Difficulty in bone union after arthrodesis to treat Charcot arthropathy of the foot and ankle

Mitsuru Hanada; Kensuke Hotta; Yukihiro Matsuyama

doi:10.1016/j.jor.2024.10.018

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62 (); 13-16

doi:

10.1016/j.jor.2024.10.018

Difficulty in bone union after arthrodesis to treat Charcot arthropathy of the foot and ankle

Mitsuru Hanada , Kensuke Hotta, Yukihiro Matsuyama

Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, 431-3192, Japan

⁎Corresponding author: Mitsuru Hanada. mitsuruhanada@gmail.com

Received: 2024-7-17, Accepted: 2024-10-9, Published: 2024-10-10

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

A major complication of arthrodesis is non-union in patients with Charcot arthropathy. This study examined the bone union in joints affected arthrodesis for Charcot arthropathy of the foot and ankle.

The current retrospective study enrolled 15 patients (20 feet) who underwent arthrodesis (performed in 47 joints) for Charcot arthropathy from 2014 to 2020. Post-operative radiographs were classified based on the Brodsky anatomical classification system at 6 months, 1 year, and 2 years post-operatively. The association with pre-operative and intra-operative data was determined.

Bone union was achieved in 28 % of patients at 6 months, 57 % at 1 year, and 66 % at 2 years post-operatively. The bone union rates according to the Brodsky anatomic classification at 6 months, 1 year, and 2 years were 50 %, 67 %, and 67 % for type 1; 20 %, 44 %, and 56 % for type 2; and 36 %, 86 %, and 86 % for type 3A, respectively. At 1 year after arthrodesis surgery, the odds ratio for non-union in Brodsky type 2 compared to that in type 3A joints was 8.727 (95 % CI: 1.623–46.935, p = 0.006).

Arthrodesis procedures in joints affected by Charcot arthropathy, especially in Brodsky type 2 joints, should ensure perfect bone-to-bone fitting, good adaptation, sufficient bone grafting, and strong fixation.

Keywords

Charcot arthropathy

Foot

Ankle

Diabetes mellitus

Bone union

Brodsky anatomical classification

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1 Introduction

Charcot arthropathy (CA) is caused by sensory impairment primarily resulting from diabetic or drug-induced peripheral neuropathy, and characterized by destructive changes. The development of fractures and/or dislocations following CA changes in the foot and ankle joints predisposes patients to morbidity due to deformity and ulceration, significantly deteriorating their quality of life.¹^,² Although there are various causes of CA, the primary cause, as initially reported by Jordan in 1936, is diabetic neuropathy.³ Furthermore, CA is also caused by repetitive microtrauma and infection and is associated with impaired superficial and deep sensations due to spinal cord disease or the effect of medicines.¹^,² Although the instability of foot and ankle joints, caused by the looseness of joint ligaments and bone destruction, results in severe deformity, most patients experience mild or no pain. Therefore, a lack of knowledge regarding this illness may cause severe infections with intractable callosities and ulcers in the foot. The lower extremity amputation risk is high (7 %) in patients with CA, despite the absence of initial ulcers. If ulcers are present at the initial examination, the risk of amputation increases by 28 %.⁴ The most commonly affected anatomical region due to CA is the midfoot, which accounts for 60 % of the cases, followed by the ankle (30 %) and hindfoot (10 %).^5–7

Primary treatments for CA changes in acute phase are conventionally non-operative and using off-loading techniques like total contact casting, bracing, and the use of orthotic devices.⁸ Surgery is not recommended in the acute phase with inflammation owing to high risks of wound healing problems, failure of bone fixation, and infection.² Surgical treatment may be opted for when non-operative procedures are unable to manage deformity and ulceration.¹^,² Several procedures, such as exostectomy,^9–11 arthrodesis,^12–14 ulcer debridement,¹⁵ and Achilles tendon lengthening,¹⁶^,¹⁷ have often been employed simultaneously to reconstruct plantigrade weight bearing. Arthrodesis is a common procedure performed to stabilize the foot and ankle joints. However, a major complication of arthrodesis is the possibility of non-union after the surgery.

We were interested in the bone union rate after arthrodesis for CA and difference in the CA location site. We hypothesized that the bone union rate would be low and depend on the CA location. Therefore, the current retrospective study aimed to examine the bone union rates after arthrodesis for CA of the foot and ankle.

