Charcot Reconstruction/Salvage Procedure Utilizing The Plantar Plate for Lisfranc’s Dislocation Lawrence A. DiDomenico, DPM FACFAS, AO FELLOW Director-Youngstown Podiatric Residency Program Charcot Joint Pathophysiology Neurotraumatic Theory( German ) Johnson,JBJS,49A:1-30,1967 Result of cumulative mechanical trauma, usually unrecognized microtrauma in a joint that is insensitive to propioception and pain Peripheral Neuropathy – sensory, motor Charcot Joint Pathophysiology Neurovascular Theory ( French ) Brower,Allman, Radiology 139:349-354,1981 Joint dissolution occurs from bone resorption and ligamentous weakening as a result of neurally stimulated vascular reflex – autonomic neuropathy Loss of vasomotor tone Epidemiology Approx. 0.2% Diabetics in U.S. will develop Charcot More common in those with diabetes >15 years (Range 0-45 years) Men=Women Bilateral involvement approx. 30% Associated Causes Tabes Dorsalis(Jean Martin Charcot-1868) Diabetes Mellitus Leprosy Syringomyelia Alcoholic Neuropathy Charcot-Marie-Tooth Disease Associated Causes Hansen’s Disease Scleroderma Hereditary sensory neuropathy Lumbar Radiculopathy Healing Time of diabetic fractures Overall union rate of fractures 163% longerLoder(1988) Healing time 187% longer in displaced fractures that require ORIF-Loder(1988) RESULT-Prolonged immobilization required! – Total contact cast – Bivalved AFO Eichenholtz Classification STAGE I- DEVELOPMENTAL(0-3 months) – Clinical-acute inflamation, edema, erythema, warmth • persistant edema most consistent physical finding – Radiographic- Demineralization, peri-articular Fragmentation, joint dislocation Eichenholtz Classification STAGE II-COALESCENCE(3-6 months) Clinical-Decreased edema, erythema, warmth Radiographic-Bony Coalescence, callus formation, periosteal NEW bone formation Eichenholtz Classification STAGE III-CONSOLIDATION(6 months-2 years) Clinical-Fixed deformity, bony prominence, “rocker bottom foot” Radiographic-Sclerotic bone formation, smoothong fracture fragments, fibrous ankylosis NEW STAGE-STAGE 0 1990-Shibata, Tada, and Hashizume Clinical-Early edema, erythema, and warmth Radiographic-Absent or minimal Schon Classification Classification for midtarsus deformities joint involvement with resulting prominences four types with three stages Rearfoot involvement not included Areas of destruction allows prediction of prominences locations Concept of lateral column involvement in stages A, B, C – – – – lateral column collapse malignant in the insensate foot unprotected overloading plantar-laterally with instability, ulceration, OM poorer prognosis with institution of more definitive earlier treatment emphasis on both medial and lateral fusion Schon Classification Schon Classification Brodsky Classification Type I foot – require treatment of ulcerations with TCC, AFO braces or Sx resection – immobilization typically less than 1 year Type II foot – extremely unstable foot type – average period of immobilization until E-II, III ~ 2 years – normal shoegear virtually impossible to achieve in this foot type Type IIIA foot – average period of immobilization until E-II, III ~ 2 years – varus/valgus disallows safe bracing – Bracing would contribute to chronic ulceration, infection, OM Brodsky Classification Brodsky Classification Role of TAL Peak plantar pressures (Armstrong et al,JBJS, 1998) – higher in acute charcot arthropathy and neuropathy with ulceration – vs. patients w/o hx of arthropathy and neuropathy of ulceration TAL (Armstrong et al, JBJS, 1999) – peak plantar forefoot pressures are reduced (27%) from 86N to 63N – decrease lever arm and osseous collapse in the mid-foot Conservative treatment Stage I – Immobilization – NWB, Bulky Dressing with posterior splint – NWB Total Contact Cast – Bi-valved AFO Conservative treatment Stage II Total Contact Cast- partial WB CROW(Charcot Restraint Orthosis Walker) Conservative treatment STAGE III CROW Double Upright brace with total contact orthosis and extra-depth shoe Diabetic Shoe Surgical treatment/indications Chronic Ulcers with assoc. bony deformities or contractures Unstable joints that are not shoe-able or braceable Recurrent infected ulcers with bony prominences Acute displaced fractures in neuropathic patients with adequate circulation Surgical Goal To restore stability and alignment so that foot wear and bracing are possible “Achieve a planti-grade weight-bearing surface that is free of