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This is Lawrence A. DiDomenico from the Youngsten Podiatric Residency Program. My talk today will consist of a Charcot reconstruction, a salvage procedure, utilizing a plantar plate for Lisfranc dislocation.
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There are 2 theories on the development of Charcot arthropathy. One is the neurotraumatic, which is a German theory. Basically, this theory consists of peripheral neuropathy consisting of sensory and motor, the loss of sensation, and a result of a mechanical trauma has gone unrecognized, microtrauma that eventually breaks down the foot.
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The second theory is the French theory, which is a neurovascular theory. This is a loss of vasomotor tone and basically this is a joint dissolution or washing out of the bones or ligaments and weakness in this area. Due to the neuropathy, the joint eventually will break down. The truth of it is probably Charcot arthropathy is probably due to a combination of both the German and French theory, both the vascular and the traumatic theory.
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Diabetes has become an epidemic in the United States. Approximately 8% of diabetics will develop neuropathic joint disease. It is more common in those with diabetes greater than 15 years. The range is from 0-45 years. Men and women are equal. Bilateral involvement is approximately 30%.
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This is a list of several diseased processes that can contribute to Charcot arthropathy.
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This is a continuation of the list of associated disease processes that can contribute to Charcot arthropathy.
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Healing time in diabetic fracture is clearly longer than the nondiabetics. Loder demonstrated in 1998 that overall union rates of fractures was 163% longer. He also demonstrated that healing time was 187% longer in displaced fractures that required open reduction internal fixation. The result is that prolonged immobilization is required.
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Eichenholtz stage I is also known as the developmental stage between 0 and 3 months. Clinically, the patient usually presents with an acute inflammation, edema, erythema, warmth; persistent edema usually is the most consistent physical finding. Radiographs typically reveal demineralization, periarticular fragmentation, and joint dislocation.
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Stage II of Eichenholtz is coalescent stage. This is typically between 3 and 6 months. Clinically, it reveals decreased edema, erythema, and warmth. Radiographically, there is bony coalescence, there callus formation, and periosteal new bone formation demonstrated radiographically.
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Eichenholtz stage III is also known as consolidation, typically between 6 months and 2 years. Clinically presents with a fixed deformity, bony prominences, and rocker bottom foot. Radiographically, presents with sclerotic bone formation, smoothing of fracture fragments, and fibrosis ankylosis.
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In 1990, Shibata named a new stage 0. This is a preclinical or a pre-stage Charcot disease. Typically, these patients present with early edema, erythema, and warmth. Radiographic appearances are minimal or absent at this time.
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Classification is limited to midtarsal deformities, joint involvement with resulting prominences. There are 4 types of the 3 stages. Rearfoot involvement is not included. Areas of destruction allows prediction of prominences in locations.
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This slide demonstrates Schonâs classification, describes the type, the involvement, and the prominences.
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This slide demonstrates the 4 geographical areas of the foot described by Schon.
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Brodsky also had a classification of a type I, type II, and a type III.
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This table demonstrates Brodskyâs classification very well. There is a type and clinical features. Pay particular attention to the percentages noted with midfoot, rearfoot, ankle, and hindfoot. Notice that the further you are away from the ankle, more leverage is applied to the foot, and there is more in sense of Charcot disease.
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This slide demonstrates a geographical location of Brodskyâs classification.
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Armstrong in 1998 published a paper in JBJS talking about the role of TAL in peak plantar pressures. It was noted that peak plantar pressures were higher in acute Charcot arthropathy and neuropathy with ulceration versus patients without a history of arthropathy and neuropathy and ulceration. He also demonstrated that tendo-Achilles length decreased the peak plantar pressure by 27% from the former tendo-Achilles length. This also decreased lever arm and decreased osseous collapse in the foot.
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Conservative treatment for stage I of Eichenholtz classification consists of immobilization in normal weightbearing. It can consist of bulky dressing with a posterior splint, a total contact casting or a bi-valve AFO.
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Conservative treatment for stage II Eichenholtz consists of total contact casting, partial weightbearing, and a CROW walker which stands for Charcot Restraint Orthosis Walker.
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Conservative treatment for stage III Eichenholtz classification consists of a CROW walker, a double upright brace with total contact orthosis and extra-depth shoes or diabetic shoes.
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Surgical treatments and indications consist of chronic ulcerations with associated bony deformities or contractures, unstable joints that are not shoe-able or brace-able, recurrent infected ulcers with bony prominences, and acute displaced fractures in neuropathic patients with adequate circulation.
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The surgical goal is to restore the stability and alignment so that footwear and bracing are possible. According to Myerson, the goal should be to achieve a plantargrade weightbearing surface that is free of infection.
