration. Traditional reconstructive surgical approaches involve large, open incisions to remove bone and the use of internal fixation to attempt to fuse dislocated joints. Such operations can result in shortening of the foot and/or incomplete deformity correction, fixation failure, incision healing problems, infection, and the longterm use of casts or braces. We recommend a minimally invasive surgical technique for the treatment of Charcot deformity, which we performed on 11 feet in 8 patients. Osseous realignment was achieved through gradual distraction of the joints with external fixation, after which minimally invasive arthrodesis was performed with rigid internal fixation. Feet were operated on at various stages of Charcot deformity: Eichenholtz stage I (1 foot), Eichenholtz stage II (6 feet), and Eichenholtz stage III (4 feet). When comparing the average change in preoperative and postoperative radiographic angles, the transverse plane talar-first metatarsal angle (P = .02), sagittal plane talar-first metatarsal angle (P = .008), and calcaneal pitch angle (P = .001) were all found to be statistically significant. Complications included 3 operative adjustments of external or internal fixation, 4 broken wires or half-pins, 2 broken rings, and 11 pin tract infections. Most notably, no deep infection, no screw failure, and no recurrent ulcerations occurred and no amputations were necessary during an average follow-up of 22 months. Gradual Charcot foot correction with the Taylor spatial frame plus minimally invasive arthrodesis is an effective treatment.
This study explored the concept of "beaming" the medial and lateral longitudinal columns as a variation of the current technique for hindfoot and Lisfranc Charcot reconstruction. We reviewed radiographic changes and outcomes for patients who underwent Charcot foot reconstruction at our facility over the 14-year period from January 1994 to January 2008. Beaming was performed on 71 Charcot foot deformities in 70 patients, 22 (31%) of which displayed an isolated hindfoot deformity, 20 (28%) an isolated Lisfranc deformity, and 29 (41%) with a combination of hindfoot and Lisfranc deformities. The average radiographic follow up was 31.00 ± 22.97 months. Group 1 consisted of reconstructions that involved only medial and lateral column beams and showed significant improvements in radiographic alignment between the preoperative and postoperative measurements, including Meary's angle (P < .001), calcaneal inclination angle (P = .004), tarsometatarsal angle (P = .002), talonavicular angle (P = .035), and the calcaneocuboid angle (P = .006). Group 2, which consisted of reconstructions that involved medial and lateral column beams and either a subtalar arthroereisis (n = 18) or a subtalar joint fusion (n = 10), also showed significant improvements, including Meary's angle (P < .001), tarsometatarsal angle (P < .001), talonavicular angle (P = .002), and the calcaneocuboid angle (P < .001), although calcaneal inclination did not statistically significantly change (P = .054). In both groups, the surgical intervention maintained the correction and was useful for Charcot reconstruction. Complications included pin tract infections, broken pin, osteomyelitis, transfer lesions, and ulcerations.
German-Austrian consensus on operative treatment of Charcot neuroarthropathy: a Perspective by the Charcot task force of the German Association for Foot Surgery
Armin Koller, Ralph Springfeld, Gerald Engels, Raimund Fiedler, Ernst Orthner, Stefan Schrinner, Alexander Sikorski Diabetic Foot & Ankle 2011, 2: 10207
Quote:
Anumber of published guidelines exist on the diabetic foot, yet the sections on Charcot neuroarthropathy (CN) focus mainly on diagnosis and conservative therapy. Surgical aspects, if ever present, are addressed very briefly and are very limited on surgical information and guidelines (1). For this reason, a group of German and Austrian foot surgeons who are well acquainted with the operative treatment of CN established a consensus statement despite a plethora of existing diverging opinions. The following proposal is far from scientific evidence, but may be the basis for an ongoing discussion and further research opportunity.