infection” Myerson Surgical complications Incomplete Correction Delayed Union Non-union Infection Failed Hardware Loss of correction Failure may lead to Amputation Differential Diagnosis Cellulitis Abscess Formation Gout DVT Septic joint Complications of Charcot Neuroarthropathy Deep Infection Osteomyelitis Ulcerations/Severe Deformity Amputation Why Salvage Procedure? Single limb diabetic amputees have a 55% incidence of contra-lateral amputation within 5 years 40 to 45% of all non-traumatic amputations are caused by Diabetes Banks, McGlamry,JAPMA, 1989 Diabetes and Amputation Recent reports state that 10% to 15% of patients with diabetes require lower extremity amputation at some point during their lifetime This represents a 15 to 40 times greater risk of lower extremity amputation than the general population – Nonpublished data, Cooper, P.S., Partial foot amputationa in the diabetic patient. Presentated at the Challenge of the Diabetic Foot Course of the American Orthopaedic Foot and Ankle Society, Washington DC, September 28th, 1997 Costs of arthrodesis vs. BKA in neuropathic patients Total cost of the reconstructive group during a five year period was 14% less than the total cost of the amputation group during the same period – Nonpublished data, Johnson, O’Brien,Hart, Mitchell,Gould, Annual Summer meeting of American Othopaedic Foot & ankle Society, June 30th,1996. Costs of early athrodesis in Charcot Foot 14 pts with stage I Mid-foot breakdown Avg. follow-up 41 months Mean charge for operative tx and follow-up care was $9,527 to $16,417. Mean charge for BKA in 11 pts during same period was $17,261 to $39,045. – Simon et al, JBJS,82-A:939-950, 2000 Cost of Diabetes It is estimated that 25% of Medicare expenditure is directed toward management of patients with diabetes Approximately 5% of all healthcare dollars is consumed in management of the secondary complications of diabetes – Nonpublished data, Pedowitz,W.J., Costs of treatment: Effect of managed care, presented at The Challenge of the Diabetic Foot Course of the American Orthopaedic Foot and Ankle Society, Washington DC, September 27th, 1997 Diabetes and Hospitalization The most common diabetic complication requiring hospitalization is foot disease Estimates suggest that diabetic foot disorders account for 16% of total diabetic admissions and 23% of total diabetic hospital days - Nonpublished,data, Sammarco, G.J., presented at The Challenge of the Diabetic Foot Course of the American Orthopaedic Foot and Ankle Society, Washington, DC, September 27th, 1997 Results of operative treatment Papa, Myerson, and Girard-1993-JBJS – 66% fusion rate in 29 pts. Who underwent arthrodesis procedures(with 7 of 10 remaining demonstrating clinically stable pseudoarthrosis – Stuart and Morrey-1990-Clin. Ortho • Ankle and hindfoot arthrodesis • 7out of 13 obtained clinical union(used ext. fix in 9 of 13) Results of operative treatment Shibata et al.-1990-JBJS – Hindfoot Fusions in pts. With leprtotic neuropathy using intra-medullary nail – Avg. 9.5 month follow-up – 19 out of 26 fusions-73% Timing of Surgical Intervention Traditionally Done in stage II or III Certain neuropathic fractures may be surgically reduced and fixed if treatment is performed early Remains controversial Results of early operative treatment 14 patients with Eichenholtz stage I mid-foot involvement. Avg. 41 months follow-up 100% success with no reported ulcerations or complications Early intervention may reverse Charcot process Simon et al, JBJS, 82-A:939-950,2000 Contra-indications to arthrodesis Active infection Acute phase of Charcot Poor glycemic control and nutritional status Peripheral vascular disease Poor bone stock Co-morbidities(Heart,Renal,etc) Plantar Plate: Biomechanical Analysis and Rationale Plantar Plate vs. screw fixation for mid-foot fusions in cadavers Results: Plantar plate provided a sturdier, stronger fixation when compared to screw fixation Conclusion: Plantar plate decreases the likelihood of collapse and non-union • Foot&AnkleInt,Vol 19,1998,Marks,Parks,Schon Tension Band Principles In an eccentrically loaded bone, the bending forces created are converted by the action of the plate into further compressive stresses AO Tension Band Principles Eccentric loading of a bone results in one side being loaded in tension and the other in compression AO Tension Band Principles Under an eccentric load, the gap will open first