Pantalar arthrodesis is an important salvage option for stabilizing the hindfoot and salvaging the limb following trauma or collapse. This report evaluates the healing rates and complications which occur in diabetics and post-traumatic patients.Twenty patients presenting with post-traumatic arthritis of the ankle-hindfoot (twelve) or with Type II or Type IIIA Charcot arthropathy (eight) were managed with a pantalar fusion. Followup averaged 46 months. Patients were evaluated using the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Short Musculoskeletal Function Assessment (SMFA) and the Visual Analog Pain Scale (VAS).There were no amputations in either group. Casting averaged 14.9 weeks, full weightbearing was achieved at 25.1 weeks and time to union averaged 44.1 weeks. Average age was 56.3 yrs. and BMI averaged 34.2. Fourteen patients (70%) had their surgery performed in multiple stages. Acceptable outcomes were noted for all patients for the SF-36, AOFAS and SMFA scores. VAS scores averaged 2.2. There were ten complications (50%); four patients (two in each group) required additional surgery.Pantalar arthrodesis is a reasonable salvage option for patients with severe post traumatic arthropathy and neuropathic arthropathy. Patients should be informed of the increased risks as well as the long periods of postoperative immobilization and nonweightbearing. We believe a pantalar arthrodesis can produce acceptable outcomes regardless of the cause of disability, with a staged or single approach, and whether the surgery is performed with plates and screws or an intramedullary device.

The variable disease progression of osteoarthritis (OA) and the basis for rapid joint deterioration in some subgroups of patients are poorly understood. To explore an anatomic basis for rapidly progressive OA, this observational study compared the magnetic resonance imaging (MRI) patterns of disease between patients with neuropathic joint disease (NJD) and patients with degenerative arthritis of the ankle and foot.MR images of the foot and ankle of patients with early NJD (n = 7) and patients with OA (n = 15) were assessed. The anonomized MR images were dichotomously scored by a musculoskeletal radiologist for the presence of the following abnormalities per bone (of a total of 14 bones): cartilage defects, bone cysts, bone marrow edema, fractures, joint debris, joint effusions, tendinopathy, tendinitis, and ligament tears.Although the degree of cartilage damage and joint cyst formation was comparable between the groups, the degree of ligament tears, or change in MRI signal intensity in the ligaments, was significantly greater in patients with NJD compared with patients with OA (median of 3 tears versus 0, of 14 total bones; P < 0.01). Moreover, in patients with early NJD compared with patients with OA, there was a significantly greater degree of diffuse bone marrow edema (median of 6.5 tarsal bones versus 2 adjacent bones, of 14 total bones; P < 0.01), a greater number of bone fractures (median 4 versus 0; P < 0.01), and more frequent bone debris (median 4.5 versus 0; P = 0.013).This analysis of NJD in the foot and ankle shows the predominance of bone and ligament abnormalities in NJD compared with the pattern of involvement in OA. These findings highlight the importance of structures other than articular cartilage in OA of the ankle and foot, and suggest that rapid joint degeneration in NJD may be more ligamentogenic or osteogenic in nature.

One of the most devastating complications of diabetes is Charcot osteoarthropathy. It can lead to gross structural deformities of the foot and ankle, and subsequent skin ulceration and lower limb amputation from soft tissue or bony infection. However, it is often unrecognised, with deleterious consequences.This article describes the case of a man with type 1 diabetes who presented with Charcot osteoarthropathy of both feet, with a 3 month delay in diagnosis between the two presentations.Treatment, patient comorbidities and risk management were similar for both feet, with a marked difference in outcome, demonstrating the importance of the timely diagnosis of Charcot osteoarthropathy.

Charcot neuro-osteoarthropathy (CNO) is a devastating condition affecting most commonly the foot/ankle joint in diabetic patients and may lead to severe deformities and amputation. Peripheral sensory neuropathy seems to be a pre-requisite to the development of CNO. The aim of this review article is to summarise the skeletal effects of the nervous system on bone remodelling and fracture healing of normal and damaged joints and to describe how neuropathy, in the context of modern concept of neuro-osteopathology, is crucial in the predisposition of the patient to develop acute CNO.

