Charles L. Saltzman

Diabetes mellitus and its related complications are increasing at epidemic rates in the United States. Similarly, Charcot foot and ankle deformities are becoming more prevalent. We did a retrospective review of 115 patients (127 limbs) with diabetes mellitus-associated neuroarthropathy to determine the major clinical outcomes. We hypothesized that an intensive disease-specific protocol would result in low rates of amputations. A single treatment protocol was followed for all subjects treated in a tertiary-based orthopaedic department from 1983-2003. Major outcome variables assessed included rates of below-knee amputation, long-term brace wear, reulceration, reconstructive surgeries, and bilaterality. Survivorship analyses were done during a median followup of 3.8 years. In this cohort, diabetic Charcot arthropathy treated in a structured, intensive, and nonoperative manner was associated with an approximately 2.7% annual rate of amputation, a 23% risk of requiring bracing for more than 18 months, and a 49% risk of recurrent ulceration. Limbs with open ulcers at initial presentation or chronically recurrent ulcers had increased risk for amputation. These results suggest that improved methods of care are needed for patients with diabetes who have Charcot arthropathy. Level of Evidence: Therapeutic study, Level IV (case series-no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

The purpose of our study was to identify the cause of symptomatic ankle arthritis in a consecutive series of patients presenting in a tertiary care setting. Between 1991 and 2004, 639 patients with Kellgren grade 3 or 4 ankle arthritis presented to the University of Iowa Orthopaedic Foot and Ankle Surgery service. The cause of the arthritis was determined based on medical history, physical examination, and imaging studies. To get a sense of the relative prevalence of the etiologies of lower extremity arthritis in our setting, we evaluated the cause of arthritis of all new patients presenting to the University of Iowa Orthopaedic Department from 1999-2004 with arthritis of the ankle, to those with arthritis of the hip or knee during one year. Of the 639 arthritic ankles, 445 (70%) were post-traumatic, 76 (12%) were rheumatoid disease and 46 (7%) were idiopathic (primary osteoarthritis). The post-traumatic ankle arthritis patients were most commonly associated with past rotational ankle fractures. The majority of ankle arthritis is associated with previous trauma, whereas the primary cause of knee or hip arthritis is idiopathic. Unique strategies to prevent or treat post-traumatic ankle arthritis are needed.

Salvage of diffuse ankle osteomyelitis, especially in compromised hosts, is a challenging problem. The purpose of this report was to evaluate early complications and results using a standardized salvage protocol. Eight patients with diffuse ankle osteomyelitis were treated by resection of all infected tiissue and hybrid-frame compression arthrodesis. At presentation, five had open wounds. According to the Cierny/Mader classification, all had diffuse anatomic involvement and six of eight were compromised hosts. Seven had central distal tibial column involvement and one had primarily talar involvement. Surgical technique involved a two-inicision approach, removal of all infected materialand application of a compression circumferential frame with five thin wires across the foot, two across the tibia and two half-pins in the tibia. Fusion of eight ankles and four subtalar joints was attempted. All patients received six weeks of intravenous antibiotics. Open wounds were treated with wound vacuum assisted closure (VACs) devices until closure was achieved. Frames were removed at three months and walking casts were appliedfor one to two more months. Ankle sepsis was eradicated in all patients. Seven of eight ankles fused at an average of 13.5 weeks (range, 10 to 16 weeks). One limb required below-knee amputation (BKA) at five weeks due to nonreconstructible vascular insufficiency. Three of four subtalar joints fused. Fixation problems included two pin-track infections cleared with oral cephalexin and one broken half-pin. Two diabetic Charcot patients required long-term ankle-foot orthosis (AFO) use due to subtalar instability. At average 3.4-year follow-up, none of the seven fused ankles has required further surgery. Use of this standardized salvage treatment protocol for these difficult problems in selected patients was effective with a relatively low associated complication rate.