on the tension side AO Tension Band Principles If the plate is applied to the concave side which is under compression, under load the only resistance to deformity is the stiffness of the plate AO Tension Band Principles A plate applied to the tension side of bone will prevent the deformity As load increases, the plate will be put under tension and the cortex opposite the plate will come under compression Case Presentation #1-LA 72 y/o male, IDDM, Hx of unstable Right midfoot with CC pain in medial aspect of foot PMH:IDDM ALL:NKDA SOCIAL Hx: 40 pack year Hx VASC:palpable DP/PT B/L Case Presentation #1-LA Neuro: Absent protective sensation Musc: Equinas deformity Right Pre-op clinical views Pre-op AP Radiograph Pre-op Lateral Radiograph TAL Incision Tendo-Achilles Lengthening Tendo-Achilles Lengthening Medial Incision Medial Dissection Medial Capsule Dissection Medial Capsule Dissection Exposure of Charcot Bone Exposure of Charcot Bone Removal Charcot Bone Removal of Charcot bone Across Lisfranc’s Joint Fractured Charcot Bone from 2nd Metatarsal base Removal of Charcot Bone Across Lisfranc’s joint Reconstruction Plate Application of reconstruction plate to plantar aspect 3.5mm cortical screws to fasten plate Plantar plate applied Intra-op Fluoroscope Intra-op Fluoroscope 3.5mm cortical screw outside of plate into 2nd met base Bone grafting Bone graft in place Drain inserted Post-op views Post-op Post-op clinical Post-op clinical Gait Evaluation Gait Evaluation Case Presentation #2- HW 60 y/o Female, IDDM, Chronic ulceration lateral plantar foot secondary to unstable L mid-foot PMH: IDDM SOCIAL Hx:Denies smoking, alcohol use ALL:NKDA VASC: Palpable DP/PT Left foot Case Presentation #2-HW NEURO: Absent protective sensation MUSC: Equinas deformity present L foot Pre-op clinical views Pre-op clinical views Pre-op Radiographs Pre-op lateral Radiograph Medial view Charcot bone Resection of Charcot bone Lateral Incision Plantar Plate Applied Intra-op Fluoroscope Post-op Medial view Post-op Medial view Post-op views Northside Hospital Case Presentation #3-MF HPI: 68 y/o female with CC diabetic ulcer Left medial foot for past 6 years. PMH:IDDM, HTN, PVD ALLERGIES:PCN, Iodine,Seafood SOCIAL Hx:Denies tobacco,alcohol use Case Presentation #3-MF VASC: L femoral to peroneal by-pass prior to sx NEURO: Absent sensation L foot MUSC: Equinas deformity L foot Pre-op clinical views Pre-op radiographs Pre-op lateral Pre-op lateral Tendo-achilles lengthening Medial view Lateral Incision Intra-op Fluoroscope Intra-op Fluoroscope 4 weeks post-op 4 weeks post-op Post-op clinical Post-op clinical Comparison Pre vs. Post Case Presentation #4-WF 42 y/o male, IDDM, Hx chronic ulcer plantar lateral aspect R foot PMH:Renal Dialysis, IDDM, B/L Charcot Deformity PSH:S/P I&D L foot with antibiotic beads Case presentation #4-WF VASC: DP/PT palpable B/L NEURO: Absent protective sensation B/L MUSC:Equinas deformity present B/L Pre-op clinical Pre-op radiograph Pre-op radiograph Temporary Stabilization Exposure of Charcot bone Resection of bone Intra-op fluoroscope Plantar plate in place Intra-op fluoroscope Post-op radiograph Post-op radiograph 8 weeks 10 weeks Post-op radiographs Case presentation #5-JM 62 y/o male,IDDM, hx of chronic ulcer medial aspect R foot PMH: IDDM PSH: Partial 1st Ray resection R foot Case presentation #5-JM VASC: DP/PT palpable B/L NEURO: Protective sensation absent B/L MUSC: Equinas deformity present B/L Pre-op clinical Pre-op clinical Pre-op clinical Pre-op radiograph Pre-op Lateral Post-op radiograph Post-op radiograph Pre vs. Post PRE-OP POST-OP Gait Evaluation Gait Evaluation Case presentation #6-RN 54 y/o male, IDDM, Hx of dorsal ulceration 1st MPJ L foot, unstable mid-foot deformity PMH:IDDM PSH: Multiple Debridements R foot X 20 years Case presentation #6-RN VASC: DP/PT palpable B/L NEURO: Protective sensation absent B/L MUSC: Equinas deformity present B/L Pre-op clinical Pre-op clinical Resection of 1st metatarsal head Pre-op radiographs Intra-op fluoroscope Intra-op fluoroscope Post-op clinical Post-op clinical Post-op radiograph Gait Evaluation Gait Evaluation Results 16 14 12 10 AVG.- 10.8 weeks Radiographic Weeks to Fusion 8 6 4 2 0 HW MF EB LA RN WF JM Patients Results 20 18 16 14 12 10 8 6 4 2 0 HW MF EB LA RN WF JM AVG.- 13.1 weeks Weeks to Ambulation Patients Charcot Reconstruction THANK YOU!
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