One of the more serious diabetic complications is Charcot neuroarthropathy (CN), a disease that results in arch collapse and permanent foot deformity. However, very little is known about the etiology of CN. From a mechanical standpoint, it is likely that there is a ;;vicious circle'' in terms of (i) arch collapse causing increased midfoot joint pressures, and (ii) increased joint contact pressures exacerbating the collapse of midfoot bones. This study focused on assessment of peak joint pressure difference between diabetic and non-diabetic cadaver feet during simulated walking. We hypothesized that joint pressures are higher for diabetics than normal population.Sixteen cadaver foot specimens (eight control and eight diabetic specimens) were used in this study. Human gait at 25% of typical walking speed (averaged stance duration of 3.2s) was simulated by a custom-designed Universal Musculoskeletal Simulator. Four medial midfoot joint pressures (the first metatarsocuneiform, the medial naviculocuneiform, the middle naviculocuneiform, and the first intercuneiform) were measured dynamically during full stance.The pressures in each of the four measured midfoot joints were significantly greater in the diabetic feet (p = 0.015, p = 0.025, p < 0.001, and p = 0.545, respectively).Across all four tested joints, the diabetic cadaver specimens had, on average, 46% higher peak pressures than the control cadaver feet during the simulated stance phase.This finding suggests that diabetic patients could be predisposed to arch collapse even before there are visible signs of bone or joint abnormalities.

Haemophilia is a congenital haemorrhagic diathesis that in its most severe form leads to a seriously disabling arthropathy as a result of recurring intraarticular bleeding. Within the last couple of years there have been significant advances in the treatment of haemophiliacs that are helping to prevent crippling musculoskeletal deformities, but a relatively large number of young adults still present with advanced arthropathic changes when treatment was started too late or has failed to prevent changes from taking place. We present the case of a 44-year-old male with advanced haemophilic arthropathy of the knee and ankle joints, who, during 8 weeks of therapy that consisted of physical therapy and rehabilitation using PNF techniques (Proprioceptive Neuromuscular Facilitation), achieved mobility improvement according to the SPPB scale (Short Physical Performance Battery Test) and a reduction of pain in the knee and ankle joints, according to a VAS scale. The therapeutic regimen proved to be an effective method improving the locomotor function of the patient.

To evaluate the diagnostic accuracy and indications of arthrography with Multidetector Computed Tomography (arthro-MDCT) of the wrist in patients with absolute or relative contraindications to magnetic resonance imaging (MRI) studies and in patients with periarticular metal implants using diagnostic arthroscopy as the gold standard.After intra-articular injection of iodixanol and volumetric acquisition, 43 wrists in patients of both genders (18 females, 25 males, age range 32-60 years) were examined with a 16-detector-row CT scanner. Fifteen patients had prior wrist surgery. The patients had arthralgia, degenerative and traumatic arthropathies as well as limited range of motion, but no radiologically detected fractures. All examinations were interpreted by two experienced musculoskeletal radiologists. The findings were compared with arthroscopic findings carried out within 28 days of the CT study.In non-operated and operated wrists the comparison between arthro-MDCT and arthroscopy showed sensitivity, specificity and accuracy ranging between 92% and 94% for triangular fibrocartilage complex (TFCC), between 80% and 100% for intrinsic ligaments located within the proximal carpal compartment, and between 94% and 100% for articular cartilage. Inter-observer agreement between two radiologists, in the evaluation of all types of lesions, was almost perfect (k=0.96) and statistically significant (p<0.05).Arthro-MDCT of the wrist provides an accurate diagnosis to identify chondral, fibrocartilaginous and intra-articular ligament lesions in patients who cannot be evaluated by MRI, and in post-surgical patients.

This study evaluated Magnetic Resonance Imaging (MRI) in infected diabetic foot ulcers.Sixteen diabetic patients underwent foot MRI between January 2006 and September 2007 for suspected unilateral osteomyelitis. Three of 16 patients showed radiographic changes due to Charcot neuropathic osteoarthropathy. Twelve of 16 patients also underwent MR angiography of the lower limbs for the purpose of planning surgical or endovascular treatment. The musculoskeletal and vascular MRI studies were retrospectively reviewed by three radiologists.The final diagnosis, based on clinical, imaging, microbiological and histological findings, was osteomyelitis in 13/16 cases. Foot MRI allowed a correct diagnosis in 15/16 patients, with 1 false positive result demonstrated by computed tomography (CT)-guided bone biopsy. MR angiography of the lower limbs was considered nondiagnostic in 5/12 patients in the infrapopliteal region owing to venous contamination.MRI has high sensitivity for the detection of osteomyelitis in the diabetic foot but lower specificity related to Charcot neuropathic osteoarthropathy. If diagnostic uncertainty persists, a bone biopsy is indicated. The inflammatory hyperaemia caused by the ulcer deteriorates the diagnostic quality of 40%-50% of MR angiography studies in the infrapopliteal region. In these cases, selective arteriography is appropriate, as it can be performed in the same session as angioplasty.

We report three cases of neuropathic arthropathy secondary to syringomyelia. In two cases both the shoulder and elbow were involved. In the third case only involvement of the elbow was observed.