May 2013

A recent study in The Journal of Foot and Ankle Research asserts that an increasing talar declination angle and decreasing calcaneal inclination angle are associated with decreases in ankle joint mobility in individuals with neuropathic midfoot deformity.

   The study notes that researchers used goniometry and lateral view radiography to assess ankle joint mobility in three groups of patients: 20 patients with diabetic peripheral neuropathy and midfoot deformity due to Charcot neuroarthropathy, 20 patients with diabetic peripheral neuropathy with no deformity and 20 patients without diabetes, neuropathy or deformity.

   According to the study, the association between talar declination and calcaneal inclination angles with ankle plantarflexion range of motion was strongest in participants with neuropathic midfoot deformity due to Charcot neuropathy. In addition, researchers note that Charcot neuropathy may contribute to excessive stresses and ultimately plantar ulceration of the midfoot.

   Andrew Rice, DPM, FACFAS, notes these findings are consistent with the majority of his patients with neuropathic midfoot deformity. The first step in assessing such patients is to conclude that your findings are not due to acute neurotrophic changes, such as Charcot osteoarthropathy, notes Dr. Rice, an Assistant Clinical Professor in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine.

   “I will initially manage patients (with neuropathic midfoot deformity) with a deep seated orthosis with a high medial and lateral flange shoe with stability,” explains Dr. Rice. “Secondly, I will utilize an AFO or Richie Brace with soft cover for protection. Thirdly, if the ankle is very unstable, I will use a CROW walker, FROG walker or Freedom Brace (FWD Mobility).”

   Regarding measures to prevent abnormal stresses in patients with neuropathic deformities, Dr. Rice recommends a variety of orthotics and walkers. In cases of acute neurotrophic changes, he recommends complete offloading.

   According to Dr. Rice, podiatrists might benefit from a three-phase bone scan to help differentiate between acute changes versus chronic, slowly progressive deformities. Practitioners might also want to assess the presence of associated bony deformation, which would increase the incidence of ulceration and require surgical resection, adds Dr. Rice.

Is Arthroscopic Debridement Effective Long-Term For Osteochondral Defects?

By Brian McCurdy, Senior Editor

A recent study in the Journal of Bone and Joint Surgery gives high marks to the long-term efficacy of arthroscopic debridement and bone marrow stimulation for talar osteochondral defects.

   The study involved 50 patients with primary osteochondral defects who received arthroscopic debridement and bone marrow stimulation. Evaluating these patients after a mean follow-up of 12 years, researchers noted that 94 percent of patients had resumed work and 88 percent had resumed sports.

   Radiographs indicated an osteoarthritis grade of 0 in 33 percent of the patients, I in 63 percent, II in 4 percent, and III in 0 percent, according to the study. The authors added that in comparison with the preoperative osteoarthritis classification, 67 percent of radiographs showed no progression and 33 percent showed progression by one grade.

   Jeffrey Bowman, DPM, MS, cites several advantages to arthroscopic procedures. He notes that since the incisions are small, there is less chance of infection and in some cases, patients can walk the day of surgery or the next day. Minimal dissection also means less pain and swelling, according to Dr. Bowman, a Past President of the Texas Podiatric Medical Association.

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