Journal of Foot and Ankle Surgery (Asia Pacific)

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2023 | August | Volume 10 | Issue S1

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Rajesh Simon, Venu Kavarthapu

India Becoming an Emerging Diabetic Capital Burdened with an Explosion of Unrecognized Charcot Feet

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:2] [Pages No:S1 - S2]

   DOI: 10.5005/jp-journals-10040-1303  |  Open Access | 



Gautam Kumar, Dennis P Jose, Udit Agrawal, Inderjit Singh

Charcot Theories and Pathophysiology: A Narrative Review

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:3] [Pages No:S3 - S5]

Keywords: Charcot joint, Charcot neuroarthropathy, Neuropathy, Receptor activator of nuclear factor-kB ligand

   DOI: 10.5005/jp-journals-10040-1305  |  Open Access | 


Charcot neuropathic osteoarthropathy (CNO) is defined as relatively painless, progressive, noninfectious, and degenerative arthropathy involving soft tissues and one or more joints with an underlying neurological deficit. Major theories of pathophysiology include neurovascular theory (French theory), neurotraumatic theory (German theory), and neuro-osseous-inflammatory theory. As per the neurovascular theory, loss of sensation due to neuropathy acted as a barrier for feeling pain and discomfort in patients, which predisposed them to repeated trauma and microfractures. Charcot patients have been found to have increased blood flow, which increases venous pressure enhancing fluid filtration due to capillary leakage, which in turn leads to increased compartmental pressure and ischemia compromising the tendons and ligaments. The neurotraumatic theory states that insensate feet are predisposed to repetitive unrecognized trauma and abnormal loading of the joint. The forefoot act as a lever due to increased plantar pressure forcing the collapse of the midfoot. In neuro-osseous-inflammatory theory, emphasis is given to disturbances in the balance between pro and anti-inflammatory cytokines. Increased proinflammatory markers activate cytokine pathways centered on receptor activator of nuclear factor kB (NF-kB) ligand (RANKL). The ratio of RANKL/osteoprotegerin (OPG) is elevated. RANKL induces differentiation of osteoclast precursor to osteoclast and leads to osteolysis. Factors with significant CNO association include hyperglycemia, neuropathy, low bone mineral density (BMD), inflammation, and neuropathy.



Rajagopalakrishnan Ramakanth, Karthikeyan Pratheeban, Terence Dsouza, Sundararajan Silvampatti Ramasamy, Shanmuganathan Rajasekaran

Comparison of Hindfoot Charcot's (Brodsky 3A) vs Combined Hindfoot–Midfoot Charcot's (Brodsky 4) Arthropathy Primarily Operated with Hindfoot Nailing

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:9] [Pages No:S6 - S14]

Keywords: Charcot's arthropathy, Diabetic mellitus, Hindfoot, Hindfoot nail, Midfoot, Tibiatalocalcaneal fusion

   DOI: 10.5005/jp-journals-10040-1321  |  Open Access | 


Aim and background: Charcot's arthropathy affecting the hindfoot (Brodsky's type 3A) and combined hindfoot–midfoot (Brodsky type 4), dilemma to fuse, hindfoot alone or hindfoot with midfoot, are not clearly defined yet. Our study aims to compare the outcomes and complications of primary hindfoot stabilization for the hindfoot alone vs combined hindfoot–midfoot Charcot's arthropathy. Materials and methods: This is a retrospective study of all the patients who were operated on for Charcot's arthropathy between 2018 and 2021. Included hindfoot and combined hindfoot–midfoot Charcot's arthropathy after trivial trauma/failed and neglected ankle fractures and excluded Brodsky's 1,2,3b,5 type—Charcot's arthropathy, nonneuropathic arthritis, inflammatory arthritis. Around N = 62 patients were grouped based on Brodsky's classification—group I (41) included hindfoot Charcot's alone (type 3A) and group II (21) included combined hindfoot and midfoot Charcot's arthropathy (type 4). Patient demographic details like age, sex, duration of symptoms (months), Brodsky classification, Eichenholtz staging, random blood sugar (RBS), glycated hemoglobin (HbA1c) at admission, diabetic status (controlled/uncontrolled), duration of diabetes mellitus (DM), duration of preoperative antibiotics, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), urea and creatinine. Radiological and functional outcomes [American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale and Foot and Ankle Outcome Score (FAOS)] were compared between the groups. Results: Average follow-up is 19.17 ± 3.1 (months) and 19.48 ± 2.7 (months) in groups I and II. The mean age was 58.5 ± 11.05 years and 53.3 ± 11.27 in groups I and II. Male: female is 24:17 in group I and 12:9 in group II. Both the groups were similar in terms of biochemical parameters except HbA1c, which was significantly higher in group II (p = 0.003). Similarly, there was a higher number of patients with uncontrolled diabetes in group II (p = 0.010). The mean postoperative AOFAS and FAOS hindfoot scores in both groups I and II had improved significantly compared to their preoperative value (p-value group I—0.005 and group II—0.005). However, no statistical significance for AOFAS and FAOS between the groups (p-0.202 and p = 0.103). Around 67.2% of patients were able to walk unaided during the final follow-up. Tibiocalcaneal angle in both the groups during the final follow-up was statistically more significant than their preoperative value (p-value group I—0.01 and group II—0.005). However, there was an insignificant average secondary varus collapse of 4.75 ± 15.3° in group I and 5.45 ± 18.3° in group II. Around 11 of 41 (26.8%) in group I and 10 of 21 (47.6%) in group II had complications. Minor complication (superficial infection, minor implant failure (screw back-out), stable hindfoot with implant breakage)—12.2% in group I, 14.3% in group II. Major complication (deep infection, major implant failure that required nail removal/amputation, ulcer)—14.6% in group I, 33.3% in group II. Two patients needed implant removal, two required below knee amputation (BK) amputation and one plantar bony deformity required exostectomy. Conclusion: Around 67. 2% of patients with a good clinical and radiological outcome following hindfoot nailing were able to walk unassisted, and 95% of patients’ limbs were salvageable by hindfoot nailing. Patients with combined midfoot and hindfoot arthropathy were more likely to experience complications. High HbA1c is one of the significant factors that led to complications.



