Enzo J. Sella

Staging of charcot neuroarthropathy along the medial column of the foot in the diabetic patient

Diabetes mellitus is the leading cause of Charcot neuroarthropathy. The most common location is along the medial column of the foot. Over a 2-year period, the process can result in a severely deformed foot, which is highly prone to ulcers, infection, and subsequent amputation. To help identify the early stages of the disease process, the histories, physical examinations, and radiographs of 40 patients with 51 neuropathic feet were evaluated. We were able to identify five stages of Charcot deformities. Stage 0 is a clinical stage in which the patient presents with a locally swollen, warm, and often painful foot. Radiographs are negative and technetium 99 bone scan is markedly positive. Indium and gallium scans are normal. Stage 1, in addition to the clinical findings, demonstrates periarticular cysts, erosions, localized osteopenia, and sometimes diastases. Stage 2 is marked by joint subluxations, usually starting between the second cuneiform and the base of the second metatarsal and spreading laterally. Stage 3 is identified by joint dislocation and arch collapse. Stage 4 is the healed and stable end result of the process. Clinically, there is no temperature gradient between the two feet. Radiographically, there is bony trabeculation across joint spaces indicative of mature fusion. Treatment of stage 0 consists of limited weightbearing and close observation while the diagnosis becomes clear. Stage 1 is treated with casting followed by a University of California Biomechanics Lab orthosis (UCBL), to maintain the arch while allowing limited weightbearing. In stage 2, a partial weightbearing total contact cast followed by a Charcot restraint orthotic walker (CROW) is used. Surgery may be needed at this stage, while the joints are still reducible. Arthrodesis with rigid fixation is recommended. Stage 3 is treated with casting for the acute phase, then with a patellar-tendon-bearing ankle-foot orthosis, CROW, or caliper orthosis. If ulcers are present, they are treated with weekly local debridement, antibiotics, and total contact casting. Occasionally decompressive ostectomy is required. Stage 4 may need surgical removal of the bony prominences causing the nonhealing ulcers. Extra-depth shoes and pressure-relieving orthoses are also used. Twenty-five percent of our patients diagnosed and treated in the early stages (stages 0, 1 and 2) did not develop deformity. Surgery to prevent deformity is recommended early, before the destructive stage (stage 3). Close follow-up, especially in a noncompliant population is necessary.

Endoscopic decompression of the retrocalcaneal space

BACKGROUND Pain in the retrocalcaneal space can be incapacitating. Patients who do not respond to nonoperative treatment may seek a surgical solution. The first purpose of this paper was to describe and evaluate the efficacy of a minimally invasive procedure to address retrocalcaneal pain caused by retrocalcaneal bursitis, a Haglund spur, and impingement. The second purpose was to compare the endoscopic technique with a standard open technique. METHODS Our prospective study included thirty-three heels in thirty consecutive patients with chronic pain in the retrocalcaneal space for which nonoperative treatment had failed and endoscopic decompression was performed. The mean age was forty-nine years (range, nineteen to seventy-nine years). This group was compared with a group of seventeen heels in fourteen patients with the same diagnostic criteria who were treated with an open technique. Both groups of patients were evaluated preoperatively and postoperatively with the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale, and the patients treated with the endoscopic procedure were also evaluated postoperatively with the University of Maryland 100-point Painful Foot Center Scoring System. RESULTS In the endoscopic group, the AOFAS scores averaged 61.8 points preoperatively and 87.5 points postoperatively (p < 0.001). The endoscopic procedures yielded nineteen excellent, five good, three fair, and three poor results at an average of twenty-two months postoperatively. (Three patients were excluded from the study.) In the open-treatment group, the AOFAS scores averaged 58.1 points preoperatively and 79.3 points at an average of forty-two months postoperatively (p = 0.006). The scores after the endoscopic procedures were numerically, but not significantly (p = 0.115), better than those after the open procedures. The time to recovery was the same in the two groups. The endoscopic procedures were performed more quickly than the open procedures (forty-four compared with fifty-six minutes) and were associated with fewer complications (a 3% compared with a 12% rate of infection, a 10% compared with an 18% rate of altered sensation, and a 7% compared with an 18% rate of scar tenderness). CONCLUSIONS Endoscopic decompression is a feasible and efficient procedure for the treatment of retrocalcaneal disorders. It produces final results equal to or better than those of an open technique, with a similar recovery time, fewer complications, and a better cosmetic appearance.