2 Materials and methods

2.1

2.1 Patients

The study was performed retrospectively and was approved by the ethics committee of our institution. The requirement for informed consent was exempted because of the retrospective design in this study.

Between 2014 and 2020, 15 patients (20 feet), involving six males and nine females (mean age, 60 years; range, 32–77), who underwent arthrodesis for CA of the foot and ankle were included. The patients were diagnosed with CA following history interviews, and physical, radiographic, and computed tomography (CT) examinations. The blood laboratory examinations were performed in all patients preoperatively, and the significant pre-operative comorbidities of CA, which overlapped among patients, were as follows: diabetes mellitus in eight patients, neuromuscular disease in five, spinal cord disease in two, neuropathy due to anticancer medication and trauma-induced neuropathy in one patient each, and an unknown disease in two. None of the patients underwent surgical treatment in any other region other than the CA-affected joints.

In all patients, we recorded pre-operative data, including age, height, weight, body mass index (BMI), comorbidities, blood hemoglobin, and serum albumin, as well as intra-operative data of operative duration and intra-operative blood loss.

2.2

2.2 Arthrodesis procedures and post-operative care

All the surgeries were open procedures. The joint surfaces were curetted and freshened to obtain proper alignment and achieve bone to bone compatibility. No primary autogenous cancellous bone grafting was done. For joint fixation, intramedullary nails or plate systems and screws were used either alone or in combination.

A below-knee cast was applied for 6–8 weeks, with weight bearing prevented for 6 weeks. Subsequently, partial weight bearing with orthosis was permitted for the next 6 weeks, following which patients were allowed full weight bearing. According to the swelling, wound healing assessment, and radiographic evaluation of bone union, the casting duration was modified in each patient. Patients used orthosis until complete bone union was confirmed.

2.3

2.3 Radiographic evaluations

Post-operative radiographic examinations were performed at 6 months, 1 year, and 2 years. The radiographs indicating CA were analyzed and classified by the Brodsky anatomic classification (BAC).¹⁸^,¹⁹ Type 1 classification involved tarsometatarsal and naviculocuneiform joints; type 2, the subtalar, talonavicular, and calcaneocuboid joints; type 3A, the tibiotalar (ankle) joint; and type 3B, calcaneal tuberosity fracture. The bone union after arthrodesis was diagnosed using radiography with anteroposterior, lateral, and oblique views by one surgeon (M.H.). When the radiographic evaluation was unclear, CT examination was performed, and achievement of bone union was defined according to three or more slices of CT images revealing bone continuity.

2.4

2.4 Statistical analysis

The distribution of union rates according to the BAC was calculated using Fisher's exact probability test at 6 months, 1 year, and 2 years after surgeries. The odds ratios for non-union between the BAC joint types were calculated at time points where significant differences were observed.

the patients were divided into two groups based on operated joints that exhibited bone union after 2 years. Patients with bone unions in all joints that underwent arthrodesis were assigned to Group I, and those who had at least one non-union joint after arthrodesis were assigned to Group II. The demographic data and blood laboratory data results of the two groups were compared using a parametric t-test. SPSS version 25 (IBM Corporation, Armonk, NY, USA) was used in all statistical analyses. P-values and 95 % confidence intervals (CIs) were calculated, and the significance level was set at p < 0.05.

3 Results

Arthrodesis was performed in 47 joints, including 14 tibiotalar, 15 talocalcaneal, and 6 talonavicular and calcaneocuboid joints each, along with 3 cuneonavicular and 3 medial tarsometatarsal joints (Table 1). No case had deep infection. However, two cases of implant breakage and one of reoperation were reported. Bone union was observed in 13 joints (27.7 %) at 6 months, 27 (57.4 %) at 1 year, and 31 (66.0 %) at 2 years post-operatively (Table 1).

Table 1 Distribution of the bone union numbers after arthrodesis surgery.

