Foot and Ankle Charcot Reconstruction PDF

Foot and Ankle Charcot Reconstruction A L L E N J K E M P F, D P M , M S , FA C FA S A S S I S TA N T P R O F E S S O R C O L L E G E O F P O D I AT R I C M E D I C I N E A N D S U R G E R Y DES MOINES UNIVERSITY D M U...

Foot and Ankle Charcot Reconstruction A L L E N J K E M P F, D P M , M S , FA C FA S A S S I S TA N T P R O F E S S O R C O L L E G E O F P O D I AT R I C M E D I C I N E A N D S U R G E R Y DES MOINES UNIVERSITY D M U F O OT A N D A N K L E C L I N I C S Modified from presentation by Dr. Pehde on Charcot arthropathy Objectives §Identify the goals of Charcot reconstruction surgery §Demonstrate knowledge of the various surgical techniques for Charcot reconstruction §Recognize the complications of Charcot reconstruction Definition “Charcot foot is a progressive condition characterized by joint dislocation, pathological fractures, and severe destruction of the pedal architecture.” JFAS, supplement 2000, Diabetic Foot Disorders: A Clinical Practice Guideline, p S38 Complex foot and ankle trauma in complex patients Diagnosis History ◦ Neuropathy – known or unknown by patient, variable causes ◦ Trauma – common but may not be realized by patient ◦ Surgery – minor or major procedures Clinical ◦ Red, hot swollen foot (>2 degrees C from contralateral limb) ◦ Pain is typically minor relative to the severity of injury Imaging ◦ Radiographs are typically all that is needed ◦ MRI – can be useful in early stages for increased inflammation ◦ CT and bone scan if unsure AO Principles for Foot and Ankle Trauma Accurate anatomical reduction Rigid internal compression fixation Preservation of blood supply Early pain free mobilization Difficult to adhere to these principles with surgical Charcot management  Treatment of Charcot Deformity oTreatment is “reactive” oDo not have the ability to screen or predict who or when a Charcot event will occur oThe goal of treatment whether it be surgical or non-surgical is to achieve a stable and plantigrade foot that enables functional ambulation with footwear and bracing or a stable limb for transfers.  When to perform Surgery ? Historically conservative care was instituted in acute stages and surgery was considered only during the quiescent stages Currently, much controversy exists about performing surgery earlier to stabilize more acute stages of Charcot arthropathy Charcot Literature Difficult to develop Evidence Based Medicine Standards Patient population with Charcot is diverse ◦ Normal BMI to the Morbidly obese ◦ Few medical comorbidities to many organ system dysfunctions Goals of treatment varies between patients ◦ Activity level can vary from transfers and minimal ambulation to being a community ambulator and gainfully employed Literature is based on expert opinion ◦ Surgical versus non –surgical care ◦ Timing of surgery ◦ What type of surgery ◦ Method of surgery Common Reasons to Operate in the Literature Recalcitrant ulcers despite appropriate offloading trial Acute fractures and dislocations in the hindfoot and ankle Unstable and painful foot and ankle deformity Resecting infected bone in cases of osteomyelitis Achilles tendon lengthening to mitigate midfoot forces Rogers et al, “The Charcot Foot in Diabetes” Diabetes Care, Vol 34, September 2011, 2123- 2129 Arthrodesis as an Early Alternative to Nonoperative Management of Charcot Arthropathy of the Diabetic Foot Sheldon Simon, et al JBJS –A, July 2000 43 diabetic patients with acute tarsal-metatarsal Eichenholtz stage-1 fracture –dislocations 14 patients elected immediate fusion with internal fixation All patients healed well without complications Gait analysis comparison was made to 2 control groups ◦ Diabetics with neuropathy and without deformity or ulceration ◦ Diabetics with BKA ◦ Did not compare outcomes with non-surgically treated patients ?? Concluded that immediate surgical correction of an acute Charcot event in the midfoot was a viable option to restore anatomical alignment and improve function Surgical Versus Accommodative Treatment for Charcot Arthropathy of the Midfoot Michael Pinzur, MD, Foot and Ankle International August 2004 147 patients with midfoot Charcot Goal of therapy: Long term, ulcer free management with commercially available depth-inlay shoes and custom accommodative orthotics Those with a plantigrade foot treated non-surgically and those without treated surgically At 1 year 87 patients met this goal without the need of surgical intervention 60 patients required surgery ◦ 42 Corrective osteotomy and attempted fusion ◦ 18 Exostectomy ◦ 8 Amputations (1 TMA, 3 Symes, 4 BKA) Author’s admitted limitations: ◦ His opinion of what was a plantigrade or not plantigrade foot ◦ His opinion that management of deformity with custom shoes or and AFO was not a desirable outcome Charcot Classifications Radiographic/Functional ◦ Eichenholtz ◦ Stage 0 (Shibata) Anatomical ◦ Brodsky ◦ Sanders and Frykberg Risk Assessment ◦ Roger’s System Are these classifications useful