Publications by authors named "Felix W A Waibel"

18 Publications

  • Page 1 of 1

How good are clinicians in predicting the presence of spp. in diabetic foot infections? A prospective clinical evaluation.

Endocrinol Diabetes Metab 2021 04 9;4(2):e00225. Epub 2021 Feb 9.

Department of Orthopedic Surgery Balgrist University Hospital Zurich Switzerland.

Introduction: The most frequently prescribed empirical antibiotic agents for mild and moderate diabetic foot infections (DFIs) are amino-penicillins and second-generation cephalosporins that do not cover spp. Many clinicians believe they can predict the involvement of in a DFI by visual and/or olfactory clues, but no data support this assertion.

Methods: In this prospective observational study, we separately asked 13 experienced (median 11 years) healthcare workers whether they thought the spp. would be implicated in the DFI. Their predictions were compared with the results of cultures of deep/intraoperative specimens and/or the clinical remission of DFI achieved with antibiotic agents that did not cover .

Results: Among 221 DFI episodes in 88 individual patients, intraoperative tissue cultures grew in 22 cases (10%, including six bone samples). The presence of was correctly predicted with a sensitivity of 0.32, specificity of 0.84, positive predictive value of 0.18 and negative predictive value 0.92. Despite two feedbacks of the interim results and a 2-year period, the clinicians' predictive performance did not improve.

Conclusion: The combined visual and olfactory performance of experienced clinicians in predicting the presence of in a DFI was moderate, with better specificity than sensitivity, and did not improve over time. Further investigations are needed to determine whether clinicians should use a negative prediction of the presence of in a DFI, especially in settings with a high prevalence of pseudomonal DFIs.
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http://dx.doi.org/10.1002/edm2.225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8029573PMC
April 2021

The quantitative influence of current treatment options on patellofemoral stability in patients with trochlear dysplasia and symptomatic patellofemoral instability - a finite element simulation.

Clin Biomech (Bristol, Avon) 2021 Apr 27;84:105340. Epub 2021 Mar 27.

Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.

Background: Trochlear dysplasia is highly associated with patellofemoral instability. The goal of conservative and surgical treatment is to stabilize the patella while minimizing adverse effects. However, there is no literature investigating the quantitative influence of different treatment options on patellofemoral stability in knees with trochlear dysplasia. We created and exploited a range of finite element models to address this gap in knowledge.

Methods: MRI data of 5 knees with trochlear dysplasia and symptomatic patellofemoral instability were adapted into this previously established model. Vastus medialis obliquus strengthening as well as double-bundle medial patellofemoral ligament reconstruction and the combination of medial patellofemoral ligament reconstruction and trochleoplasty were simulated. The force necessary to dislocate the patella by 10 mm and fully dislocate the patella was calculated in different flexion angles.

Findings: Our model predicts a significant increase of patellofemoral stability at the investigated flexion angles (0°-45°) for a dislocation of 10 mm and a full dislocation after medial patellofemoral ligament reconstruction and the combination of medial patellofemoral ligament reconstruction and trochleoplasty compared to trochleodysplastic (P = 0.01) and healthy knees (P = 0.01-0.02). Vastus medialis obliquus strengthening has a negligible effect on patellofemoral stability.

Interpretations: This is the first objective quantitative biomechanical evidence supporting the place of medial patellofemoral ligament reconstruction and medial patellofemoral ligament reconstruction combined with trochleoplasty in patients with symptomatic patellofemoral instability and trochlear dysplasia type B. Vastus medialis obliquus strengthening has a negligible effect on patellar stability at a low total quadriceps load of 175 N.
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http://dx.doi.org/10.1016/j.clinbiomech.2021.105340DOI Listing
April 2021

Long-term follow-up of conservative treatment of Charcot feet.

Arch Orthop Trauma Surg 2021 Apr 7. Epub 2021 Apr 7.

Divisions of "Prosthetics and Orthotics" and "Foot and Ankle Surgery", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland.

Background: Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN.

Methods: A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development.

Results: Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations.

Conclusions: With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking.

Level Of Evidence: III, long-term retrospective cohort study.
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http://dx.doi.org/10.1007/s00402-021-03881-5DOI Listing
April 2021

Symptomatic leg length discrepancy after total hip arthroplasty is associated with new onset of lower back pain.

Orthop Traumatol Surg Res 2021 Feb 11;107(1):102761. Epub 2020 Dec 11.

Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland.