Ly recommended by physicians. We performed this study to assess the effects of early weight-bearing on the healing rates of plantar ulcers in patients with diabetes who were wearing a total contact cast....

Background: Arthrodesis is the most common surgical treatment for foot and ankle arthritis. In adults, these procedures are associated with a 5% to 10% rate of nonunion. Pulsed electromagnetic field (PEMF) stimulation was approved by the Federal Drug Administration (FDA) for treatment of delayed unions after long-bone fractures and joint arthrodesis. The purpose of this study was to examine the results of PEMF treatment for delayed healing after foot and ankle arthrodesis. Methods: Three hundred and thirty-four foot and ankle arthrodeses were done. Nineteen resulted in delayed unions that were treated with a protocol of immobilization, limited weightbearing, and PEMF stimulation for a median of 7 (range 5 to 27) months. All patients were followed clinically and radiographically. Results: The use of PEMF, immobilization, and limited weightbearing to treat delayed union after foot and ankle arthrodesis was successful in 5 of 19 (26%) patients. Of the other 14 patients with nonunions, nine had revision surgery with autogenous grafting, continued immobilization, and PEMF stimulation. Seven of these eventually healed at a median of 5.5 (range 2 to 26) months and two did not heal. One patient had a below-knee amputation, and four refused further treatment. Conclusions: The protocol of PEMF, immobilization, and limited weightbearing had a relatively low success rate in this group of patients. We no longer use this protocol alone to treat delayed union after foot and ankle arthrodesis.

In the Agility® total ankle replacement system, motion is constrained by the implant’s articulating surfaces and the peri-ankle ligaments. The effects of plausibly occurring implant malpositioning on peri-ankle ligament functional extension during walking were explored in this study. The intent was to determine whether certain ligaments could serve as guides to assist in proper component positioning at implantation. Using a cadaver preparation with simulated physiologic motion and loading, we monitored change of ligament length of the anterior talofibular, posterior talofibular, calcaneofibular, and tibiocalcaneal ligaments resulting from controlled malpositioning of the tibial component relative to a neutral position. During a simulated walking cycle, effects of mediolateral and anterior/posterior translation, internal and external rotation, inversion and eversion, and elevation of the component were evaluated. In all cases, tibial component displacement from the neutral position caused atypical length change in one or more of the peri-ankle ligaments. In particular, anterior/posterior displacement significantly changed the lengthening behavior of all four tested ligaments. The anterior talofibular ligament was sensitive to transverse plane displacements, whereas the tibiocalcaneal ligament was sensitive to coronal plane displacements. For the Agility® prosthesis, these two ligaments seem to be sensitive guides for tibial component positioning at implantation.

Background: We previously reported the intermediate-term results with the early version of the Agility total ankle replacement, a unique design that takes advantage of arthrodesis of the tibiofibular syndesmosis for tibial component support. The purpose of this study was to report longer-term results of this procedure in the treatment of disabling ankle arthritis. Methods: We conducted an independent review of all Agility total ankle replacements performed by a single surgeon between 1984 and 1994. Follow-up evaluation consisted of completion of a validated ankle osteoarthritis scale and a short questionnaire and a review of the radiographs. All radiographs were evaluated for evidence of the development of progressive hindfoot arthritis, nonunion of the tibiofibular syndesmosis, progressive radiolucent lines, osteolysis, and component subsidence. Results: One hundred and thirty-two arthroplasties were performed in 126 patients. After a mean follow-up period of nine years, thirty-three patients (thirty-six implants) had died, fourteen patients (11%) had a revision of the implant or an ankle arthrodesis, and one had the leg amputated because of an unrelated cause. Of the remaining seventy-eight patients (eighty-one ankles), sixty-seven (sixty-nine ankles) were followed clinically. More than 90% of them reported that they had decreased pain and were satisfied with the outcome of the surgery. We found modest differences in a comparison of the pain and disability scores with those of age-matched controls. Of the 117 ankles that had been followed radiographically for a minimum of two years, twenty-two (19%) had progressive subtalar arthritis, seventeen (15%) had progressive talonavicular arthritis, and nine (8%) had a syndesmosis nonunion. Eighty-nine (76%) of the 117 ankles had some evidence of peri-implant radiolucency. Conclusions: Arthrodesis of the tibiofibular syndesmosis impacts the radiographic and clinical outcomes with the Agility total ankle replacement. The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging. Agility total ankle replacement is a viable and durable option for the treatment of ankle arthritis in selected patients. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