to guide treatment ? ◦ An opinion – radiographic/ functional and the anatomical classifications on their own are not useful to guide treatment. Combination of the two much more useful to guide surgical treatment options. Eichenholtz Stage 1 - Developmental (acute) Hyperemia due to autonomic neuropathy weakens bone and ligaments Diffuse swelling, joint laxity, subluxation, frank dislocation, fine periarticular fragmentation, debris formation Eichenholtz Stage I  Eichenholtz Stage 2-Coalescence Start of this stage occurs when osseous debris is resorbed and new bone is laid down Bone healing occurs in same manner as fracture healing- woven bone followed by lamellar bone Edema and joint crepitus reduced and joint stability increased Quiescent or reparative stage Eichenholtz Stage II Eichenholtz Stage 3-Reconstruction Lasts months to years Further remodeling of bone and joint structures Joints reestablished as pseudoarthroses or ankyloses Quiescent or reparative stage Eichenholtz Stage III Radiographic and Clinical Presentation Stage 0 (Shibata) Patient with profound neuropathy with an acute sprain or fracture – subject to full blown Charcot event This is the time to intervene with treatment to hopefully prevent a full blown Charcot event! Eichenholtz Stage 0  Sanders and Frykberg I IPJ’s, phalange, MTP’s, and Metatarsals II Tarsometatarsal joints III NC, TN, and CC joints IV Ankle joint V Calcaneus  Roger’s Charcot Foot Classification System Based on location and stage Location Forefoot to Rearfoot/Ankle Stage Charcot with and without deformity Charcot deformity with ulcer Charcot deformity with osteomyelitis Predictor of Extremity amputation Rogers LC, Bevilacqua NJ. The diagnosis of Charcot foot. Clinics in Podiatric Medicine and Surgery, 2008;25: 43-51 Charcot Classifications Are these classifications useful to guide treatment ? (opinion) ◦ Radiographic/ functional and the anatomical classifications on their own are not useful to guide treatment. ◦ Minimally helpful in combination Surgical Treatment Surgical Treatment There is not a set algorithm for treating Charcot deformities Many different approaches by several experts in the field with good success (lowest quality of evidence) Ultimately, it is up to the comfort and skill level of the treating surgeon. Surgical Treatment Management of soft tissue and osseous infections ◦ Need to eradicate all soft tissue and osseous infections before final reconstruction for optimal, lasting outcomes Amputation ◦ Partial foot ◦ Below Knee or Above Knee ◦ Consider in patients who medically and psychologically are not prepared for long treatment period with almost guaranteed complications Surgical Treatment In general, perform more simple procedures to more complex Correction of equinus deformity Exostectomies - not typical for hindfoot and ankle When foot is structurally stable and bony prominence is underlying etiology Arthrodesis and Osteotomy procedures When architecture of foot and ankle is not structurally stable Surgical Approaches Large extensile incisions ◦ Allow access to bone and joints ◦ Anatomy is typically aberrant ◦ Better for patients with better skin quality Minimal incision approach ◦ Can utilize Gigli saw to make osteotomies ◦ May also use bur for osteotomies ◦ Keeps soft tissue envelopes intact ◦ Better for patients with poor tissue quality Ulcers ◦ Soft tissue reconstructive ladder for approach ◦ Secondary healing versus resection and flap Fixation Considerations Bone quality ◦ Will screw fixation be stable Has infection been cleared ? ◦ Avoid internal fixation in areas of infection Fixation Considerations Amount of deformity correction ◦ May need to consider external fixation or Intramedullary Nailing for sever hindfoot deformities Can patient be non-weightbearing ? ◦ Caution in allowing neuropathic patients to bear weight in external fixator – Can “walk out of the frame” ◦ Utilize external fixation to augment and protect surgery  Internal Fixation Options Internal Fixation ◦ Screws ◦ Cannulated ◦ Non-cannulated ◦ K-wires ◦ Steinman pins Plates Intramedullary Nailing ◦ Tibial-talo-calcaneal fusions Staples External Fixation Options Circular Ring Fixator Computer Assisted Ring Fixators Uniplanar fixator Delta Frame Hybrid Combined Fixation Internal and External Fixation Can utilize static external fixator to augment internal fixation ◦ Patients who cannot be fully NWB ◦ Prevent further acute Charcot changes induced by internal fixation Can utilize dynamic external fixator for correction of deformity and then apply internal fixation Acute Charcot When to Perform Surgery in Acute Charcot Events Ankle and hindfoot trauma with fracture and/or dislocation Calcaneus fractures with and without ulcers Severe Charcot event in patients with contralateral proximal leg amputations or recent contralateral foot and ankle reconstruction When to Perform Surgery ? Ankle and Rearfoot “Given the common failures of nonsurgical management of CN of the ankle, the task force members agree