Venu Kavarthapu

Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered.

Reproducibility and Accuracy of Templating Uncemented THA With Digital Radiographic and Digital TraumaCad Templating Software

The reproducibility and accuracy of a digital software templating program on digital images was examined for primary uncemented total hip arthroplasty (THA). Forty-five patients waiting for an uncemented THA had templating performed of their digital picture archiving and communication systems (PACS) pelvic images with the TraumaCad software program (Orthocrat Ltd, Petach-Tikva, Israel). Acetabular cup size, femoral stem size, and femoral offset were noted by 2 observers, and again by 1 of the observers a week later. Through correlation coefficients and significance testing, the degree of intraobserver and interobserver variability was evaluated, as well as the level of accuracy for digital templating. Excellent correlation was found for all data sets, with no significant difference between them in intraobserver reproducibility. Also in terms of interobserver reproducibility, we found good levels of correlation, with no significant difference between the data sets. In terms of accuracy, the correlation was at least acceptable with no significant difference between any of the data sets. The use of the TraumaCad digital software program provides a reliable method of templating digital images for uncemented THAs. There is little intraobserver and interobserver variability, and the method produces an acceptable level of accuracy.

Transformation of the Multidisciplinary Diabetic Foot Clinic Into a Multidisciplinary Diabetic Foot Day Unit Results From a Service Evaluation

The natural history of the diabetic foot is aggressive and complex. To counteract this, we describe the transformation of a Multidisciplinary Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit, which delivers an emergency open access system for patients, with a “one-stop,” same day service in which investigations are performed, results reviewed and treatment implemented. It also provides joint clinics with vascular, orthopaedic, and plastic surgeons and specialized clinics for casting of complex neuropathic feet and for the administration of intravenous or intramuscular antibiotics on the same day. The aim was to document these increasingly wide-ranging facilities by undertaking a retrospective evaluation over a 6-week period, with analysis of notes, investigations, and an anonymous patient satisfaction survey. The clinic was visited by 597 patients who attended in 1076 appointments, of which 112 (10.4%) were emergency visits; these patients attended the clinic without a booked appointment but via an open access policy, 93 of whom were known to the clinic, but 19 were new self-referred patients to the service. Furthermore, 197 (18%) were seen in a Joint Vascular Diabetic Foot Clinic and 98 (9%) were seen in a Joint Orthopaedic Plastic Diabetic Foot Clinic, 570 (53%) were seen in an Active Ulcer Clinic and 97 (9%) in a Total Contact Casting Clinic. Forty-five percent of patients were prescribed antibiotics, including 188 (76%) as oral and 45(18%) as intravenous antibiotics and 15(6%) as intramuscular injections. Of the 1076 appointments, 150 (14%) patients were in the foot clinic for more than 4 hours. Sixty (10%) patients were reviewed 4 or more times over the 6-week period. Only 22 (2%) were admitted to hospital. Of the 125 survey responders, 98% were satisfied with this service, which has evolved from a Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit.

The medial column Synthes Midfoot Fusion Bolt is associated with unacceptable rates of failure in corrective fusion for Charcot deformity: Results from a consecutive case series.

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°). However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot. In its present form, we cannot recommend the routine use of this bolt.

Undiagnosed severe sleep apnoea and diabetic foot ulceration – a case series based hypothesis: a hitherto under emphasized factor in failure to heal

Although great progress has been made in managing diabetic foot disease, it continues to carry significant morbidity and mortality. Obstructive sleep apnoea (OSA) and diabetes frequently coexist and recent studies suggest significant under‐recognition of OSA in those with diabetes. There are no current reports on the direct clinical impact of OSA on acute or chronic diabetic foot ulcer healing.

The impact of body weight on rivaroxaban pharmacokinetics

Essentials The optimal dosing strategy of rivaroxaban for patients at the extremes of body weight is not known. A pharmacokinetic study was conducted based in real‐world patients in a London teaching hospital. In the cohort of patients studied, weight on its own did not impact significantly on rivaroxaban pharmacokinetics. A larger study with patients in the weight categories of interest from the real‐world population is required to further clarify the situation.

The Diabetic Foot Attack: “’Tis Too Late to Retreat!”

The “diabetic foot attack” is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of “time is tissue” and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.