Background: Leg length discrepancy (LLD) is common after total hip arthroplasty (THA) with a plethora of clinical consequences. The associations between symptomatic (sLLD; disturbing perception of anatomical leg length discrepancy), anatomical (aLLD; side difference in leg length between the center of rotation of the hip and the center of the ankle joint) and intraarticular (iLLD; side difference between the tear drop figure and the most prominent point of the trochanter minor) LLD and lower back have not yet been reported in the literature. We performed a retrospective study to answer if postoperative (1) symptomatic LLD, (2) anatomic LLD, and (3) a change in intraarticular leg length are associated with lower back pain in patients undergoing THA. Further, we aimed to answer (4) whether symptomatic LLD is associated with the magnitude of anatomical LLD and the change in intraarticular leg length.

Hypothesis: LLD after THA is associated with lower back pain.

Materials And Methods: Seventy-nine consecutive patients were retrospectively analyzed for the presence of aLLD and iLLD using EOS™ and X-rays, and were interviewed for the presence of sLLD and lower back pain using a questionnaire 5 years after primary THA.

Results: Postoperative new onset of lower back pain was reported by 9 (11%) patients. Twenty (25%) patients reported sLLD. Anatomical LLD>5mm was present in 44 (56%) (median 8.0 (IQR -3.0 to 12.0; range -22 to 22) mm) and>10mm in 17 (22%) (median 12.0 (IQR 11.0 to 16.5; range -22 to 22) mm) patients. iLLD changed>5mm in 44 (56%) (median 8.5 (IQR 7.0 to 10.0; range -8 to 18) mm) and>10mm in 10 (13%) (median 14.0 (IQR 12.5 to 14.5; range 11 to 18) mm). New onset lower back pain was associated with sLLD (p=0.002) but not with aLLD or iLLD. Patients without preoperative lower back pain had a statistically significant association between presence of sLLD and an aLLD of >10mm (p=0.01).

Conclusions: Symptomatic LLD after primary THA is associated with postoperative new onset of lower back pain irrespective of the magnitude of LLD. In patients without lower back pain prior to THA, symptomatic LLD is associated with anatomical LLD of more than 10mm.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.otsr.2020.102761DOI Listing
February 2021

Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis.

J Orthop Res 2020 Dec 6. Epub 2020 Dec 6.

Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland.

An established treatment strategy in surgical site infection after hindfoot and ankle surgery is a two-stage procedure with debridement and placement of a cement spacer, followed by antibiotic treatment and secondary arthrodesis. However, there is little evidence to favor this treatment over a one-stage procedure with debridement, followed by primary arthrodesis with an Ilizarov external fixator and antibiotic treatment. We compared the infection control and clinical and radiological outcome of a two-stage and a one-stage procedure. In this study, 7 patients with a two-stage revision and 11 patients with a one-stage revision between 2005 and 2015 were included. The primary outcome was infection control (absence of the Musculoskeletal Infection Society PJI criteria) 2 years after the ankle or hindfoot arthrodesis. Secondary outcome measures were the AOFAS hindfoot score and radiological consolidation rate. Infection control was 85% (6 out of 7 patients) in the two-stage group and 81% (9 out of 11 patients) in the one-stage group (p = 1.0). One patient (14%) of the two-stage and two patients (18%) in the one-stage group needed below-knee amputation. In the two-stage group, the mean postoperative AOFAS score was 74.8 (SD: ±11.3) versus 71.7 (SD: ±17.8) in the one-stage group. Radiological consolidation could be achieved in 71% in the spacer group (n = 5) and in 72% in the Ilizarov external fixator group (n = 9). Infection control, AOFAS score, and radiologic consolidation of hindfoot and ankle arthrodesis were comparable in both groups of patients with complicated postsurgical hindfoot or ankle infections.
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http://dx.doi.org/10.1002/jor.24938DOI Listing
December 2020

Patellofemoral instability in trochleodysplastic knee joints and the quantitative influence of simulated trochleoplasty - A finite element simulation.

Clin Biomech (Bristol, Avon) 2021 Jan 9;81:105216. Epub 2020 Nov 9.

Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland.

Background: Patellofemoral instability is a debilitating condition mainly affecting young patients and has been correlated with trochlear dysplasia. It can occur when the patella is insufficiently guided through its range of motion. Currently, there is no literature describing patellofemoral stability in trochleodysplastic knees and the effect of isolated trochleoplasty on patellofemoral stability.