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Surgical complications consist of incomplete correction, delayed union, nonunion, infection, failed of hardware, loss of correction, and failure may lead to amputation.
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Differential diagnosis for Charcot neuropathy consists of cellulitis, abscess formation, gout, DVT, and septic joint.
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Complication of Charcot neuroarthropathy consists of deep infection, osteomyelitis, ulceration with severe deformity, and amputation
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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 of amputations are caused by diabetes
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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
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Costs of arthrodesis versus BKA in a neuropathic patient. Total cost of the reconstructive group during a 5-year period was 14% less than the total cost of the amputation group during the same time period.
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In year 2000 JBJS, Simon published an article demonstrating cost of early arthrodesis in Charcot patients. This article consisted of 14 patients with stage 1 mid foot breakdown average followup 41 months. The mean charge for operative tax and followup care was $9,527 to $16,417.
Mean charge for BKA in 11 patients during same time period was between $17,261 to $39,045. Clearly, the arthrodesis treatment options are much less expensive.
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Cost of diabetes. It is estimated that 25% of Medicare expenditure is directed towards management of patients with diabetes. Approximately 5% of all healthcare dollars is consumed in management of the secondary complications of diabetes.
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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.
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Review of results of operative treatment in diabetics. In 1993, Papa, Myerson, Girard-JBJS demonstrated 66% fusion rate in 29 patients who underwent arthrodesis procedure. Stuart and Morrey in 1990-Clinic of Orthopedics demonstrated 7 out of 13 obtained clinical union in ankle and hindfoot arthrodesis.
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Shibata in 1990 demonstrated that he had a 73% success rate and average followup of 9.5 months.
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Timing of surgical intervention. Traditionally, this has been done in stage II or III. Certain neuropathic fracture may be surgically reduced and fixed if treatment is performed early. This is becoming a controversial subject.
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Simon published in JBJS year 2000 results of early operative treatment. He had 14 patients with Eichenholtz stage I mid foot involvement. Average followup time was 41 months. There was a 100% success with no reported ulcerations or complications. Early intervention may reverse the Charcot process. This continues to remain controversial.
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This slide demonstrates incidence by location as described by Brodsky in 1992. The midfoot has the highest incidence of Charcot arthropathy.
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Contraindications to arthrodesis: Active infection, acute phase of Charcot arthropathy, although this can be debatable, poor glycemic control and nutritional status, peripheral vascular disease, poor bone stock, Co-morbidities.
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Marks, Parks, and Schon in Foot and Ankle Int, in 1998 did a publication talking about plantar plate, biomechanical analysis and rationale. The study consists of plantar plate versus screw fixation for mid-foot fusion in cadavers. Results demonstrated that plantar plate provided a sturdier, stronger fixation when compared to screw fixation. Conclusion leads that the plantar plate decreases the likelihood of collapse and non-union.
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AO Tension band principles. In an eccentrically loaded bone, the bending forces created are converted by the action of the plate into further compressive stresses.
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A Tension band plate generates âDynamic Compressionâ through eccentric loading.
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Eccentric loading of a bone results in one side being loaded in tension and the other in compression.
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Under an eccentric load, the gap will open first on the tension side. In a weightbearing foot at the tarsometatarsal area, this is on the plantar aspect.
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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.
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A plate applied to the tension side of bone will prevent the deformity. As the load increases, the plate will be put under tension and the cortex opposite the plate will come under compression.
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We will go through some case presentations at this time.
The first case is #1-LA.
A 72-year-old male, IDDM, history of unstable right mid-foot.
Past medical history: IDDM.
Allergies: No known drug allergies.
Social history: A 40-year tobacco history.
Vascular: Palpable pedal pulses bilaterally.
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Neurological: Absent protective sensation.
Musculoskeletal: Equinus deformity.
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Preop radiograph revealed Charcot arthropathy secondary to trauma to the second and third metatarsal area.
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This slide demonstrates the incision for Tendo-Achilles lengthening.
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This slide demonstrates the length gain by doing a frontal plane Z-section Tendo-Achilles lengthening.
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The incision for the plantar plate is a medial dissection along the first metatarsal into the mid-foot.
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The incision is carried deep to the bone, reflecting all soft tissues, exposing the Charcot bone. Take note of the Lisfranc joint, notice the irregularities of the bone, the sclerosing of the bone, and abnormality of the bone.
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With good osseous exposure, all diseased Charcot bone must be resected. The bone must be resected to good healthy bleeding bone; this is a very, very important part of the procedure.
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This slide shows an osteotome being used to resect the necrotic bone at the Lisfranc joint.
