Session 7: Foot and Ankle
Torsdag den 24. oktober
09:30 - 10:30
Lokale: Vingsal 1
Chairmen: Ellen Hamborg-Petersen og Jens Kurt Johansen
Tue Smith Jørgensen, Maria Leinum, Hans Gottlieb, Stig Brorson, Ylva Hellsten, Birgitte Høier
Orthopedic, sport and foot surgery, Gentofte; Nutrition exercise and sports, university of copenhagen; Orthopedic, Herlev Hospital; Orthopedic, Zealand university Hospital; Nutrition exercise and sports, university of copenhagen; Nutrition exercise and sports, university of Copenhagen
Background: Diabetic foot ulcers are a frequent and serious complication in diabetes. Exercise can promote wound healing but as, many of the patients have poor exercise tolerance, passive movement may be an alternative.
Purpose / Aim of Study: To evaluate the effect of 8 weeks of passive movement training of both legs on wound healing in patients with non- healing diabetic foot ulcers.
Materials and Methods: Twenty-one patients were included in a randomized, controlled, clinical trial with two-leg passive movement. Wound healing, patient compliance, femoral blood flow, blood samples, functional tests and muscle proteins related to vascular function and angiogenesis were assessed.
Findings / Results: 16 participants completed the trial. Two participants from the intervention group and two from the control group were excluded due to adverse events not related to the intervention. There was a clinically, but not statistically, significant improvement of 40% in wound healing (p=0.062) with the passive movement intervention. There was a significant negative correlation (p=0.037) between the duration of the wound at baseline and wound area reduction after the eight-week intervention period. The intervention did not alter blood flow, and there was no change in measured angiogenic or vascular proteins.
Conclusions: The intervention was well tolerated and had a clinically significant effect on wound healing. The modality has potential as an effective first line treatment in diabetic patients with reduced physical abilities to accelerate healing of non-healing ulcers.
Orthopedic, sport and foot surgery, Gentofte; Nutrition exercise and sports, university of copenhagen; Orthopedic, Herlev Hospital; Orthopedic, Zealand university Hospital; Nutrition exercise and sports, university of copenhagen; Nutrition exercise and sports, university of Copenhagen
Background: Diabetic foot ulcers are a frequent and serious complication in diabetes. Exercise can promote wound healing but as, many of the patients have poor exercise tolerance, passive movement may be an alternative.
Purpose / Aim of Study: To evaluate the effect of 8 weeks of passive movement training of both legs on wound healing in patients with non- healing diabetic foot ulcers.
Materials and Methods: Twenty-one patients were included in a randomized, controlled, clinical trial with two-leg passive movement. Wound healing, patient compliance, femoral blood flow, blood samples, functional tests and muscle proteins related to vascular function and angiogenesis were assessed.
Findings / Results: 16 participants completed the trial. Two participants from the intervention group and two from the control group were excluded due to adverse events not related to the intervention. There was a clinically, but not statistically, significant improvement of 40% in wound healing (p=0.062) with the passive movement intervention. There was a significant negative correlation (p=0.037) between the duration of the wound at baseline and wound area reduction after the eight-week intervention period. The intervention did not alter blood flow, and there was no change in measured angiogenic or vascular proteins.
Conclusions: The intervention was well tolerated and had a clinically significant effect on wound healing. The modality has potential as an effective first line treatment in diabetic patients with reduced physical abilities to accelerate healing of non-healing ulcers.
Rasmus Mikkelsen, Sanja Somodi, Per Hölmich, Kristoffer Barfod
Artroskopisk Center, SORC-C, Hvidovre Amager Hospital ; Radiologisk afdeling, Herlev og Gentofte Hospital; Artroskopisk Center, SORC-C, Hvidovre Amager Hospital ; Artroskopisk Center, SORC-C, Hvidovre Amager Hospital
Background: Orthoses are an important part of both conservative and operative treatment of acute Achilles tendon rupture. It is believed to be of critical importance to position the foot in equinus in order to protect the torn tendon from strain and allow the tendon to heal in correct length.