Long-term Follow-up of Tibiocalcaneal Arthrodesis in Diabetic Patients with Early Chronic Charcot Osteoarthropathy
Carlo M.F. Caravaggi et al Journal of Foot and Ankle Surgery (in press)
Quote:
Charcot osteoarthropathy with severe ankle instability and deformity is often managed with below-the-knee amputation if deformity and cutaneous compromise result in osteomyelitis. Recently, some surgeons have reported satisfactory outcomes with ankle arthrodesis in the coalescence or remodeling (subacute and chronic) stages of the disease before the onset of joint instability, severe deformity, and ulcer formation. This observational study describes the clinical outcomes of ankle arthrodesis in a cohort of 45 diabetic patients who underwent unilateral ankle arthrodesis for Charcot neuroarthropathic ankle deformity before the development of ulceration and bone infection. Two (4.44%) of the patients were lost to follow-up, whereas 2 (4.44%) others underwent below-the-knee amputation shortly after the ankle arthrodesis because of postoperative infection. After a mean follow-up duration of 5 ± 2.85 years, 39 (86.67%) patients returned to independent ambulation wearing custom-made shoes with molded insoles, whereas 2 (4.44%) others required pneumatic casts for ambulation.
A new limb-salvaging technique for the treatment of late stage complicated Charcot foot deformity: Two-staged Boyd's operation.
Altindas M, Kilic A, Ceber M. Foot Ankle Surg. 2012 Sep;18(3):190-4.
Quote:
BACKGROUND:
Depending on the stage of disease, several operative and non-operative treatment options exist for diabetic patients with Charcot foot deformity. In the early stages of the disease, the most effective treatment is total-contact cast application. In patients with multiple bone fractures and deformations, surgical interventions are generally required for the reconstruction of foot architecture. Exostectomy, osteotomy, arthrodesis, and internal-external fixation are some of these operative methods. However, recurrence of ulcer and infection is very likely following these surgical procedures. If the lesion and infection reach to midfoot and hindfoot region, a major amputation is usually required for treatment.
METHODS:
We have been performing Boyd's operation for the last 10 years in diabetic foot patients who had complicated lesions in midfoot and hindfoot regions. Furthermore, since 2004, we have been doing the same operation for complicated Charcot foot deformities. So far, we have treated 11 patients.
RESULTS:
The mean age of the patients was 53.4±10.2 years, and the mean duration of diabetes mellitus (DM) was 17.5±7.2 years. All patients had chronic infections with fractures of the tarsal bones for at least 2 years. Durable wound coverage and ankylosis were achieved in all patients with two-staged Boyd's operation. No recurrence is detected in any of the patients during mean post-operative follow-up period of 2.1±0.8 years.
CONCLUSION:
Boyd's operation is a reliable option for the treatment of patients with late stage Chatcot foot deformity.
Solid Bolt Fixation of the Medial Column in Charcot Midfoot Arthropathy
Martin Wiewiorski, MD, Tetsuro Yasui, MD, PhD, Matthias Miska, MD, Arno Frigg, MD, Victor Valderrabano, Journal of Foot and Ankle Surgery (in press)
Quote:
Charcot medial column and midfoot deformities are associated with rocker bottom foot, recurrent plantar ulceration, and consequent infection. The primary goal of surgical intervention is to realign and stabilize the plantar arch in a shoe-able, plantigrade alignment. Different fixation devices, including screws, plates, and external fixators, can be used to stabilize the Charcot foot; however, each of these methods has substantial disadvantages. To assess the effectiveness of rigid, minimally invasive fixation of the medial column and midfoot, 8 cases of solid intramedullary bolt fixation for symptomatic Charcot neuroarthropathy were reviewed. The patients included 6 males (75%) and 2 females (25%), with a mean age of 63 (range 46 to 80) years. The Charcot foot deformity was caused by diabetic neuropathy in 7 cases (87.5%) and alcoholic neuropathy in 1 (12.5%). The mean duration of postoperative follow-up period was 27 (range 12 to 44) months. The mean radiographic correction of the lateral talar–first metatarsal angle was 15° (range 3° to 19°), and the mean radiographic correction of the dorsal midfoot dislocation was 9 (range −4 to 23) mm. The mean loss of correction of the lateral talar–first metatarsal angle and midfoot dislocation after surgery was 7° (range 0° to 26°) and 1 (range 0 to 7) mm, respectively. No bolt breakage was observed, and no cases of recurrent or residual ulceration occurred during the observation period. Bolt removal was performed in 3 cases (37.5%), 2 (25%) because of axial migration of the bolt into the ankle joint and 1 (12.5%) because of infection. The results of the present review suggest that a solid intramedullary bolt provides reasonable fixation for realignment of the medial column in cases of Charcot neuroarthropathy.
