A 2-Stage Approach in Managing Diabetic Forefoot Ulcers.

BACKGROUND: Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer. METHODS: A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations. RESULTS: Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion. CONCLUSION: TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Managing Cavovarus Feet in Diabetic Patients.

A cavovarus foot is characterized by exacerbated medial longitudinal arch (cavus), hindfoot varus, plantar flexed first ray, forefoot pronation (apparent supination), forefoot adduction, and claw toe deformities. It can be broadly divided as flexible and rigid and further classified based on the neurological and non-neurological causes. Diabetes associated peripheral neuropathy complicates individual bony deformities associated with cavovarus foot with early callus which can breakdown to ulceration rapidly. Based on the disease progression in neurological and non-neurological causes of cavovarus feet in patients with diabetic neuropathy, 3 stages of the disease and its management is described.

Outcomes of Tendo-Achilles lengthening and weight-bearing total contact cast for management of early midfoot charcot neuroarthropathy.

AIM OF STUDY: To report outcomes of tendo-Achilles lengthening (TAL) followed by weight-bearing total contact cast (TCC) in the out-patient setting for patients presented with midfoot Charcot neuroarthropathy (CN) and, develop a new classification system for midfoot CN based on this experience. PATIENT AND METHODS: Published evidence suggests that tight Achilles-gastrocnemius-soleus complex is the deforming force in the initiation and progression of midfoot CN and TAL has shown to improve the range of ankle dorsiflexion and reduction of midfoot plantar pressures. We utilised this technique in the out-patient setting followed by weight-bearing TCC for all new patients who presented with a diagnosis of midfoot CN from February 2018.We report their outcomes after a 12 months follow-up and propose a new classification system based on the clinical and radiographic parameters. RESULTS: TAL followed by weight-bearing TCC was performed in 33 feet. In 30 feet, the disease progression either stopped or receded to a lower stage on the new classification system. The procedure was well tolerated by patients in an out-patient setting and there were no reported complications such as wound healing, complete transaction of tendon or deep vein thrombosis. At 12 months follow-up, 30 of 33 pts returned to their pre-procedure level of mobilisation with their usual walking aids or customised shoes. The inter-observer agreement was k = 0.86 for read 1 and k = 0.96 for read 2; and intra-observer agreement ranged from 0.93 to 1.00 for the double read indicating excellent inter-observer and intra-observer agreement. CONCLUSION: TAL followed by weight-bearing TCC is a safe and well tolerated procedure when performed in an out-patient setting. The Charcot disease of the midfoot slowed in the early stages of midfoot CN and in some cases, receded. The new classification system is easy to use, reliable, reproducible and sensitive enough to detect changes in the disease progression.

Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis.

BACKGROUND: Avascular necrosis (AVN) of the femoral head is an irreversible complication seen in the treatment of developmental dysplasia of hip (DDH) with the Pavlik harness. Its incidence is reported to be low after successful reduction of the hip but high if the hip is not concentrically relocated. We aim to investigate its incidence after failed Pavlik harness treatment. METHODS: We prospectively followed up a group of children who failed Pavlik harness treatment for DDH treated at our institution by the senior author between 1988 and 2001 and compared their rates of AVN with a group of children who presented late and hence were treated surgically. AVN was graded as described by Kalamchi and MacEwen and only grade 2 to 4 AVN was considered significant and included in the analysis. RESULTS: Thirty-seven hips were included in the failed Pavlik group (group 1) and 86 hips in the no Pavlik group (group 2). Ten hips in group 1 developed AVN (27%), whereas only 7 hips in group 2 (8%) developed AVN; the odds of developing AVN after failed Pavlik treatment was 4.7 (95% confidence interval, 1.3-14.1) (P=0.009) with a relative risk of 3.32 (range, 1.37 to 8.05). CONCLUSIONS: There was no statistically significant association observed with duration of splintage and severity of AVN (Spearman's correlation, -0.46; P=0.18). However, there was a positive correlation noted with age at presentation and severity of AVN. Therefore, we advise close monitoring of hips in the Pavlik harness and discontinue its use if the hips are not reduced within 3 weeks. LEVEL OF EVIDENCE: Level III.