Purpose / Aim of Study: The aim of the study was to test four different orthoses, commercially available and commonly used in treatment of acute Achilles ruptures.
Materials and Methods: Lateral radiographs were taken of the right ankle and foot in 5 healthy study participants. Each participant had 11 true lateral radiographs taken: One of the ankle joint in neutral position. One of a circular equinus cast (CEC). Three of an adjustable equinus boot (VACOped) with the foot in 30°, 15° and 0° of plantar flexion, respectively. Three of a DJO AirSelect Standard boot with 3, 2 and 1 Aircast Achilles wedge (AAW), respectively. And finally, three of a DJO AirSelect Standard boot with 3, 2 and 1 BREG wedges, respectively. The radiographs were analyzed by a radiologist for the following two radiographic measurements: The tibiocalcanar angle (TCA) and the Achilles Relief Distance (ARD).
Findings / Results: The lateral radiographs showed a mean (SD) TCA of 86 (7,8) in CEC, 76 (7,3) with 3 AAW, 90 (6,9) with 3 BREG wedges and 84 (6,6) in the VACOped in 30 of plantarflexion. There was significant greater TCA using VACOped (p<0.01) and 3 BREG (p<0.01) compared to 3 AAW. The mean ARD (SD) was 10mm (6,6) in CEC, 19mm (5,5) with 3 AAW, 7mm (4,5) with 3 BREG and 12mm (4,6) using VACOped in 30. ARD was significantly lower in CEC (p<0.05), 3 BREG (p<0.01) and VacoPed 30 (p<0.05) compared to 3 AAW. No difference was shown comparing 1 vs 3 AAW´s in ARD (p=0,18) with a mean of 22,6 mm and 19,0 mm respectively.
Conclusions: The study found that CEC, 3 BREG and VACOped 30 produced significantly better equinus compared to 3 AAW. We believe the difference to be of clinical relevance in the treatment of acute Achilles tendon ruptures.
Artroskopisk Center, SORC-C, Hvidovre Amager Hospital ; Radiologisk afdeling, Herlev og Gentofte Hospital; Artroskopisk Center, SORC-C, Hvidovre Amager Hospital ; Artroskopisk Center, SORC-C, Hvidovre Amager Hospital
Background: Orthoses are an important part of both conservative and operative treatment of acute Achilles tendon rupture. It is believed to be of critical importance to position the foot in equinus in order to protect the torn tendon from strain and allow the tendon to heal in correct length.
Purpose / Aim of Study: The aim of the study was to test four different orthoses, commercially available and commonly used in treatment of acute Achilles ruptures.
Materials and Methods: Lateral radiographs were taken of the right ankle and foot in 5 healthy study participants. Each participant had 11 true lateral radiographs taken: One of the ankle joint in neutral position. One of a circular equinus cast (CEC). Three of an adjustable equinus boot (VACOped) with the foot in 30°, 15° and 0° of plantar flexion, respectively. Three of a DJO AirSelect Standard boot with 3, 2 and 1 Aircast Achilles wedge (AAW), respectively. And finally, three of a DJO AirSelect Standard boot with 3, 2 and 1 BREG wedges, respectively. The radiographs were analyzed by a radiologist for the following two radiographic measurements: The tibiocalcanar angle (TCA) and the Achilles Relief Distance (ARD).
Findings / Results: The lateral radiographs showed a mean (SD) TCA of 86 (7,8) in CEC, 76 (7,3) with 3 AAW, 90 (6,9) with 3 BREG wedges and 84 (6,6) in the VACOped in 30 of plantarflexion. There was significant greater TCA using VACOped (p<0.01) and 3 BREG (p<0.01) compared to 3 AAW. The mean ARD (SD) was 10mm (6,6) in CEC, 19mm (5,5) with 3 AAW, 7mm (4,5) with 3 BREG and 12mm (4,6) using VACOped in 30. ARD was significantly lower in CEC (p<0.05), 3 BREG (p<0.01) and VacoPed 30 (p<0.05) compared to 3 AAW. No difference was shown comparing 1 vs 3 AAW´s in ARD (p=0,18) with a mean of 22,6 mm and 19,0 mm respectively.