that surgical management could be considered a primary treatment.” ◦ Task force 15 experts from around the globe Rogers et al, “The Charcot Foot in Diabetes” Diabetes Care, Vol 34, September 2011, 2123- 2129 Trauma – Fractures Wukich et al, “Outcomes of Ankle Fractures in Patients with Uncomplicated Versus Complicated Diabetes, FAI, Feb 2011, 120-130 Retrospective review of 105 diabetic patients with mean follow up of 21.4 months ◦ Complicated 46 patients ◦ PVD, neuropathy, nephropathy ◦ Uncomplicated 59 patients ◦ Absence of major end organ damage Trauma – Fractures Wukich et al, “Outcomes of Ankle Fractures in Patients with Uncomplicated Versus Complicated Diabetes, FAI, Feb 2011, 120-130 Group with complicated diabetes had ◦ 3.8 times increased risk of overall complications ◦ 3.4 times increased risk of non-infectious (malunion, nonunion, Charcot) complication ◦ 5 times higher likelihood of needing revision surgery/arthrodesis Conclude that : ◦ Preoperative assessment of neurovascular status is imperative for adequate treatment ◦ Treat patients with diabetic neuropathy and unstable ankle fractures as a Stage O Charcot ◦ Utilize additional fixation and prolonged NWB of 3 months Case presentation: 51-year-old diabetic male with peripheral neuropathy Well known to Provider for previous left 2nd toe wound leading to successfully healed toe amputation. Called to cancel his regular diabetic foot exam for the morning due to falling on ice – went to ER ◦ He knew he broke his ankle, not because of pain but because of the severe angle of his ankle and swelling Treatment Closed reduced in ER by staff doctor due to neurovascular compromise and splint applied OR that day for application of Delta Frame for stabilization of ankle fracture and soft tissue 6 days lateral internal fixation applied and delta frame left intact Delta frame removed at 7 weeks Fiberglass cast for 2 weeks Transitioned to cam boot for 3 weeks and then into shoe gear. Neuropathic Calcaneal Fractures Significant injury that can lead to limb amputation Scarce literature on topic ◦ Mostly case studies and descriptive analysis ◦ Little evidence to guide best treatment options ◦ Primary proximal amputation ◦ Resection of fracture fragments ◦ Calcanectomy ◦ Non-surgical casting ◦ Soft tissue closure Case presentation: Diabetic male with large chronic plantar heel wound treated successfully with angioplasty for PVD and aggressive debridement with wound vac therapy. Healed wound 80% over 8-week period without incident. Called with minor pain in heel and acute bleeding from wound Immediate Post op Loss majority of superficial layer of plantar flaps Subcutaneous tissue survived – no bone exposed Aggressive wound care with wound vac Skin grafting with ex-fix removal 7 Weeks Post Op 11 Months Post Op Ambulates in CROW Legally blind due to complications of retinopathy Charcot restraint orthotic walker Chronic Charcot Surgery When to perform Surgery in Chronic Charcot Ulcers not amenable to conservative care in a timely fashion ( weeks to months?) Deformities that are unable to be braced Instability of foot and ankle Chronic pain in the foot and ankle  Case Presentation: Chronic Charcot Arthropathy with a Recent Flare-Up 64-year-old female presents with continued Physical exam: complications to the left ankle/rearfoot.( history of a previous Charcot arthropathy and ankle Vasc: Dp and Pt +1/4 barely palp B/L fracture.) Patient also has a history of a cft< 3sec. B/L transmetatarsal amputation of the right foot. Neuro: epicritic sensation diminished B/L PMH: (Sharp/dull, protective, proprioception are all -Diabetes with neuropathy, HTN diminished) Musc:+5/5 extrinsic musculature B/L collapsed midfoot, with developing varus deformity Imaging work up for surgical planning should consist of a flat foot series and a CT. Sagittal evaluation of CT 3D reconstruction of the CT External fixation Remained on the leg for 12 weeks Internal fixation was placed once the external fixation was removed It didn’t take long before complications arose, although patient had a very good outcome Wound dehiscence occurred post correction 1 year S/P the original surgery, 3 months S/P revision Case Presentation: Exostectomy with Flap Closure Steinman pin to hold alignment of rearfoot and ankle – will be removed Case Presentation 52-year-old female PMH: NIDDM, HTN, peripheral neuropathy, urinary incontinence Meds: glucovance, prinizide, avapro, cardura NKDA PsxHx: noncontributary Pre-operative evaluation Wound culture: polymicrobic mix of organisms ◦ ID consult, PICC, Zosyn Vascular studies: ABI 1.0 bilateral, biphasic pulses Ceretec scan: + cellulitis, with clinical correlation - osteomyelitis 50-Year-Old Diabetic Male with Charcot RockerBottom deformity Treated with multiple surgical debridements of the lateral plantar cuboid and 5th ray for infections. Lead to PB dysfunction and complex rockerbottom and varus deformity Non-healing wound despite aggressive wound care and non-surgical offloading