Methods: The effect of isolated trochleoplasty in trochleodysplastic knees of patients with symptomatic patellofemoral instability was investigated using a quasi-static finite element model. MRI data of five healthy knees were segmented, meshed and a finite element analysis was performed in order to validate the model. A second validation was performed by comparing simulated patellofemoral kinematics to in-vivo values obtained from upright- weight bearing CT scans. Subsequently, five trochleodysplastic knees were modelled before and after simulated trochleoplasty. The force necessary to dislocate the patella by 10 mm and to fully dislocate the patella was calculated in various knee flexion angles between 0 and 45°.

Findings: The developed models successfully predicted outcome values within the range of reference values from literature. Lateral stability was significantly lower in trochleodysplastic knees compared to healthy knees. Trochleoplasty was determined to significantly increase the force necessary to dislocate the patella in trochleodysplastic knees to comparable values as in healthy knees.

Interpretation: This is the first study to investigate lateral patellofemoral stability in patients with symptomatic patellofemoral instability and dysplasia of the trochlear groove. We confirm that patellofemoral stability is significantly lower in trochleodysplastic knees than in healthy knees. Trochleoplasty increases patellofemoral stability to levels similar to healthy.
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http://dx.doi.org/10.1016/j.clinbiomech.2020.105216DOI Listing
January 2021

The influence of different patient positions on the preoperative 3D planning for surgical resection of soft tissue sarcoma in the lower limb-a cadaver pilot study.

Surg Oncol 2020 Dec 21;35:478-483. Epub 2020 Oct 21.

Department of Orthopedics, Balgrist University Hospital, Investigation Performed at Balgrist University Hospital, Zurich, Switzerland.

Introduction: Complete surgical resection remains the mainstay of the treatment of soft tissue sarcomas. Intraoperative positioning of the patient is dictated by tumor location, whereas preoperative imaging is always performed in the supine position. The effect of changing the patient position on the exact location of the tumor with regard to neurovascular structures and bone is unknown.

Material And Methods: Two fresh frozen cadavers (pelvis and legs) were thawed and warmed. Three standardized tumor models were implanted in the thigh and calf. MR/CT images of the cadavers were obtained sequentially in four different patient positions. The minimal distance of each "tumor" to neurovascular structures was measured on axial MR images and the 3D shift of the center of the tumor to the bone was measured after segmentation of the CT images.

Results: A significant difference of the minimal distance of the "tumor" to the femoral artery (P = 0.019/0.023) and a significantly greater number of deviations of more than 5mm/10 mm in the thigh between the supine position and the other positions compared to two supine positions (p = 0.027/0.028) were seen. The center of the "tumor" compared to the bone shifted significantly in the thigh (P < 0.001/0.002) but not the lower leg.

Conclusion: Obtaining images in the same patient position as the planned tumor resection may become particularly relevant if computer assisted surgery, which is based on preoperative imaging, is introduced into soft tissue sarcoma surgery as the patient position significantly influences the spatial position of the tumor.
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http://dx.doi.org/10.1016/j.suronc.2020.10.008DOI Listing
December 2020

Resting TcPO2 levels decrease during liner wear in persons with a transtibial amputation.

PLoS One 2020 28;15(9):e0239930. Epub 2020 Sep 28.

Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland.

Background: In our clinic, a substantial number of patients present with transtibial residual limb pain of no specific somatic origin. Silicone liner induced tissue compression may reduce blood flow, possibly causing residual limb pain. Thus, as a first step we investigated if the liner itself has an effect on transcutaneous oxygen pressure (TcPO2).

Methods: Persons with unilateral transtibial amputation and residual limb pain of unknown origin were included. Medical history, including residual limb pain, was recorded, and the SF-36 administered. Resting TcPO2 levels were measured in the supine position and without a liner at 0, 10, 20 and 30 minutes using two sensors: one placed in the Transverse plane over the tip of the Tibia End (= TTE), the other placed in the Sagittal plane, distally over the Peroneal Compartment (= SPC). Measurements were repeated with specially prepared liners avoiding additional pressure due to sensor placement. Statistical analyses were performed using SPSS.

Results: Twenty persons (9 women, 11 men) with a mean age of 68.65 years (range 47-86 years) participated. The transtibial amputation occurred on average 43 months prior to study entry (range 3-119 months). With liner wear, both sensors measured TcPO2 levels that were significantly lower than those measured without a liner (TTE: p < 0.001; SPC: p = 0.002) after 10, 20 and 30 minutes. No significant differences were found between TcPO2 levels over time between the sensors. There were no significant associations between TcPO2 levels and pain, smoking status, age, duration of daily liner use, mobility level, and revision history.