Standardizing Methods of Measurement of Foot Shape by Including the Effects of Subtalar Rotation

At the present time, there is no easily performed method of measuring foot shape that can quantitatively differentiate types of feet. We studied 44 feet of individuals with normal appearing asymptomatic feet and flat symptomatic feet to find criteria for measurement of foot shape. We found that measurements of footprints are unreliable. Radiographic methods must include measurements in different positions, or at least specify the position of subtalar rotation to be meaningful, since the height of the arch can change just by rotating the tibia. Traditional measurements of talocalcaneal angles have no precision and are unreproducible.

Haglund's syndrome.

Haglunds syndrome is a painful condition of the heel caused by mechanically induced inflammation of the retrocalcaneal bursa, supracalcaneal bursa, and Achilles tendon. Surgical management has included calcaneal osteotomy, but results have been unpredictable because of the inability to measure accurately bone removal. A method was devised in this study to accurately determine radiographically the amount of bone removal necessary. Sixteen heels in 13 patients underwent surgery after failing 21 months of conservative treatment. The desired osteotomy angle (preop x-rays) was compared to the actual angle obtained at surgery. A patient questionnaire, developed by the Outcome Study Committee of the AOFAS, was used to assess results. There were 13 good results and 3 failures. The average actual angle of the good results was 49 degrees and that of the poor results was 61 degrees. These results were statistically significant to a p = .0012. The average score obtained by the good results was 87 points, while that of the failures was 25 points. Follow-up was 42 months. The authors recommend that the osteotomy be made in such a way as to remove not only the superolateral deformity, but also to decompress the retrocalcaneal bursa and to remove the calcaneal step. In order to do so, an osteotomy angle of 49 degrees should be achieved.

The painful accessory navicular

The accessory navicular is usually considered a normal anatomic and roentgenographic variant. The term may refer to two distinct patterns. First, a sesamoid bone may be present within the posterior tibial tendon (Type 1); this is anatomically separate from the navicular. Second, an accessory ossification center may be medial to the navicular (Type 2). During postnatal development this is within a cartilaginous mass that is continuous with the cartilage of the navicular. At skeletal maturity the accessory center usually fuses with the navicular to form a curvilinear bone The Type 2 pattern may be associated with a painful foot, particularly in the athletic adolescent, and should not be arbitrarily dismissed as a roentgenologic variant in the symptomatic patient.The clinical, radiologic, pathologic, and surgical findings in ten cases are reviewed. Roentgenographically the ossicle is triangular or heartshaped. 99mTc MDP imaging may be of value when the significance of the ossicle is uncertain. Even when the roentgenographic variant is bilateral, increased radionuclide activity occurs only on the symptomatic side. Histologic examination of surgically excised specimens reveals inflammatory chondro-osseous changes in the navicular-accessory nacicular synchondrosis compatible with chronic trauma and stress fracture. Nonsurgical treatment with orthotics or cast immobilization produces variable results and resection of the accessory navicular may be the treatment of choice.