Complications Complication Definition In medicine, an unanticipated problem that arises following, and is a result of, a procedure, treatment, or illness. A complication is so named because it complicates the situation Complication Types Patient Complication Soft Tissue ◦ Irritation ◦ Infection - superficial, deep, abscess ◦ Impingement ◦ Skin loss Bone ◦ Fracture ◦ Osteomyelitis ◦ Nonunion, malunion, delayed union Neurological ◦ Traction injury ◦ Wire or pin insertion injury Vascular ◦ Acute trauma from wire or pin insertion ◦ Latent vascular compromise Hardware Complication Internal fixation Hardware breakage and or infection External Fixation ◦ Broken wires ◦ Broken half pin ◦ Loose wire ◦ Loose half pin ◦ Broken or compromised rings ◦ Broken components Sizing errors ◦ Rings too big - leads to trampoline effect ◦ Rings too small - soft tissue impingement http://www.southfloridasportsmedicine.com/fractures-pictures.html Complication Severity Minor Moderate Severe Minor Complications An event in which a change is not required in the index procedure treatment plan. Can be resolved as an outpatient and does not require invasive procedures. Examples ◦ Pin tract infection resolved with wound care and oral antibiotics ◦ Frame adjustment changes in the office setting – Russian Technique for loose wire Moderate Complications An event in which a change is not required in the index procedure treatment plan. Requires more invasive care and admission to hospital or outpatient surgical setting to resolve. Examples ◦ IV antibiotics for pin tract infection ◦ Exchange of broken wires or half pins. ◦ Unexpected modification of frame that does not involve the index procedure Major Complications An event in which a change is required in the index procedure treatment plan or additional surgical procedures are required to correct a complication related directly to the external fixator. Requires more invasive care and admission to hospital or outpatient surgical setting to resolve. Examples ◦ Premature removal of frame due to severe infection or failure of frame and alternative treatments to index procedure are required (need for BKA ) ◦ Correction of major soft tissue deficits with extended wound care or surgical soft tissue reconstruction ◦ Treatment of osteomyelitis with extended IV antibiotics and/ or surgical resection External Fixation Common for some type of post operative issues Pin tract infections most commonly reported ◦ Studies report between 5 to 100 % Variability in literature on descriptions of complications and underlying factors ◦ Definition of a major versus minor complication Diabetes plays a major role in complications 15 patients (16 Limbs) Complications ◦ Serious pin tract infection - 5 ◦ Required hospitalization for IV antibiotics and or removal and wire exchange ◦ Pin fracture - 4 ◦ Wound Dehiscence – 9 ◦ Complication of external fixation ?? 283 patients over an 11-year period with Charcot foot, ankle or combined reconstruction Minimalist approach to pin care 59 patients (20.8%) developed clinical signs of pin tract infection in at least 1 site All Infections resolved with local pin care and oral antibiotics None required premature removal of wire Compared rate of complications in diabetic (33) versus non –diabetic (23) over 3-year period Males with greater number of complications Diabetics with 7 –fold risk for wire complications Divided complications into minor and major ◦ Minor – Event that did not require change in treatment plan (pin irritation, minor infection) ◦ Major – Event that did require change in treatment plan (wire exchange for broken wire or modification of frame pin tract infection requiring IV antibiotics ) Total complications ◦ DM 44 Non-DM 14 Minor ◦ DM 27 Non-DM 10 Major ◦ DM 17 Non-DM 4 Majority of complications wire or half pin No osteomyelitis or amputation 1 fracture Mechanical Complication Mild Mechanical complications Mild or moderate Soft tissue pin tract infection with abscess Moderate  Skin Complication Major Vascular Status fully intact per arteriogram Required wound care and soft tissue reconstruction with lateral calcaneal artery flap Case presentation:  Osseous complication Major Latent osteomyelitis Required removal of hardware and partial calcanectomy Preventing Complications Many complications can be avoided by technique in the OR ◦ Safe zone application of pins and wires ◦ Pre op sizing of rings ◦ Allow sizing adjustment for ESRD on dialysis to allow for some swelling ◦ Technique for application of pins and wires Post operative care ◦ Pin site care ◦ Controlling edema in operative limb Post operative weight bearing Conclusions Foot and ankle Charcot is a reactive disease The treatment goal of the Charcot foot is to allow a plantigrade braceable foot that is not prone to further breakdown. Development of Evidence Based Medicine principles for surgical versus non-surgical treatment is difficult due to the variability of patients, the Charcot event, and the treating surgeons approach