Conclusion: Resting TcPO2 levels decreased significantly while wearing a liner alone, without a prosthetic socket. Further studies are required to investigate the effect of liner wear on exercise TcPO2 levels.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239930PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521692PMC
November 2020

Smoking Is Associated with Anterior Ankle Impingement After Isolated Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus.

Cartilage 2020 Sep 17:1947603520959405. Epub 2020 Sep 17.

Department of Orthopedics, University Hospital Balgrist, University of Zurich, Zurich, Switzerland.

Objective: To determine potential predictive associations between patient-/lesion-specific factors, clinical outcome and anterior ankle impingement in patients that underwent isolated autologous matrix-induced chondrogenesis (AMIC) for an osteochondral lesion of the talus (OLT).

Design: Thirty-five patients with a mean age of 34.7 ± 15 years who underwent isolated cartilage repair with AMIC for OLTs were evaluated at a mean follow-up of 4.5 ± 1.9 years. Patients completed AOFAS (American Orthopaedic Foot and Ankle Society) scores at final follow-up, as well as Tegner scores at final follow-up and retrospectively for preinjury and presurgery time points. Pearson correlation and multivariate regression models were used to distinguish associations between patient-/lesion-specific factors, the need for subsequent surgery due to anterior ankle impingement and patient-reported outcomes.

Results: At final follow-up, AOFAS and Tegner scores averaged 92.6 ± 8.3 and 5.1 ± 1.8, respectively. Both body mass index (BMI) and duration of symptoms were independent predictors for postoperative AOFAS and Δ preinjury to postsurgery Tegner with positive smoking status showing a trend toward worse AOFAS scores, but this did not reach statistical significance ( = 0.054). Nine patients (25.7%) required subsequent surgery due to anterior ankle impingement. Smoking was the only factor that showed significant correlation with postoperative anterior ankle impingement with an odds ratio of 10.61 when adjusted for BMI and duration of symptoms (95% CI, 1.04-108.57; = 0.047).

Conclusion: In particular, patients with normal BMI and chronic symptoms benefit from AMIC for the treatment of OLTs. Conversely, smoking cessation should be considered before AMIC due to the increased risk of subsequent surgery and possibly worse clinical outcome seen in active smokers.
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http://dx.doi.org/10.1177/1947603520959405DOI Listing
September 2020

Midterm Fate of the Contralateral Foot in Charcot Arthropathy.

Foot Ankle Int 2020 Oct 22;41(10):1181-1189. Epub 2020 Jul 22.

Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland.

Background: The contralateral foot in Charcot arthropathy or neuroarthropathy (CN) is subject to increased plantar pressure. To date, the clinical consequences of this pressure elevation are yet to be determined. The aim of this study was to evaluate ulcer and amputation rates of the contralateral foot in CN.

Methods: We abstracted the medical records of 130 consecutive subjects with unilateral CN. Rates of contralateral CN development and recurrence, contralateral ulcer development, and contralateral amputations were recorded. Statistical analysis was performed to identify possible risk factors for contralateral CN and ulcer development, and contralateral amputation. Mean follow-up was 6.2 (SD 4) years.

Results: After a mean of 2.5 years, 19.2% patients developed contralateral CN. Female gender was associated with contralateral CN development (odds ratio 3.13, 95% confidence interval 1.27, 7.7). Overall, 46.2% patients developed a contralateral ulcer. Among the patients who developed contralateral CN, 60% developed an ulcer. Sanders type 2 at the index foot (midfoot CN) was significantly associated with contralateral ulcer development. Ulcer-free survival (UFS) differed significantly between patients with diabetes type 1 (median UFS 5131 days) and patients with diabetes type 2 (median UFS 2158 days). A total of 25 amputations had to be performed in 22 (16.9%) patients. Three of those 22 patients (2.3%) needed major amputation.

Conclusion: Almost 20% of patients developed contralateral CN. Nearly half of people with CN developed a contralateral foot ulceration. Patients with type 2 diabetes had significantly shorter UFS than patients with diabetes type 1. Every sixth patient needed an amputation, with the majority being minor amputations. The contralateral foot should be monitored closely and included in the treatment in patients with CN.