The Medial Column Fusion Bolt Meta-Analysis of Its Medium Term Results

Category: Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) of the foot can cause severe bone and joint destruction. The aim of reconstruction is to correct the deformity and achieve bone fusion, in order to provide a plantigrade foot to ambulate with using accommodative footwear. Column beaming using the Medial Column Fusion Bolt (MCB) is a new technique described to stabilize - medial and/or lateral columns. We performed a meta-analysis to assess the outcome of the use of column beaming in treatment of CN. Methods: We performed a search of the English literature for the following search terms: ‘Charcot’, ‘arthropathy’, ‘column bolt’, ‘superconstruct’, ‘intramedullary’, ‘beaming’, ‘rodding’, ‘midfoot fusion’, ‘midfoot arthrodesis and ‘fusion bolt’. We included all the studies published until 2015. Only 10 studies met the inclusion criteria, and were identified for evaluation. Results: There were a total of 197 feet in 191 patients 47; average age 58.1 years (29-81 years). Diabetes mellitus was the most common cause of CN (81.8%). The average follow-up duration post-operatively was approximately 30 months (range 3-137 months). Several classification systems were used to grade deformity, implants were commonly combined with other fixation based on the location and severity of the deformity, presence or absence of ulcers and surgeon’s preference. All studies reported improvement in correction of deformities both clinically & radiologically with an associated-loss of correction over the follow-up period. Overall, we observed 49.8% of patients experienced a complication, including screw breakage or migration (33), infection (42), wound dehiscence (20) and peri-prosthetic fractures (4). Resulting in revision and lower than expected fusion rates and recurrent ulceration. Conclusion: The MCB provides excellent correction of deformity, with high-failure-rate. This is especially true if a single-rod is used, as it may not provide enough stability to achieve osseous-fusion, due its inability to provide enough compression, reduce shear stress at bone interfaces when used in isolation. Thus additional-implants in neutralising rotational-instability to achieve a stable ‘‘superconstruct’’ may-avoid implant-failure, recurrent-deformity & high-complication-rates. Further assessment & stratification of CN deformity and implant use must be ascertained prior to definitive conclusions being reached regarding the use of the MCB. Whilst there is significant heterogeneity, current evidence suggests surgeons should use this device with caution.

Modern Orthopedic Inpatient Care of the Orthopedic Patient With Diabetic Foot Disease.

In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 admissions (19 emergency, 11 elective) were included. The pathways were coordinated by a multidisciplinary team and comprised initial assessment and investigation and a series of key events, which consisted of emergency and elective surgery together with the introduction, and change of intravenous antibiotics when indicated. Patients had rigorous microbiological assessment, in the form of deep ulcer swabs, operative tissue specimens, joint aspirates, and blood cultures according to their clinical presentation as well as close clinical and biochemical surveillance, which expedited the prompt institution of key events. Outcomes were assessed using amputation rates and patient satisfaction. In the emergency group, there were 5.6 ± 3.0 (mean ± SD) key events per admission, including 4.2 ± 2.1 antibiotic changes. In the elective group, there were 4.8 ± 1.4 key events per inpatient episode, with 3.7 ± 1.3 antibiotic changes. Overall, there were 3 minor amputations, and no major amputations. The podiatric and surgical tissue specimens showed a wide array of Gram-positive, Gram-negative, aerobic and anaerobic isolates and 15% of blood cultures showed bacteremia. When 9 podiatric specimens were compared with 9 contemporaneous surgical samples, there was concordance in 2 out of 9 pairs. We have described the successful modern care of the orthopedic diabetic foot patient, which involves close clinical, microbiological, and biochemical surveillance by the multidisciplinary team directing patients through emergency and elective pathways. This has enabled successful surgical intervention involving debridement, pressure relief, and stabilization, with low rates of amputation.

Transmalleolar Approach for Arthroscopy-Assisted Headless Screw Fixation of an Osteochondral Talar Dome Fracture

Displaced osteochondral fractures of the body of talus quite often require a malleolar osteotomy to gain access to the fracture fragment during internal fixation. We describe a case report in which access to a displaced osteochondral fracture of the lateral talar dome was achieved using an arthroscopy-assisted fibular tunnel approach. This technique resulted in satisfactory fracture healing and a satisfactory clinical outcome.