Conclusions: The study found that CEC, 3 BREG and VACOped 30 produced significantly better equinus compared to 3 AAW. We believe the difference to be of clinical relevance in the treatment of acute Achilles tendon ruptures.
Marianne Christensen, Jennifer A Zellers, Inge Lunding Kjær, Karin Grävare Silbernagel, Michael Skovdal Rathleff
Physiotherapy and Occupational Therapy, Orthopaedic Research Unit, Department of Clinical Medicine, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA; Orthopaedic Research Unit, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA, Department of Orthopaedics, University of Gothenburg, Sweden; Physiotherapy and Occupational Therapy, Aalborg University Hospital
Background: Achilles tendon rupture is associated with long-term deficits in lower leg muscle strength and function which impairs the ability to participate in sport, physical activity and physically demanding work. Irrespective of surgical or non-surgical treatment, Early Functional Rehabilitation (EFR) is recommended after initial treatment. Resistance exercise is a key component of EFR, but no synthesis of the specific exercises exists.
Purpose / Aim of Study: To describe the resistance exercises used in EFR in the treatment for acute Achilles tendon rupture and to investigate the completeness of the exercise descriptions.
Materials and Methods: A systematic review was performed in MEDLINE, Embase, PEDro, CINAHL and Cochrane. Inclusion criteria were RCTs, cohort studies and case series (¡Ý10 participants) using resistance exercise in the immobilization period within eight weeks after Achilles tendon rupture. Completeness of the exercise description in the publications was assessed with the CERT and the Toigo & Boutellier exercise reporting checklists.
Findings / Results: 38 studies were included, containing 51 different programs with resistance exercises. Twenty consisted of isometric exercise, 6 used heel-rises, 13 used strengthening with external resistance and 12 were unspecified. None of the studies reported all items of the reporting checklists. Repetitions and sets were described in 6 of the 51 interventions. The completion of CERT were median (IQR) 8(6;10) of the 19 items possible. Completion of Toigo and Boutellier were 2(1;3) of the 13 items possible.
Conclusions: Resistance exercise as part of EFR captures a variety of approaches targeted at training the ankle plantar flexors, however, this review highlights the inadequate description of these interventions. When even the most common exercise descriptors are lacking it presents a substantial obstacle in implementing evidence- based exercise in clinical practice.
Physiotherapy and Occupational Therapy, Orthopaedic Research Unit, Department of Clinical Medicine, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA; Orthopaedic Research Unit, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA, Department of Orthopaedics, University of Gothenburg, Sweden; Physiotherapy and Occupational Therapy, Aalborg University Hospital
Background: Achilles tendon rupture is associated with long-term deficits in lower leg muscle strength and function which impairs the ability to participate in sport, physical activity and physically demanding work. Irrespective of surgical or non-surgical treatment, Early Functional Rehabilitation (EFR) is recommended after initial treatment. Resistance exercise is a key component of EFR, but no synthesis of the specific exercises exists.
Purpose / Aim of Study: To describe the resistance exercises used in EFR in the treatment for acute Achilles tendon rupture and to investigate the completeness of the exercise descriptions.
Materials and Methods: A systematic review was performed in MEDLINE, Embase, PEDro, CINAHL and Cochrane. Inclusion criteria were RCTs, cohort studies and case series (¡Ý10 participants) using resistance exercise in the immobilization period within eight weeks after Achilles tendon rupture. Completeness of the exercise description in the publications was assessed with the CERT and the Toigo & Boutellier exercise reporting checklists.
Findings / Results: 38 studies were included, containing 51 different programs with resistance exercises. Twenty consisted of isometric exercise, 6 used heel-rises, 13 used strengthening with external resistance and 12 were unspecified. None of the studies reported all items of the reporting checklists. Repetitions and sets were described in 6 of the 51 interventions. The completion of CERT were median (IQR) 8(6;10) of the 19 items possible. Completion of Toigo and Boutellier were 2(1;3) of the 13 items possible.