Amit S Patel, Manjunathan Sivaprakasam, Ines LH Reichert, Raju Ahluwalia, Chris Manu, Venu Kavarthapu

Reconstruction of the ‘Foot at Risk’ during Acute Charcot Neuroarthropathy

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:6] [Pages No:S15 - S20]

Keywords: Ankle, Charcot neuroarthropathy, Diabetic foot, Reconstruction, Surgery

   DOI: 10.5005/jp-journals-10040-1304  |  Open Access | 


Introduction: Charcot neuroarthropathy (CN) of the foot and ankle presents significant challenges to the foot and ankle surgeon. Established practice focuses on conservative management during the acute phase with offloading followed by deformity correction during the chronic phase. However, if the deformity progresses in spite of optimal offloading, ulceration, infection, and limb loss are possible. Our aim was to assess the outcomes of primary surgical management with early reconstruction, even in the acute phase, when the foot is at risk of major amputation. Methods: This was a retrospective review of all cases of Charcot foot reconstruction done within our unit between 2011 and 2019. Only patients presenting with acute CN foot that required surgical reconstruction due to failure of nonoperative measures have been included in this study. A detailed assessment was then made for this subsets of patients, who underwent reconstruction while still within the acute CN phase. We reported on their clinical outcomes of mobility, ulcer healing, bone union, and need for repeat surgery. Results: A total of 92 Charcot reconstructions were done between 2011 and 2019, and there were 26 patients (27 feet) who had reconstruction during their acute phase; 15 in Eichenholtz stage I and 12 in stage II with instability due to non-union resulting in progressive deformity. All had peripheral neuropathy, and the majority were due to diabetes (96%). A total of 14 of these were performed as single-stage procedures, whereas 13 were as two-stage reconstructions. These included isolated hindfoot reconstructions in eight, midfoot in four, and combined in 15 feet. The mean age at the time of operation was 55 years (range 31–78). Preoperative ulceration was evident in 15 feet. Mean follow-up was 45 months (range 12–98). One patient died before completing a minimum follow-up. There was 100% limb salvage. Final ambulation outcomes demonstrated full-weight-bearing in 25 patients (96%), mobilizing in bespoke footwear in 18 and in an ankle foot orthosis (AFO), Charcot restraint orthotic walker (CROW) or bivalve cast in seven. All preoperative ulcerations had healed within 12 months of follow-up. Full bone union was seen in 19/22 hindfoot reconstructions and 7/19 midfoot reconstructions. There were nine episodes of return to theater, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion: Early surgical management following acute and unstable CN of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows better rates of bony union compared to midfoot reconstruction. It should be considered in stage I presentations and stage II with instability, if the nonoperative measures fail and there is a risk of limb loss due to progression of deformity, ulceration and infection.