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At this point, the surgeon must find a level of necrotic bone to healthy bone. Here, you can see that the osteotome is palpating to a healthy area. If you look to the left side of the osteotome, the bone appears to be much more organized and much more healthy in appearance. The bone to the right of the osteotome is much more disorganized and unhealthy in appearance. When we are doing this surgery, by palpating the bone and feeling with the osteotome or using our instruments, one can tell what is a healthy and an unhealthy bone.
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Typically, in my hands, I have been resecting approximately 1 cm of bone. Again, if you notice, the bone distal to the resected segment, the bone is pink, healthier, good bleeding, and appears to be very solid. The bone in the middle appears to be necrotic, avascular, and diseased in nature.
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After all necrotic bone is resected, the foot is put into a plantargrade stable anatomical position and temporarily fixated with two 62 K-wires. Intraoperative fluoroscopy is identified ______ and then the plate is applied to the tension site or the plantar aspect of the foot, eccentric loading putting first screw into the most stable portion, which is the cuneiform and then eccentric loading of the second screw into the base of the first metatarsal.
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Here, we continue to eccentrically load the plate on the plantar aspect of the foot and gaining compression through the plate.
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Two transfixation screws are done throughout. These are typically 3.5 mm cortical screws, one from the base of the fist metatarsal into the intermediate cuneiform and one from the medial cuneiform into the second metatarsal base, trying to bring the first and second metatarsal cuneiform raised together, making this a stable medial proximal block.
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Bone grafting is utilized to fill any voids, any defects in the area.
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A drain is inserted.
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This is a lateral x-ray demonstrating the plate applied to the plantar aspect of the first metatarsal cuneiform and navicular. Also, take note of the 2 transfixation screws.
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This is a clinical picture approximately 6 months following the surgery of the right foot versus the left foot.
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This is a posterior view of the right operative foot versus the left nonoperative foot.
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These movie clips demonstrate the patientâs gait postoperatively without aid.
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Another movie clip of the patientâs gait without aid.
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Case #2 â HW.
A 60-year-old female, IDDM, chronic ulceration lateral plantar foot secondary to unstable left mid foot.
Past medical history: IDDM.
Social history: The patient denied smoking or alcohol use. Allergies: No known drug allergies.
Vascular: Good vasculature to the left foot.
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Neurologic: Absent protective sensation.
Muscular: Equinus deformity of the left foot.
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Preoperative clinical views. Notice the abduction of the forefoot on the hindfoot. Notice the large ulceration is not infected at the large prominent area.
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Preoperative clinical view. Notice the abduction of the forefoot on the hindfoot. Notice the bulging of the plantar outer aspect of the foot.
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Preoperative radiographs pay particular attention to the medial oblique. Notice no necrotic bone at the tarsometatarsal joint. The lateral radiograph is a normal-appearing radiograph, but still one can appreciate the necrotic bone tarsometatarsals and notice the elevated first metatarsal.
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A preoperative lateral radiograph, weightbearing. Notice the forefoot supinatus and necrotic bone tarsometatarsal area.
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This slide demonstrates the Charcot diseased bone following incision.
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Resection of the Charcot bone. As discussed earlier, it is imperative that all diseased bone is removed. I suggested earlier it is usually approximately 1 cm of necrotic bone that is resected. The key is to look into the remaining bone that is healthy in appearance and is very firm. The other key in doing this is making sure you have good retractors as you are pulling all the soft tissue structures off the tarsometatarsal area and freeing of the soft tissue so that resection can be performed. The osteotome must be taken away across the entire Lisfranc joint, from the first metatarsal base to the fifth metatarsal base. In order to remove all necrotic bone, often times it is necessary to make a second incision.
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The second incision is sometimes needed, and is done over the fourth and fifth metatarsal base. Take note of the amount of necrotic bone in the tarsometatarsal area of the base of the fourth metatarsal.
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After resecting all the necrotic bone to good healthy bleeding bone, the foot is plantarflexed and abducted and stabilized with temporary K-wires.
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Next, a plantar plate is applied to the tension site of the foot.
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Intraoperative fluoroscopy showing a plantar plate. Notice the transfixation screws and pay particular attention to the resection all the way to the fifth metatarsal base. Because the fifth metatarsal comes more proximal, you have to resect the bone from the fifth metatarsal base. If all the bone is not resected all the way across, the foot cannot be adducted and plantarflexed. I think a common worry with surgeons when they look at this procedure is that they are potentially worried about the instability of all the metatarsals, realize you have all the interosseus muscles between all the metatarsals will have the interosseus ligaments holding these metatarsals together. When doing this procedure, all the metatarsals function as 1 sole unit to the soft tissue structures.