Conclusions: Resistance exercise as part of EFR captures a variety of approaches targeted at training the ankle plantar flexors, however, this review highlights the inadequate description of these interventions. When even the most common exercise descriptors are lacking it presents a substantial obstacle in implementing evidence- based exercise in clinical practice.
Marianne Christensen, Jennifer A Zellers, Inge Lunding Kjær, Michael Skovdal Rathleff, Karin Grävare Silbernagel
Physiotherapy and Occupational Therapy, Orthopaedic Research Unit, Department of Clinical Medicine, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA; Orthopaedic Research Unit, Aalborg University Hospital; Physiotherapy and Occupational Therapy, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA, Department of Orthopaedics, University of Gothenburg, Sweden
Background: Early functional rehabilitation is a key feature in treatment of Achilles tendon rupture, but there is a lack of consistency in what defines early functional rehabilitation across studies.
Purpose / Aim of Study: To define early functional rehabilitation when used to treat Achilles tendon rupture, and to identify outcome measures evaluating the effect of treatment.
Materials and Methods: 174 studies (published 1979-2018) were included. Studies rated a median (IQR) of 17(15-20) on the Downs & Black. Early functional rehabilitation incorporated weight bearing (95%), range of motion (73%) and isometric/strengthening exercise (50%). Weight bearing was initiated within the first week, whereas exercise (i.e. ankle range of motion, strengthening, whole body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (3.0(2.0-4.0)weeks), simple (2.0(0.0-2.3)weeks), or augmented surgical repair (0.5(0.0-2.8) weeks)(p = 0.017). Functional outcomes were reported in 130 studies, including ankle range of motion (n=84) and strength (n=76). Other outcome domains included patient reported outcomes (n=89), survey-based functional outcomes (n=50), and tendon properties (n=53).
Findings / Results: 174 studies (published 1979-2018) were included. Studies rated a median (IQR) of 17(15-20) on the Downs & Black. Early functional rehabilitation incorporated weight bearing (95%), range of motion (73%) and isometric/strengthening exercise (50%). Weight bearing was initiated within the first week, whereas exercise (i.e. ankle range of motion, strengthening, whole body conditioning) was initiated in the second week. Functional outcomes were reported in 130 studies, including ankle range of motion (n=84) and strength (n=76).
Conclusions: Early functional rehabilitation includes weight bearing and a variety of exercise-based interventions initiated within the first 2 weeks following acute Achilles tendon rupture. Because early functional rehabilitation has lacked a standardised definition, interventions and outcome measures are highly variable and pooling data across studies should be done with attention to what was included in the intervention and how treatment was assessed.
Physiotherapy and Occupational Therapy, Orthopaedic Research Unit, Department of Clinical Medicine, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA; Orthopaedic Research Unit, Aalborg University Hospital; Physiotherapy and Occupational Therapy, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA, Department of Orthopaedics, University of Gothenburg, Sweden
Background: Early functional rehabilitation is a key feature in treatment of Achilles tendon rupture, but there is a lack of consistency in what defines early functional rehabilitation across studies.
Purpose / Aim of Study: To define early functional rehabilitation when used to treat Achilles tendon rupture, and to identify outcome measures evaluating the effect of treatment.
Materials and Methods: 174 studies (published 1979-2018) were included. Studies rated a median (IQR) of 17(15-20) on the Downs & Black. Early functional rehabilitation incorporated weight bearing (95%), range of motion (73%) and isometric/strengthening exercise (50%). Weight bearing was initiated within the first week, whereas exercise (i.e. ankle range of motion, strengthening, whole body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (3.0(2.0-4.0)weeks), simple (2.0(0.0-2.3)weeks), or augmented surgical repair (0.5(0.0-2.8) weeks)(p = 0.017). Functional outcomes were reported in 130 studies, including ankle range of motion (n=84) and strength (n=76). Other outcome domains included patient reported outcomes (n=89), survey-based functional outcomes (n=50), and tendon properties (n=53).
Findings / Results: 174 studies (published 1979-2018) were included. Studies rated a median (IQR) of 17(15-20) on the Downs & Black. Early functional rehabilitation incorporated weight bearing (95%), range of motion (73%) and isometric/strengthening exercise (50%). Weight bearing was initiated within the first week, whereas exercise (i.e. ankle range of motion, strengthening, whole body conditioning) was initiated in the second week. Functional outcomes were reported in 130 studies, including ankle range of motion (n=84) and strength (n=76).