Operated joints	(n)	Number of joints achieving bone union postoperatively
Operated joints	(n)	6 months	1 year	2 years
tibiotalar	14	5	12	12
subtalar	15	1	5	8
talonavicular	6	1	1	1
calcaneocuboid	6	3	5	6
naviculocuneiform	3	1	1	1
tarsometatarsal	3	2	3	3
Total	47	13 (27.7 %)	27 (57.4 %)	31 (66.0 %)

There were significant differences in bone union rates at 1 year after surgery among the BAC types (p = 0.017) (Table 2). The odds ratio with non-union of type 1 relative to type 2 was 0.344 (95 % CI: 0.053–2.215, p = 0.242), and that of type 2 with non-union relative to type 3A was 8.727 (95 % CI: 1.623–46.935, p = 0.006). In the sub-analysis of BAC type 2, the bone union rate was low in the subtalar and talonavicular joints except for those treated using plate fixation (Table 3).

Table 2 Number of joints, according to the Brodsky anatomic classification, achieving bone union.

Brodsky anatomic classification	n	Number of joints achieving bone union
Brodsky anatomic classification	n	6 months	1 year	2 years
Type 1	6	3	4	4
Type 2	27	5	11	15
Type 3A	14	5	12	12
Fisher's exact probability test	(p value)	0.189	0.017∗	0.157

Table 3 Number of BAC type 2 joints achieving bone union according to the implants used for arthrodesis.

Operated BAC type 2 joints	Number of joints achieving bone union at 2 years postoperatively
Operated BAC type 2 joints	Plate	Intramedullary nail	Screw(s)	Staple
subtalar	2/3^a	6/12	2/3^a
talonavicular	1/2		0/2	0/2
calcaneocuboid	6/6
Total	9 (82 %)	6 (50 %)	2 (40 %)	0

a Three joints were treated with both the plate and screws.

The BMI values of patients in Group I were significantly greater than those of patients in Group II (Table 4). No significant difference could be detected in the demographic data and laboratory test results, except for the BMI, between Groups I and II (Table 4). The bone union rate was not associated with joint numbers of arthrodesis surgeries performed simultaneously for one foot.

Table 4 Comparison between the group achieving bone union in all joints undergoing arthrodesis (Group I) and the group having at least one nonunion joint (Group II).

	Group I (n = 9)	Group II (n = 11)	p value
Age (y)	59.9 ± 13.0	61.9 ± 7.8	0.676
Body height (cm)	159.0 ± 6.7	158.0 ± 9.5	0.805
Body weight (kg)	74.0 ± 14.9	61.5 ± 12.2	0.068
BMI (kg/m²)	29.0 ± 3.8	24.7 ± 4.2	0.039^a
Hemoglobin (g/dL)	11.9 ± 2.3	13.1 ± 1.0	0.160
Albumin (g/dL)	4.2 ± 0.46	4.2 ± 0.28	0.657
Operative duration (min)	279.6 ± 50.7	268.9 ± 90.4	0.771
Intraoperative blood loss (mL)	322.5 ± 171.6	213.9 ± 182.3	0.216
Number of joints that simultaneously underwent arthrodesis per foot (n)	2.1 ± 0.4	2.6 ± 1.2	0.358
	(2; 8, 3; 1)	(1; 2, 2; 4, 3; 3, 4; 1, 5; 1)	0.358
Diabetes mellitus (n)	5 (55.6 %)	5 (45.5 %)	0.500

a P < 0.05.

4 Discussion

The critical discovery from this study was that the union rate of arthrodesis performed for CA was worse for BAC-classified type 2 joints compared to types 1 and 3A. The union rate of the talonavicular joint was particularly low. Internal fixation materials, such as screws, plates, or intramedullary nail, have been commonly used for arthrodesis,^20–25 although there are no reports that directly compare these devices. Arthrodesis is a form of treatment that may be performed either alone or in conjunction with another procedure. Recently, external fixator has been used for surgical treatment of CA deformity compared to intramedullary nails.^26–28 However, it is associated with several problems, including pin site and skin infections, pin fracture, phlegmon, and bone fracture. It was recently reported that 80–100 % patients with diabetes experience at least one complication during CA treatment using external fixator.²⁹ Therefore, several reports have described a combination of intramedullary nails and external fixators for CA treatment.³⁰^,³¹ Since there are various surgical options that can be used in conjunction with arthrodesis, it may be necessary to compare them in the future.