Level Of Evidence: Level IV, retrospective study.
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http://dx.doi.org/10.1177/1071100720937654DOI Listing
October 2020

Plantar Fasciitis in Diabetic Foot Patients: Risk Factors, Pathophysiology, Diagnosis, and Management.

Diabetes Metab Syndr Obes 2020 22;13:1271-1279. Epub 2020 Apr 22.

Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland.

Plantar fasciitis (PF) is a common degenerative disorder and a frequent cause of heel pain, mostly affecting patients in their fourth and fifth decades. Diabetic patients are particularly at risk due to the presence of common risks and co-morbidities such as obesity or a sedentary lifestyle. The diagnosis of PF is mainly clinical. Imaging is not recommended for the initial approach. The initial management is conservative and should include physiotherapy, off-loading, stretching exercises, and nonsteroidal anti-inflammatory drugs. Glucocorticoid injections or surgery is an option at a later stage in recalcitrant cases. The overall management of PF does not differ between patients with diabetic foot problems and non-diabetic patients, although the details can differ. This narrative review summarizes the state of the art in terms of the risk factors, pathophysiology, diagnosis, assessment, and management of PF in diabetic patients.
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http://dx.doi.org/10.2147/DMSO.S184259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183784PMC
April 2020

Long-term results after internal partial forefoot amputation (resection): a retrospective analysis.

Arch Orthop Trauma Surg 2021 Apr 7;141(4):543-554. Epub 2020 Apr 7.

Division of Technical Orthopedics, Department of Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.

Introduction: Internal partial forefoot amputation (IPFA) is a treatment option for osteomyelitis and refractory and recurrent chronic ulcers of the forefoot. The aim of our study was to assess the healing rate of chronic ulcers, risk of ulcer recurrence at the same area or re-ulceration at a different area and revision rate in patients treated with IPFA.

Materials And Methods: All patients who underwent IPFA of a phalanx and/or metatarsal head and/or sesamoids at our institution because of chronic ulceration of the forefoot and/or osteomyelitis from 2004 to 2014 were included. Information about patient characteristics, ulcer healing, new ulcer occurrence, and revision surgery were collected. Kaplan-Meier survival curves were plotted for new ulcer occurrence and revision surgery.

Results: A total of 102 patients were included (108 operated feet). 55.6% of our patients had diabetes. In 44 cases, an IPFA of a phalanx was performed, in 60 cases a metatarsal head resection and in 4 cases an isolated resection of sesamoids. The mean follow-up was 40.9 months. 91.2% of ulcers healed after a mean period of 1.3 months. In 56 feet (51.9%), a new ulcer occurred: 11 feet (10.2%) had an ulcer in the same area as initially (= ulcer recurrence), in 45 feet (41.7%) the ulcer was localized elsewhere (= re-ulceration). Revision surgery was necessary in 39 feet (36.1%). Only one major amputation and five complete transmetatarsal forefoot amputations were necessary during the follow-up period. Thus, the major amputation rate was 0.9%, and the minor amputation rate on the same ray was 13.9%.

Conclusions: IPFA is a valuable treatment of chronic ulcers of the forefoot. However, new ulceration is a frequent event following this type of surgery. Our results are consistent with the reported re-ulceration rate after conservative treatment of diabetic foot ulcers. The number of major amputations is low after IPFA.

Level Of Evidence: Retrospective Case Series Study (Level IV).
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http://dx.doi.org/10.1007/s00402-020-03441-3DOI Listing
April 2021

Modifications of the pirogoff amputation technique in adults: A retrospective analysis of 123 cases.

J Orthop 2020 Mar-Apr;18:5-12. Epub 2019 Nov 1.

Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.

Background: The Pirogoff amputation (1854) was initially developed to provide full-weight-bearing stumps and therefore allow a short ambulation without prosthesis. Modifications of the original technique including Boyd (1939) and the "Modified Pirogoff" were developed, which further reduced complications and improved the outcome. However, the current evidence regarding the techniques is scarce. The functional outcome, survivorship and complication rates are unknown. It was the purpose of this study to expand the knowledge with a retrospective case series and ultimately summarize and analyze the data with a systematic review.

Methods: A retrospective study of the Boyd procedures from our institution between 1999 and 2018 was performed. Outcome was determined based on the PLUS-M Score (Prosthetic Limb Users Survey of Mobility). Survivorship (absence of more proximal amputation), postoperative leg-length discrepancy, time to early fusion and time to mobilization were also evaluated. Finally, in the second part of the study, the results were integrated in a systematic review, which followed the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) guidelines. The quality of all the studies were then assessed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC).