Imaging modalities of the diabetic foot

Charcot osteoarthropathy is a devastating process that occurs in the diabetic foot. It must be distinguished from other conditions, such as osteomyelitis, with efficiency and accuracy. The prognosis and treatment depends on it. Charcot progresses along four radiographically identifiable stages; therefore, plain films should be the first step in the evaluation. When osteomyelitis is suspected, a three-phase bone scan may allow clear enough anatomic detail to diagnosis bony involvement compared with soft tissue in the forefoot. In the midfoot, a three-phase bone scan alone is not specific enough to distinguish between Charcot and osteomyelitis. Enhancing the bone scans by adding an additional phase (four-phase) or tracer (gallium) does not appear to improve specificity significantly. Computerized bone flow studies may be more helpful in making the distinction, particularly in acute presentation. A CT scan is not indicated because the MR image will better define the anatomic extent of the process for preoperative planning. The combined WBC scans and sulfur colloid marrow scans show improved specificity and can distinguish between Charcot and osteomyelitis. Combined leukocyte scan with bone marrow imaging is superior to leukocyte and bone scan alone or in combination for detecting infection in the neuropathic foot. The combined leukocyte scan and bone marrow imaging is the current gold standard for evaluating the presence of diabetic foot infection versus osteoarthropathy, and MR imagine is the anatomic gold standard that may be used to define the extent of the process.

Biomechanics of the Accessory Navicular Synchondrosis

The accessory navicular is commonly considered an asymptomatic variant, but when traumatized, it can become the source of clinical symptoms. The accessory naviculars were divided into Types I, IIa and b, and III based on their appearance and location with relationship to their parent navicular. Only Type IIa and b accessory naviculars have a synchondrosis. The synchondrosis of Type IIa and b can undergo tension, shear, and compression forces causing avulsion or a painful pseudarthrosis to develop.

Arthropathy Secondary to Transfusion Hemochromatosis

Hemochromatosis (bronze diabetes, pigment cirrhosis) is a multisystem disease produced by the accumulation of iron in tissues in large amounts. It may be idio pathic or acquired, but the deleterious changes produced by the iron are the same regardless of etiology. Finch and Finch stated that there are no distinctive features that separate idiopathic hemochromatosis from the terminal stages of other iron storagediseases. Idiopathic hemochromatosis is thought to be an inborn error of metabolism, probably a deficiency of hepatic xanthine oxidase 12 Exogenous hemochromatosis is produced when the absorption of iron is increased chronically, as in alcoholism where there is excessive intake of beverages with a high iron content (wine), or where the intake of medicinal iron is occasioned by treatment of refractory anemias or where multiple blood transfusionsare given. One of the features of idiopathic hemochromatosis is the development of a specific migratory polyarthritis which has been described repeatedly @ @†̃¿ 10,14,16, but a similar polyarthritis which occurs in acquired hemochromatosis has not received adequate recognition. With the exception of one paper “¿ containing data on four autopsy cases, the subject of hemochromatosis has not been discussed in the ortho paedic literature since I 95 1. The occurrence of arthritis in hemochromatosis was then thought to be totally fortuitous. Collins stated that the collection of iron pig ment in synovial tissue led to no significant pathological abnormality. The bulk of the published literature strongly favors the opposite conclusion @ @†̃¿ 10,14,16,19 The purpose of this paper is to re-emphasize the musculoskeletal complications of hemo chromatosis.

Current Concepts Review: Diagnostic Imaging of the Diabetic Foot

The costs associated with the care of the neuropathic, infectious, and vascular conditions that affect the diabetic foot are substantial. The total expenditure for the care of diabetic patients in 2002 was

An Office-based Orthotic System in Treatment of the Arthritic Foot

132 billion dollars and this figure continues to increase annually.2 Diabetic foot conditions cause more hospital admissions than any other aspect of the disease and have been reported to result in a mean inpatient stay of 6 weeks.19,20,29 With approximately 20% of diabetic patients developing a foot ulcer and 6% requiring an amputation, the ability to make an early diagnosis in diabetic patients is critical. It is essential, therefore, to make a prompt and accurate diagnosis. In addition to differentiating soft-tissue infection from osteomyelitis, one must distinguish infection from Charcot osteoarthropathy. Both Charcot ostearthropathy and acute infection may present with warmth, swelling, and erythema. The clinical appearance of feet affected by these two processes is similar and may even be indistinguishable. Under these circumstances, the ability to select the imaging study most helpful to discriminate between Charcot osteoarthropathy and osteomyelitis is paramount. This article will review the numerous imaging studies available to diagnose neuropathic and infectious conditions affecting the diabetic foot. The use of radiographs, scintigraphy, computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography scan (PET) will be discussed using an evidence-based approach.