Overall, in our study, the union rates after arthrodesis for CA of the foot and ankle were not favorable—27.7 % at 6 months, 57.4 % at 1 year, and only 66.0 % at 2 years after surgery. The tibiotalar joint had an 85.7 % union rate after the first year and remained unchanged after the second. The talocalcaneal joint had a union rate of 33.3 % in the first year and improved up to only 53.3 % in the second year. The talonavicular joint had a 16.7 % union rate even 2 years after surgery. Although bone union may have been achieved for stable joints such as the tibiotalar and talocalcaneal, the union rate may have been low in the talonavicular joint owing to the three-dimensional range of motions it exhibits. Moreover, difficulty in determining the direction of insertion and limitation on the number of screws to be used in the talonavicular joint may also have contributed to the low union rate. Our results also showed that patients with non-union joints had low BMI, which may be because of malnourishment. This emphasizes the need for pre-operative nutritional evaluation.

The current study had a few limitations. First, a relatively small number of patients were included. Further studies including large number of subjects should be conducted in the future to validate our findings. Nevertheless, our report may help surgeons develop a surgical treatment strategy for CA, as there are few available on the operative management of this condition. Second, the differences in outcomes due to surgical devices were not considered. The number and type of devices, such as screws, intramedullary nails, and plates with or without a locking mechanism, may influence the union rate.

5 Conclusions

In the subtalar, talonavicular, and calcaneocuboid joints with worse bone union by CA, surgeons should focus on developing arthrodesis procedures involving techniques to ensure perfect bone-to-bone fitting, good adaptation, sufficient transplantation, and strong fixation. Our results relative to the BAC-classified type 2 joints could be helpful for the randomized controlled trials or prospective cohort studies in the future.

CRediT authorship contribution statement

Mitsuru Hanada: designed the study, performed the experiments, analyzed the data, and wrote the manuscript. Kensuke Hotta: investigated the subjects and confirmed the radiographic measurement. Yukihiro Matsuyama: supervised, the experiments, All authors approved the manuscript.

Conflicts of interests

All authors declare that they have no conflict of interest.

Ethical approval

The study was retrospectively conducted and approved by the Ethics Committee of our institution (No. 23-022). All procedures performed during studies involving human participants were in accordance with the ethical standards of our institution and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The requirement for informed consent was waived due to the retrospective nature of the study.

Declarations of interest

The authors declare that they have no conflict of interest.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

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Introduction

Materials and methods

Patients
Arthrodesis procedures and post-operative care
Radiographic evaluations
Statistical analysis

Results

Discussion

Conclusions

CRediT authorship contribution statement

Informed consent

Conflicts of interests

Ethical approval

Declarations of interest

Funding/sponsorship

Funding/sponsorship

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[1] Dhawan V., Spratt K.F., Pinzur M.S., Baumhauer J., Rudicel S., Saltzman C.L., . Reliability of AOFAS diabetic foot questionnaire in Charcot arthropathy: stability, internal consistency, and measurable difference. Foot Ankle Int. 2005;26:717-731.
[Google Scholar]

[2] Wukich D.K., Sung W., . Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complicat. 2009;23:409-426.
[Google Scholar]

[3] Jordan W.R., . Neuritic manifestations in diabetes mellitus. Arch Intern Med. 1936;57:307-366.
[Google Scholar]

[4] Saltzman C.L., Hagy M.L., Zimmerman B., Estin M., Cooper R., . How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet? Clin Orthop Relat Res. 2005;435:185-190.
[Google Scholar]

[5] Brodsky J.W., . The diabetic foot. 2007:1297.
[Google Scholar]

[6] Sanders L.J., Frykberg R.G., . The Charcot foot (Pied de Charcot) 2007:257-283.
[Google Scholar]

[7] Lowery N.J., Woods J.B., Armstrong D.G., Wukich D.K., . Surgical management of Charcot neuroarthropathy of the foot and ankle: a systematic review. Foot Ankle Int. 2012;33:113-121.
[Google Scholar]

[8] Mueller M.J., Sinacore D.R., Hastings M.K., Lott D.J., Strube M.J., Johnson J.E., . Impact of Achilles tendon lengthening on functional limitations and perceived disability in people with a neuropathic plantar ulcer. Diabetes Care. 2004;27:1559-1564.
[Google Scholar]

[9] Brodsky J.W., Rouse A.M., . Exostectomy for symptomatic bony prominences in diabetic charcot feet. Clin Orthop Relat Res. 1993;296:21-26.
[Google Scholar]

