Predictors of metalwork failure and nonunion after hindfoot Charcot reconstruction

Abstract

Aims Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. Methods We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded. Results There were 70 patients with mean follow-up of 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). Conclusion Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703–708.

Combined Charcot hindfoot and midfoot reconstruction using internal fixation method—surgical technique and single surgeon series

“…Najefi et al identified a 19% metal work failure rate following Charcot hindfoot reconstruction performed using a hindfoot nail ( 11 ). Kummen et al reported a higher major hardware failure of 24% among all Charcot foot reconstructions performed using internal fixation technique that included combined hindfoot and midfoot procedures ( 1 ).…”

“…This is combined with preparation of the medial gutter of the ankle joint ( Figure 3B ). Preservation of the medial malleolus during the preparation of the medial gutter is beneficial in improving the fixation construct and the outcomes ( 11 ). Subtalar joint is accessed and released.…”

“…This is factored in while choosing the position of the hindfoot nail. Three factors related to hindfoot nail have been identified to contribute to have higher bone union rates following Charcot foot reconstructions-isthmic fit of the intramedullary nail, supplementary calcaneo-tibial compression screw and intact medial malleolus ( 11 ).…”

What’s New in Foot and Ankle Surgery

“…The results of Charcot reconstruction may be slowly improving. In a retrospective review of 70 patients who underwent hindfoot Charcot reconstruction with an intramedullary nail, Najefi et al 46 reported an 83% overall hindfoot union rate at a mean follow-up of 54 months. A greater nail diameter-to-isthmus ratio (p = 0.034) and supplemental hindfoot compression screws (p = 0.038) were associated with a higher union rate.…”

Foot & Ankle

“…The aim of this study from London (UK) was to identify the factors related to the suboptimal hindfoot-specific outcomes, including recurrent deformity and nonunion, in patients undergoing hindfoot Charcot reconstruction with a standard hindfoot IMN. 4 A database of patients who underwent hindfoot Charcot reconstruction using an IMN between January 2007 and December 2019 was used to identify the study cohort. Patients who had a hindfoot reconstruction with plates or screws or a circular fixator, and those with less than one year of follow-up, were excluded.…”