We previously reported the intermediate-term results with the early version of the Agility total ankle replacement, a unique design that takes advantage of arthrodesis of the tibiofibular syndesmosis for tibial component support. The purpose of this study was to report longer-term results of this procedure in the treatment of disabling ankle arthritis. We conducted an independent review of all Agility total ankle replacements performed by a single surgeon between 1984 and 1994. Follow-up evaluation consisted of completion of a validated ankle osteoarthritis scale and a short questionnaire and a review of the radiographs. All radiographs were evaluated for evidence of the development of progressive hindfoot arthritis, nonunion of the tibiofibular syndesmosis, progressive radiolucent lines, osteolysis, and component subsidence. One hundred and thirty-two arthroplasties were performed in 126 patients. After a mean follow-up period of nine years, thirty-three patients (thirty-six implants) had died, fourteen patients (11%) had a revision of the implant or an ankle arthrodesis, and one had the leg amputated because of an unrelated cause. Of the remaining seventy-eight patients (eighty-one ankles), sixty-seven (sixty-nine ankles) were followed clinically. More than 90% of them reported that they had decreased pain and were satisfied with the outcome of the surgery. We found modest differences in a comparison of the pain and disability scores with those of age-matched controls. Of the 117 ankles that had been followed radiographically for a minimum of two years, twenty-two (19%) had progressive subtalar arthritis, seventeen (15%) had progressive talonavicular arthritis, and nine (8%) had a syndesmosis nonunion. Eighty-nine (76%) of the 117 ankles had some evidence of peri-implant radiolucency. Arthrodesis of the tibiofibular syndesmosis impacts the radiographic and clinical outcomes with the Agility total ankle replacement. The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging. Agility total ankle replacement is a viable and durable option for the treatment of ankle arthritis in selected patients.

Background: Loss of protective plantar foot sensation is the major cause of diabetic foot ulcerations and ultimate limb loss. Identification of patients without protective sensation can reduce the risk of unrecognized foot injury. The current recommended screening protocol requires 10-g monofilament testing of ten foot sites with use of a forced-choice paradigm. The objective of the present study was to determine whether testing of fewer than ten sites could provide accuracy comparable with that obtained by testing all ten sites. Methods: A cross-sectional comparative study of plantar sensory levels in diabetic subjects with and without plantar ulceration was conducted in a tertiary-care teaching hospital setting. We examined forty-seven diabetic subjects with a history of foot ulceration and forty-five diabetic subjects with no history of foot ulceration. Plantar sensory threshold values at five sites on the sole of each foot were measured with a quasi-continuous range of applied forces, and receiver operating characteristic analysis techniques were applied. Results: Screening on the basis of only the maximum force threshold for the left and right first metatarsal head sites provided comparable or better performance at high levels of sensitivity than did either the mean or the maximum force threshold across all ten sites. A sensory threshold of 4.5 g for both the left and right first metatarsal head sites predicted the risk of ulceration with a sensitivity of 100% and a specificity of 67%. Conclusions: Testing of diabetic patients for protective sensation may be simplified to testing under both first metatarsal heads with a 4.5-g monofilament. If a patient cannot sense the application of a 4.5-g monofilament under either first metatarsal head, he or she probably has lost protective sensation and should be considered to be at risk for undetected injury. Level of Evidence: Diagnostic study, Level II-1 (development of diagnostic criteria on the basis of consecutive patients [with universally applied reference “gold” standard]). See Instructions to Authors for a complete description of levels of evidence.