Results: A total of 123 procedures including 115 patients, with an average follow-up of 45 months (range, 10-300 months) could be included. A very good or good function could be achieved in 85 (69%) patients. The mean survivorship was 82.1% (range 46%-100%). In four studies, including our series, all patients remained with a functional stump at the latest follow-up. The calculated average leg-length discrepancy was 2.5 cm.

Conclusion: The "Modified Pirogoff" and Boyd amputation techniques can achieve favourable long-term functional outcome in cases of irreparable foot conditions such as osteomyelitis or trauma. Patency of the posterior tibial artery is an indispensable condition to elect for these surgical techniques. Presence of neuropathy does not preclude this amputation level. With proper patient selection, a maximal survivorship of the stump with treatable minor complications can be achieved.Level of Evidence: IV.
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http://dx.doi.org/10.1016/j.jor.2019.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7067983PMC
November 2019

Mid-term walking ability after Charcot foot reconstruction using the Ilizarov ring fixator.

Arch Orthop Trauma Surg 2020 Dec 13;140(12):1909-1917. Epub 2020 Mar 13.

Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.

Background: Failed conservative treatment and complications are indications for foot reconstruction in Charcot arthropathy. External fixation using the Ilizarov principles offers a one-stage procedure for deformity correction and resection of osteomyelitic bone. The aim of this study was to determine whether external fixation with an Ilizarov ring fixator leads reliably to walking ability.

Materials And Methods: 29 patients treated with an Ilizarov ring fixator for Charcot arthropathy were retrospectively analyzed. Radiologic fusion at final follow up was assessed separately on conventional X-rays by two authors. The association between walking ability and the presence of osteomyelitis at the time of reconstruction, and the presence of fusion at final follow up was investigated using Fisher's exact test.

Results: Mean follow up was 35 months (range 5.3-107) months; mean time of external fixation was 113 days. Ten patients (34.5%) reached fusion, but 19 did not (65.5%). Two patients needed below knee amputation. 26 of the remaining 27 patients maintained walking ability, 23 of those without assistive devices. Walking ability was independent from the presence of osteomyelitis at the time of reconstruction and from the presence of fusion.

Conclusion: Foot reconstruction with an Ilizarov ring fixator led to limb salvage in 93%. The vast majority (96.3%) of patients with successful limb salvage was ambulatory, independent from radiologic fusion, and presence of osteomyelitis at the time of reconstruction. These findings encourage limb salvage and deformity correction in this difficult-to-treat disease, even with underlying osteomyelitis.
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http://dx.doi.org/10.1007/s00402-020-03407-5DOI Listing
December 2020

Outcome of Ray Resection as Definitive Treatment in Forefoot Infection or Ischemia: A Cohort Study.

J Foot Ankle Surg 2020 Jan - Feb;59(1):27-30

Consultant Orthopaedic Surgeon, Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland.

Ray resection is frequently performed in cases of infection or ischemia, but the literature is scarce concerning its outcome as a definitive treatment. In this retrospective cohort study, we reviewed our cohort with transmetatarsal ray resection with a mean follow-up of 36.3 months. Reulcerations, transfer ulcers, and reamputations were determined. Risk factor analysis for revision surgery was conducted. Among 185 patients, 71 (38.4%) had revision surgery within a mean of 1.4 ± 2.6 years (range 2 days to 12.9 years), 22 (11.9%) had major amputations, 49 (26.5%) had minor amputations, 11 (5.9%) had same-ray reulceration, 40 (21.6%) had transfer ulceration, and 2 (1.1%) had both reulceration and transfer ulceration. Occurrence of a postoperative ulcer was statistically significantly associated with revision surgery (p < .01). In conclusion, metatarsal ray resection is a reasonable treatment option in cases of forefoot ischemia or infection to prevent major amputation but fails in 11.9%, and reulceration is associated with further revisions, making ulcer prevention paramount.
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http://dx.doi.org/10.1053/j.jfas.2019.06.003DOI Listing
July 2020

Diabetic calcaneal osteomyelitis.

Infez Med 2019 Sep;27(3):225-238

Department of Medicine, University of Washington, Seattle, USA.