[10] Catanzariti A.R., Mendicino R., Haverstock B., . Ostectomy for diabetic neuroarthropathy involving the midfoot. J Foot Ankle Surg. 2000;39:291-300.
[Google Scholar]

[11] Laurinaviciene R., Kirketerp-Moeller K., Holstein P.E., . Exostectomy for chronic midfoot plantar ulcer in Charcot deformity. J Wound Care. 2008;17:53-58.
[Google Scholar]

[12] Assal M., Stern R., . Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg Am. 2009;91:812-820.
[Google Scholar]

[13] Ayoub M.A., . Ankle fractures in diabetic neuropathic arthropathy: can tibiotalar arthrodesis salvage the limb? J Bone Joint Surg Br. 2008;90:906-914.
[Google Scholar]

[14] Bono J.V., Roger D.J., Jacobs R.L., . Surgical arthrodesis of the neuropathic foot. A salvage procedure. Clin Orthop Relat Res. 1993;296:14-20.
[Google Scholar]

[15] Leventen E.O., . Charcot foot–a technique for treatment of chronic plantar ulcer by saucerization and primary closure. Foot Ankle. 1986;6:295-299.
[Google Scholar]

[16] Holstein P., Lohmann M., Bitsch M., Jørgensen B., . Achilles tendon lengthening, the panacea for plantar forefoot ulceration? Diabetes Metab Res Rev. 2004;20(Suppl 1):S37-S40.
[Google Scholar]

[17] Maluf K.S., Mueller M.J., Strube M.J., Engsberg J.R., Johnson J.E., . Tendon Achilles lengthening for the treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait. J Biomech. 2004;37:897-906.
[Google Scholar]

[18] Bariteau J.T., Tenenbaum S., Rabinovich A., Brodsky J.W., . Charcot arthropathy of the foot and ankle in patients with idiopathic neuropathy. Foot Ankle Int. 2014;35:996-1001.
[Google Scholar]

[19] Brodsky J.W., . The diabetic foot. 1999:895-969.
[Google Scholar]

[20] Chraim M., Krenn S., Alrabai H.M., Trnka H.J., Bock P., . Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot. Bone Joint Lett J. 2018;100-B:190-196.
[Google Scholar]

[21] Ersin M., Demirel M., Chodza M., Bilgili F., Kiliçoglu O.I., . Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy. Acta Orthop. 2020;91:336-340.
[Google Scholar]

[22] Oesman I., Asdi A.R.B., . Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for Charcot osteoneuropathy of the foot: a case series. Int J Surg Case Rep. 2019;57:9-14.
[Google Scholar]

[23] Perez-Aznar A., Gonzalez-Navarro B., Bello-Tejeda L.L., Alonso-Montero C., Lizaur-Utrilla A., Lopez-Prats F.A., . Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a prospective cohort study at a minimum five year follow-up. Int Orthop. 2021;45:2299-2305.
[Google Scholar]

[24] Peterson K.S., Chapman W.D., Hyer C.F., Berlet G.C., . Short-term radiographic results and technique of tibiotalocalcaneal arthrodesis with a posterior anatomic locking plate. J Foot Ankle Surg. 2016;55:906-909.
[Google Scholar]

[25] Siebachmeyer M., Boddu K., Bilal A., et al . Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint Lett J. 2015;97-B:76-82.
[Google Scholar]

[26] ElAlfy B., Ali A.M., Fawzy S.I., . Ilizarov external fixator versus retrograde intramedullary nailing for ankle joint arthrodesis in diabetic charcot neuroarthropathy. J Foot Ankle Surg. 2017;56:309-313.
[Google Scholar]

[27] Ettinger S., Plaass C., Claassen L., Stukenborg-Colsman C., Yao D., Daniilidis K., . Surgical management of Charcot deformity for the foot and ankle-radiologic outcome after internal/external fixation. J Foot Ankle Surg. 2016;55:522-528.
[Google Scholar]

[28] Yammine K., Assi C., . Intramedullary nail versus external fixator for ankle arthrodesis in Charcot neuroarthropathy: a meta-analysis of comparative studies. J Orthop Surg. 2019;27
[Google Scholar]

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Difficulty in bone union after arthrodesis to treat Charcot arthropathy of the foot and ankle

Abstract