Alphy C Philips, Praneeth Divi, Shiv M Ajoy, Inderjit Singh, Abhishek Kini

Conservative Management of Diabetic Charcot Foot: A Narrative Review

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:6] [Pages No:S21 - S26]

Keywords: Ankle arthritis, Charcot neuroarthropathy, Diabetes mellitus, Diabetic foot complication, Diabetic foot disease, Immobilization, Midfoot Charcot's, Offloading

   DOI: 10.5005/jp-journals-10040-1309  |  Open Access | 


Aims and background: Diabetic neuroarthropathy leads to a loss of sensation in the feet due to peripheral neuropathy. This loss of sensation leads to eventual ulceration and damage to the weight-bearing surfaces of the foot. Charcot's foot, once diagnosed, should be tackled at the earliest. There exist multiple modes of conservative management. This study aims to establish the role of conservative management in patients diagnosed with Charcot's foot in the early stages by exploring the various current conservative modes of management, identifying their pros and cons, and the desired outcomes. Materials and methods: A PubMed search was performed on the date of submission of this article using the key terms of Charcot, arthropathy, neuroarthropathy, conservative management, total contact casting (TCC), bisphosphonates, calcitonin, and receptor activator of nuclear factor κ-β ligand (RANKL) inhibitors. All the studies cited here were reviewed, and the studies that reported on the conservative management of Charcot's foot were included. Results: The primary modality of treatment centers around a basic offloading and immobilization principle using TCC, and walkers where appropriate. Additionally, bisphosphonates, calcitonin, and RANKL inhibitors can be used as adjuncts in the therapy of the early stages of Charcot's neuroarthropathy. Conclusion: Charcot neuroarthropathy is a difficult early diagnosis as patients are pain-free, and hence patients once diagnosed, should be started with the appropriate methods of treatment at the earliest to avoid further progression of the disease, the need for surgical intervention and to improve the prognosis of the patient. Patients should also be educated about the necessity of microcellular rubber footwear, regular examination of their feet, and adequate glycemic control. Clinical significance: To provide a comprehensive overview of conservative management of diabetic Charcot neuroarthropathy, including the treatment options available and the benefits of each technique.



Shiv M Ajoy, Aanchal Bhatia, Dev A Galagali

Hallux Valgus: An Unusual Presentation of a Rare Disease, Forefoot Charcot Arthropathy

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:4] [Pages No:S27 - S30]

Keywords: Arthrodesis, Case report, Charcot, First metatarsophalangeal joint, Forefoot, Hallux valgus

   DOI: 10.5005/jp-journals-10040-1310  |  Open Access | 


Aim and background: Charcot neuroarthropathy is a disabling disorder affecting a large number of diabetics all over the world. It most commonly involves the midfoot. Forefoot Charcot is rare. The affection of the hallux is not usually seen. A case of isolated first metatarsophalangeal (MTP) joint disease with a valgus deformity managed surgically by arthrodesis has been described. Case description: A 52-year-old male patient presented with bilateral hallux valgus, left more than right, and a callosity over the plantar aspect of the left first MTP joint. Standard weight-bearing radiographs revealed osteolysis and osteophytes pointing toward Charcot arthropathy. A diabetic foot assessment further supported our diagnosis. The patient underwent the first MTP joint fusion using a locking plate. No intraoperative and postoperative complications were noted. Nonweight-bearing mobilization was followed for 6 weeks, followed by gradual weight-bearing over 2 weeks. An 8-week and 4-month follow-up revealed corrected deformity and healed callosity. Conclusion: Forefoot is a rare location of Charcot disease. Hallux valgus is an uncommon presentation of this disorder. Soft tissue pathologies are common due to abnormal loading of the foot. These, along with joint disease, can be managed satisfactorily by arthrodesis to offload the affected region. Clinical significance: Forefoot should not be neglected in Charcot disease. Hallux valgus in a diabetic patient must be evaluated thoroughly to rule out the neuropathic joint disorder.



Siddhartha Sharma, Sandeep Patel, Inderjit Singh, Ankit Dadra, Shiv M Ajoy, Rajesh Simon, Rajiv Shah, Mandeep S Dhillon

Designing a Novel Patient-reported Outcome Measure for Evaluating Foot and Ankle Disorders in the Indian Population: The IFAS Score Protocol

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:3] [Pages No:S31 - S33]

Keywords: Functional outcomes, Indian Foot and Ankle Society score, Patient-reported outcome measures

   DOI: 10.5005/jp-journals-10040-1317  |  Open Access | 


Patient-reported outcome measures (PROMs) play a crucial role in assessing functional outcomes and evaluating the impact of diseases on individuals’ well-being. They are widely utilized by foot and ankle surgeons and researchers globally, serving as valuable tools for monitoring treatment response and assessing intervention effectiveness in reducing morbidity. While several PROMs for the evaluation of foot and ankle disorders have been developed and validated in the literature, their applicability to diverse populations and geographical regions remains a concern. Translation into native languages may introduce misinterpretation and irrelevance to certain populations. To address these limitations and cater to the specific needs of Indian and Southeast Asian populations, the Indian Foot and Ankle Society (IFAS) has initiated the development of a tailored PROM, the IFAS score. This protocol outlines the methodology for developing the IFAS score, aiming to provide a culturally sensitive and region-specific PROM that overcomes the challenges faced by existing measures.



