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Plantar Plate for Lisfranc’s Dislocation

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					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




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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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