Conclusions: Early functional rehabilitation includes weight bearing and a variety of exercise-based interventions initiated within the first 2 weeks following acute Achilles tendon rupture. Because early functional rehabilitation has lacked a standardised definition, interventions and outcome measures are highly variable and pooling data across studies should be done with attention to what was included in the intervention and how treatment was assessed.
Hansen Maria Swennergren , Helander Katarina Nilsson , Karlsson Jon
Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark.; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
Background: The Achilles tendon Total Rupture Score (ATRS) is a commonly used patient reported outcome in patients with an acute Achilles tendon rupture. The score contains ten items of which the last three concerns tasks that some patients cannot and some do not perform. No manual for the use of ATRS has been developed. The purpose was to investigate how ATRS responds at 4, 12 and 24 months after rupture and develop a manual for the use of ATRS.
Purpose / Aim of Study: This study has a mixed method. The first part was performed as a retrospective registry study analysing prospectively gathered data from the Danish Achilles tendon Database. The data was gathered 4, 12 and 24 months after rupture. The original score based on 10 items was compared with a score based on the first 7 items adjusted to the same scale as the original score. Density- and scatterplots were made and differences between the scores were tested by t-test or Mann–WhitneyU test. The second part has an explorative design where a manual to ATRS was developed. To validate some of the changes in the manual, patient involvement is used in a focus group interview.
Materials and Methods: 2790 completed ATRS scores were included. The 7- item score statistically significantly overestimated the value of the 10 items score at all time points (p<0.001) but only at 4 months a clinically relevant difference was found (9.7points).
Findings / Results: The original ATRS needs to specified and updated.
Conclusions: When ATRS is used for evaluation within the first 4 months after injury, the results are skewed due to a problem with the last three items. Based on this finding, a manual for the use of ATRS was developed including an updated version of ATRS.
Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark.; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
Background: The Achilles tendon Total Rupture Score (ATRS) is a commonly used patient reported outcome in patients with an acute Achilles tendon rupture. The score contains ten items of which the last three concerns tasks that some patients cannot and some do not perform. No manual for the use of ATRS has been developed. The purpose was to investigate how ATRS responds at 4, 12 and 24 months after rupture and develop a manual for the use of ATRS.
Purpose / Aim of Study: This study has a mixed method. The first part was performed as a retrospective registry study analysing prospectively gathered data from the Danish Achilles tendon Database. The data was gathered 4, 12 and 24 months after rupture. The original score based on 10 items was compared with a score based on the first 7 items adjusted to the same scale as the original score. Density- and scatterplots were made and differences between the scores were tested by t-test or Mann–WhitneyU test. The second part has an explorative design where a manual to ATRS was developed. To validate some of the changes in the manual, patient involvement is used in a focus group interview.
Materials and Methods: 2790 completed ATRS scores were included. The 7- item score statistically significantly overestimated the value of the 10 items score at all time points (p<0.001) but only at 4 months a clinically relevant difference was found (9.7points).
Findings / Results: The original ATRS needs to specified and updated.
Conclusions: When ATRS is used for evaluation within the first 4 months after injury, the results are skewed due to a problem with the last three items. Based on this finding, a manual for the use of ATRS was developed including an updated version of ATRS.
Ingvild Kummen, Ngwe Phyo , Venu Kavarthapu
Department of Orthopedics/ Diabetic Foot Clinic, Kings College Hospital, London, UK; Department of Orthopedics/ Diabetic Foot Clinic, Kings College Hospital, London, UK; Department of Orthopedics /Diabetic Foot Clinic,
Background: Surgical reconstruction of the most severe Charcot foot or ankle deformities using internal fixation has become a more and more commonly used option. However, there has been a concern that this carries a higher risk of major hardware failure.
Purpose / Aim of Study: The aim of our study was to look at the demographics of hardware failure and non-union in Charcot midfoot and hindfoot reconstructions, the radiological and clinical outcomes in those with and without hardware failure.