Successful surgical reconstruction of severe hind foot Charcot deformity can be achieved by internal fixation in diabetic patients
MO Ahmed, Y Morar, M Edmonds and V Kavarthapu J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XXXIX 61
Quote:
Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and amputation. The treatment of these patients is controversial. Internal stabilisation and external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective amputation. We report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.
Conservative measures such as total contact casting were tried in 5 patients had predominant varus deformity, 2 with valgus deformity and 2 with unstable ankle joints. 5 patients had developed secondary ulceration.
All patients underwent corrective hind foot fusion with tibio-talo-calcaneal arthrodesis using a retrograde intramedullary nail fixation and screws and bone grafting. One patient also with fixed planovalgus deformity of the foot underwent a corrective midfoot reconstruction.
Patients were followed up in a diabetic/orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5 cases and limb salvage was achieved in all cases.
Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy.
In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration.
The development of a neuropathic ankle following successful correction of non-plantigrade charcot foot deformity.
Pinzur MS. Foot Ankle Int. 2012 Aug;33(8):644-6.
Quote:
BACKGROUND:
The treatment of Charcot foot arthropathy has traditionally involved immobilization during the acute phase followed by longitudinal management with accommodative bracing. In response to the perceived poor outcomes associated with nonoperative accommodative treatment, many experts now advise surgical correction of the deformity, especially when the affected foot is not clinically plantigrade. The significant rate of surgical and medical-associated morbidity accompanying this form of treatment has led surgeons to look for improved methods of surgical stabilization, including the use of the circular ring external fixation.
METHODS:
Over a 7-year period, a single surgeon performed surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a statically applied circular external fixator. Following successful correction, five patients developed a neuropathic deformity of the ipsilateral ankle after removal of the external fixator and subsequent weight bearing total contact cast.
RESULTS:
Three of the five patients progressed to successful healing of the neuropathic (Charcot) ankle arthropathy following treatment with a series of weightbearing total contact casts. Two underwent successful ankle fusion with retrograde locked intramedullary nailing.
DISCUSSION:
This unusual clinical scenario likely represents either a progression of the disease process in the foot or a complication associated with surgical correction of the original neuropathic foot deformity. A better understanding of this observation will likely become apparent as we acquire more experience with this disorder.
Charcot neuroarthropathy is a complicated condition affecting up to 1 in 680 diabetic patients that can rapidly cause severe destruction of the bony architecture in the foot, with resultant gross instability and frank deformity. Conservative care is not always successful at maintaining an intact soft tissue envelope of the foot; therefore, surgical reconstruction is often attempted in an effort to salvage the limb. The goal is to create a stable, plantigrade foot that can be placed in a shoe or simple brace. However, this effort is dramatically more challenging because of the pathologic bone biology, the inelasticity of the connective tissues, and the difficulty in maintaining nonweight-bearing status during the postoperative period. Various forms of internal and external fixation have been described in published studies for use in this setting, all of which have been accompanied by complications such as nonunion, dehiscence, and implant failure. Although the concept of beaming the longitudinal columns of the foot is not new, it has previously been described with the use of cannulated screws. Cannulated screws are inherently weaker than solid-core screws and thus subject to failure at lesser loads. The midfoot fusion bolt offers a technical advantage compared with other forms of fixation in these challenging cases. We present our limited experience with 4 patients who had this device used as a part of the surgical approach and the short-term results. All patients went on to successful union of all fusion sites and were able to return to ambulation in diabetic shoe gear and appropriate bracing.
Reconstructive Charcot surgery
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