Tibiocalcaneal arthrodesis with retrograde intramedullary nailing has gained acceptance as a salvage procedure for a multitude of ankle and hindfoot disorders and is frequently used in Charcot arthropathy of the ankle. Because of the severe osteopenia often associated with Charcot arthropathy of the ankle, an area of stress concentration leading to stress fracture at the proximal aspect of the nail has been identified.
To determine if this potential complication can be avoided, nine consecutive diabetic individuals with Charcot arthropathy of the ankle had ankle arthrodesis with a longer retrograde femoral nail. The average age of the patients was 52.3 years. Their average weight was 102.6 kg.
Fusion was evident on radiographs in all nine patients at an average of 10.5 weeks. None of the patients developed a stress fracture or evidence of stress concentration at the proximal metaphyseal tip of the nails. One wound infection resolved after debridement and antibiotic therapy, and one postoperative hematoma resolved without surgery. At an average 32-month followup, all patients were ambulatory, using commercially available therapeutic footwear. None had developed a new foot ulcer, infection, or new episode of Charcot arthropathy.
The use of a retrograde femoral nail for ankle arthrodesis in patients with Charcot arthropathy appears to decrease the risk of stress fracture compared with shorter nails without increasing the risk of other complications.
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"But then, the straight nails were only available in lengths of 15 and 18 cm, while the curved ankle nails come in lengths of 15, 20 and 30 cm. It may well be that like proximal femoral nails, ankle nails need to be customized to reach within 5 cm of the proximal tibial articular surface as proposed by Pinzur and Noonan  . However, this may then pose problems for the knee arthroplasty surgeon should the need for total knee replacement arise in future. "
[Show abstract][Hide abstract] ABSTRACT: Background:
Purpose of study was to compare nail alignment, incidence of stress riser and fracture with straight and curved nails of different lengths.
We conducted a retrospective review of consecutive, initially 13 straight and subsequently 15 curved nails implanted in 17 men and 11 women. Angles of incidence and reflection subtended by nail tip with inner tibial cortex were measured. Cortical hypertrophy was assessed on follow-up radiographs.
Angles of incidence and reflection were greater with short straight nails, less with long straight nails and stayed close to zero with long curved nails. Stress fractures occurred in 2 patients with straight nails at the level of the proximalmost tibial screw. Cortical hypertrophy was present in 7 patients with straight nails and in only 1 patient with a curved nail (p=0.01).
Both nail length and inbuilt valgus contribute to better central positioning within the tibia. However, cortical stress reactions occur less frequently with curved nails.
Full-text · Article · Sep 2014 · Foot and Ankle Surgery
"Acute ankle fractures in patients with complicated diabetes are associated with significantly higher rates of noninfectious complications and need for surgical revision when compared with diabetic patients without other organ system comorbidities (78). Numerous techniques have been reported without comparative effectiveness (79–82). All of the surgical studies are retrospective in nature without a control group and are based on a limited number of patients. "
[Show abstract][Hide abstract] ABSTRACT: The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
Full-text · Article · Sep 2011 · Journal of the American Podiatric Medical Association