Diabetic foot infection (DFI), a multi-facetted disease requiring a multidisciplinary approach for successful treatment, mostly affects the forefoot. Calcaneal osteomyelitis (CO) is an uncommon presentation of DFI with a somewhat different epidemiology, clinical features, and approach to management. These patients, compared to those with non-calcaneal DFI, more often require special surgical techniques and off-loading approaches. In this narrative review targeted to non-surgical clinicians, we explore how CO differs from other types of DFI affecting other anatomical locations. Based on our review of the literature and personal experience, we also highlight important issues regarding the management of CO osteomyelitis, including the need for specialized surgical approaches.
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September 2019

Predictors for reoperation after lower limb amputation in patients with peripheral arterial disease.

Vasa 2019 Aug 7;48(5):419-424. Epub 2019 May 7.

Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland.

Major amputations in patients with peripheral arterial disease (PAD) carry a high risk for complications, including revision of the amputation, sometimes to a higher level. Determining a safe level for amputation with good wound healing potential depends largely on vascular measurements. This study evaluated potential predictive factors for revision of major lower extremity amputations in patients with PAD. A retrospective chart review of all major lower extremity amputations at our institution was conducted. Amputations due to trauma or tumor and below-ankle amputations were excluded. Patient demographics, level/type of amputation, level/time of revision, comorbidities and risk factors were extracted. 180 patients with PAD, mean age 66.48 (range: 31-93) years, 125 (69.4%) male were included. Most (154/180, 86.6%) underwent below-knee amputation. 71 (39.4%) patients had coronary arterial disease, 104 (57.8%) had diabetes. More than half of patients, (93/138; 51.7%) had undergone previous balloon angioplasty. 44 (30%) patients required revision surgery: 42/180 (23.3%) were revised at the same level, and in 12/180 (6.7%) a more proximal amputation was necessary. PAD stage was not associated with the level of reamputation (p = 0.4369). Significantly more patients who had previous balloon angioplasty required revision surgery (66.7% versus 45.2%, p = 0.009). 67 (37.2%) patients underwent preoperative TcPO2 measurement: 40/67 (59.7%) had TcPO2 ≥ 40 mmHg; 4/67 (6%) had TcPO2 < 10 mmHG. Three patients with TcPO2 ≥ 40 mmHg, one with 30 mmHg ≤ TcPO2 ≤ 40 mmHg and one with 10 mmHg ≤ TcPO2 ≤ 20 mmHg required re-amputation to a more proximal level. TcPO2 measurements are useful for determining level of lower limb amputation and predicting wound healing problems when an amputation level with TcPO2 < 40 mmHg is chosen. In transtibial amputations, TcPO2 ≥ 40 mmHg does not safely predict wound healing.
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August 2019

Outcome After Surgical Treatment of Calcaneal Osteomyelitis.

Foot Ankle Int 2019 May 28;40(5):562-567. Epub 2019 Jan 28.

1 Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland.

Background: Surgical procedures for calcaneal osteomyelitis are partial calcanectomy (PC), total calcanectomy (TC), and below-knee amputation (BKA). With calcaneal osteomyelitis, limb-saving surgery was described to have secondary BKA rates of 4% to 20%, while secondary amputation rates after BKA are unknown. The aim of this study was to describe and compare overall revision and secondary amputation rates for each surgical option in our institution's cohort and to identify risk factors for secondary amputation.

Methods: Fifty patients treated between 2002 and 2017 were included. Revisions, secondary amputations, and possible risk factors for secondary amputation and overall revision were statistically analyzed.

Results: Minor revisions rates were 57.1% in PCs, 100% in TCs, and 27.8% in BKAs. Secondary amputation was performed in 28.6% of the PCs, in 50% of the TCs, and in 5.6% of the BKAs. No statistically significant differences between overall revision and secondary amputation rates were found. C-reactive protein values greater than 5 mg/L at the index procedure were significantly associated with overall revision while we could not identify risk factors for secondary amputation.

Conclusion: This study represents the largest group of patients treated for calcaneal osteomyelitis in the literature. In limb-preserving surgical options, secondary BKA rates are higher than previously known. Primary BKA is a procedure with a low reamputation rate of 5.6%. PC can be considered, with 28.6% needing more proximal amputation. In TC, all patients underwent revision surgery and 50% had to undergo secondary BKA. Therefore, we hesitate to consider total calcanectomy as a surgical option in calcaneal osteomyelitis anymore.

Level Of Evidence: Level IV, case series.
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May 2019