Shiv M Ajoy, Sushruth Jagadish, Ronak N Kotian

Role of Small Posterior Malleolar Fragment in Ankle Stability: A Biomechanical Cadaveric Study Using an Indigenously Developed Universal Testing Machine

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:5] [Pages No:S34 - S38]

Keywords: Ankle stability, Biomechanical study, Fragment size, Posterior malleolar fracture

   DOI: 10.5005/jp-journals-10040-1308  |  Open Access | 


Background: Posterior malleolar fragment (PMF) occurs in 7–44% of all ankle fractures. The integrity of the posterior malleolus and its ligamentous attachments is important for tibiotalar load transfer, posterior talar stability, and rotatory stability. No consensus exists on the minimum size of PMF that requires fixation. The purpose of this study is to investigate biomechanically the effect of fixing small PMF (<25% of tibial plafond) and its effect on ankle stability. Materials and methods: A total of 22 cadaveric ankle specimens were studied. They were divided into three groups according to the percentage of osteotomy performed—group I (20–30% of articular surface), group II (30–40%), and group III (40–50%). Ankles were subjected to axial loading using an indigenously developed machine with serial monitoring, load at which the fragment displacement, or posterior talar subluxation happened was noted. Internal fixation of fragment was done according to Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles and subjected to load to check for fragment displacement or posterior talar subluxation. Results: The mean prefixation load which caused the posterior talar subluxation or the fragment displacement was lower (507.60 ± 104.99 N) in group III compared to group I (1156.00 ± 172.15 N). The mean postfixation load was 1882.88 ± 75.59, 1739.00 ± 109.03, and 1313.60 ± 356.00 N in groups I, II, and III, respectively. The mean difference in load (postfixation minus prefixation) in group I was 742.44 ± 133.98, 996.00 ± 108.23 N in group II, and 806.00 ± 257.08 N in group III. The difference in prefixation and postfixation load was statistically significant in all the three groups with p-value of <0.001. Conclusion: Fixation of PMF, irrespective of the size or percentage of articular surface involvement, leads to better ankle stability. Clinical significance: Fixation of small PMF (<25% of the articular surface) will lead to better ankle stability and early rehabilitation.



Vijay Panchanadikar, Ankit B Waghela, Manish Agrawal, Sourav Neelkamal, Gaurav Ardawatia, Akash Mane, Kanishk Bathla

Gaenslen's Split-heel Approach for Management of Chronic Calcaneal Osteomyelitis: A Case Report and Literature Review

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:6] [Pages No:S39 - S44]

Keywords: Calcaneal osteomyelitis, Gaenslen, Heel pad, Split-heel pad

   DOI: 10.5005/jp-journals-10040-1269  |  Open Access | 


Background: Calcaneal osteomyelitis is difficult to treat. Various surgical procedures to manage chronic osteomyelitis of the calcaneus, that is, partial, total calcanectomy, split-heel approach, and vascularized flaps to cover the ulcer, have been employed with variable and often disappointing results. Way back in 1931, Gaenslen reported his split-heal or cloven-heel method approach, with satisfactory healing in all patients and no plastic or secondary operations. In spite of the uniformly good results in all calcaneum osteomyelitis cases shown subsequently, it seems that this is not a popular approach, the literature is sparse, and the most recent publication on this approach and technique was in 2010 by Bhattacharya and Das. This approach and technique has not received much attention as a preferred treatment choice primarily and is usually reserved for patients with resistant or recurrent disease. Our case report and systematic review of this method reveal that it is a safe and effective technique and that it shall be used primarily in all patients of calcaneal osteomyelitis, with or without a plantar ulcer, in children and adults alike. Conclusion: Overall, it seems reasonable to state that it is a safe and very effective technique. Only two recurrences and one reoperation are noted in this entire literature review. It remains a moot point whether this approach and technique shall be routinely indicated in all patients of calcaneal osteomyelitis with or without a plantar ulcer, and further studies may be required. This approach ought to be renamed the Landerer-Gaenslen approach in future references. We are hopeful that we have revisited and revived this useful and safe technique and attempted to rekindle the memory of the fascinating classic paper by author Gaenslen, reviewed and refined the indications through our case report and literature survey. Level of evidence: Level 5.



Proceedings of Indian Foot & Ankle Society Conference, IFASCON 2023

[Year:2023] [Month:August] [Volume:10] [Number:S1] [Pages:11] [Pages No:S45 - S55]

   DOI: 10.5005/jp-journals-10040-1322  |  Open Access | 


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