Materials and Methods: We retrospectively reviewed our 78 patients with the mean age of 56.5 years ±11.59 years that have undergone reconstruction of Charcot deformity affecting the midfoot, hindfoot or both, between October 2007 and December 2017. Minimal follow up was 1 year. We looked at the patients demographics, radiological bone union and ability to ambulate.
Findings / Results: 19/78 (24.4%) patients had major hardware failure. 14/25 (56.0%) of the patients who underwent combination hindfoot and midfoot surgery had hardware failure, in comparison to 5/53 (9.4%) in cases with surgery in either hindfoot or midfoot (p < .001). 7/19 (36,8%) patients developed full fusion radiologically, compared to 49/59 (83.1%) of the non-hardware failure patients (p < .001). In the hardware failure group 9/19 (47.4%) were able to weight bear in shoes, in comparison to 43/59 (72.9%) in the non-hardware failure patients (p=.040). 10/19 (52.6%) patients from the hardware failure group needed a cast or orthosis to ambulate compared to 11/59 (18.6%) in the non-hardware failure group (p= .004). 8/19 (42.2%) in hardware failure cases required revision surgery, compared to 19/59 (32.2%) in the non-hardware failure cases (p= .089) The patients with BMI over 30 were 3.5 times more likely to have hardware failure (95% CI [1.08, 12.22], p = .038). Limb salvage was achieved in all patients.
Conclusions: The hardware breakage is common following Charcot hindfoot and midfoot deformity corrections, highest among combined reconstructions. However, the clinical and radiological outcomes are still satisfactory following such complex procedures. Dedicated durable hardware designed for Charcot foot reconstructions will potentially reduce this complication and improve the patient outcomes further.
Department of Orthopedics/ Diabetic Foot Clinic, Kings College Hospital, London, UK; Department of Orthopedics/ Diabetic Foot Clinic, Kings College Hospital, London, UK; Department of Orthopedics /Diabetic Foot Clinic,
Background: Surgical reconstruction of the most severe Charcot foot or ankle deformities using internal fixation has become a more and more commonly used option. However, there has been a concern that this carries a higher risk of major hardware failure.
Purpose / Aim of Study: The aim of our study was to look at the demographics of hardware failure and non-union in Charcot midfoot and hindfoot reconstructions, the radiological and clinical outcomes in those with and without hardware failure.
Materials and Methods: We retrospectively reviewed our 78 patients with the mean age of 56.5 years ±11.59 years that have undergone reconstruction of Charcot deformity affecting the midfoot, hindfoot or both, between October 2007 and December 2017. Minimal follow up was 1 year. We looked at the patients demographics, radiological bone union and ability to ambulate.
Findings / Results: 19/78 (24.4%) patients had major hardware failure. 14/25 (56.0%) of the patients who underwent combination hindfoot and midfoot surgery had hardware failure, in comparison to 5/53 (9.4%) in cases with surgery in either hindfoot or midfoot (p < .001). 7/19 (36,8%) patients developed full fusion radiologically, compared to 49/59 (83.1%) of the non-hardware failure patients (p < .001). In the hardware failure group 9/19 (47.4%) were able to weight bear in shoes, in comparison to 43/59 (72.9%) in the non-hardware failure patients (p=.040). 10/19 (52.6%) patients from the hardware failure group needed a cast or orthosis to ambulate compared to 11/59 (18.6%) in the non-hardware failure group (p= .004). 8/19 (42.2%) in hardware failure cases required revision surgery, compared to 19/59 (32.2%) in the non-hardware failure cases (p= .089) The patients with BMI over 30 were 3.5 times more likely to have hardware failure (95% CI [1.08, 12.22], p = .038). Limb salvage was achieved in all patients.
Conclusions: The hardware breakage is common following Charcot hindfoot and midfoot deformity corrections, highest among combined reconstructions. However, the clinical and radiological outcomes are still satisfactory following such complex procedures. Dedicated durable hardware designed for Charcot foot reconstructions will potentially reduce this complication and improve the patient outcomes further.