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Here is a postoperative medial view.
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Another postoperative medial view.
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Postoperative review approximately 2 weeks following surgical procedure. Notice the foot is rectus. Notice the increased pressure off of the ulcer as that bone has been resected.
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Case #3 â MF.
A 68-year-old female with chief complaint of ulcer, left foot, medial aspect for the last 6 years, off and on; recurrent osteomyelitis.
Past medical history consists of IDDM, hypertension, and PVD.
Allergies consist of penicillin, iodine, and seafood. Social history: The patient denied tobacco or alcohol use.
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Vascular: The patient needed a left femoral to peroneal bypass prior to her surgery.
Neurologic: Also had absence of sensation in the left foot.
Muscular: Also had an equinus deformity to the left foot.
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Here is a preoperative clinical view, getting the ulcer prepared for surgery. Notice there is no infection and the ulcer is granulated at this time.
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Preoperative radiographs demonstrating necrotic bone in the tarsometatarsals.
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Preoperative lateral radiograph. Notice the instability to the tarsometatarsal joint with small fragmentation, causing the ulceration in the medial aspect of the foot.
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Another preoperative weightbearing x-ray revealing decreased calcaneal inclination angle, increased stress on this foot, and breakdown of the mid foot.
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The first step is to do a tendo-Achilles lengthening. Take note of the stitches from the previous bypass.
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Medial view with the Charcot disease joint exposed.
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A lateral incision used to resect the bone from the fourth and fifth tarsometatarsal bases.
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Intraoperative fluoroscopy demonstrated plantar plate with 2 transfixation screws. Notice again the resection of the tarsometatarsal bases and the fraction of the fifth metatarsal shortening so that the foot can be abducted and plantarflexed.
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Radiograph 4 weeks postoperatively.
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Postoperative radiograph revealing complete healing and complete union at all tarsometatarsal areas.
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Comparison of preoperative versus postoperative clinically.
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Case presentation #4 â WF.
A 42-year-old male, IDDM, history of chronic ulceration in the plantar lateral aspect of the right foot.
Past medical history: Renal dialysis, IDDM, bilateral Charcot deformity.
Past surgical history: Status post I&D, left foot, with antibiotic beads.
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Vascular: Palpable pedal pulses bilaterally.
Neurologic: Absent protective sensation bilaterally.
Musculoskeletal: Reveals equinus deformity present bilaterally.
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Preoperative clinical examination. Notice the Charcot disease and a chronic ulceration that is clean prior to the surgery.
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Preoperative lateral radiograph demonstrating a fault in the mid foot with Charcot disease.
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Preoperative radiograph, AP view, demonstrating Charcot disease and necrotic bone at the tarsometatarsal areas.
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This slide demonstrates after doing the Tendo Achilles lengthening, rotating the hindfoot of calcaneus and talus _______ tibia and walking plates for temporary stabilization. This allows you to build a mid foot relative to the hindfoot in good position.
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This slide demonstrates good exposure of Charcot bone.
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Again, approximately 1 cm of necrotic bone is resected so that the foot could be adducted and plantarflexed. The goal is to restore good anatomic alignment and shorten the foot, and to remove necrotic bone.
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I find that the use of a pituitary rongeur is often at times helpful. The slide on the right demonstrates again a
good healthy bleeding bone. In these hard to reach places, a pituitary rongeur can be very helpful in resecting the bone from difficult areas.
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The plate applied to the plantar aspect with the foot in a plantar flex adductor position with the good stable alignment.
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Postoperative radiograph demonstrating a plantar plate and transfixation screws.
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Lateral radiograph demonstrating the plate needed to be applied to the talus, all way to the first metatarsal stabilizing the whole medial column.
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Clinical views following surgery 8 and 10 weeks postoperatively.
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Case presentation #5-JM
A 62-year-old male, IDDM, history of chronic ulceration medial aspect right foot.
Past medical history: IDDM
Past surgical history: Partial first ray resection.
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Case presentation #5-JM
A 62-year-old male, IDDM, history of chronic ulcer medial aspect right foot.
Past medical history: IDDM.
Past surgical history: Partial first ray resection, right foot.
Vascular: Palpable pedal pulses bilaterally.
Neurologic: Protective sensations absent bilaterally.
Muscular: Equinus deformity bilaterally.
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Preoperative with an ulceration on plantar aspect of the stump of the first metatarsal.
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Preop lateral view notes a bulge of the area of the tarsometatarsal area.
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Preop clinical view prior to the surgery noticed the wound is in good condition and not infected.
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Preop radiograph, notice the spike at the distal aspect of the first metatarsal, notice necrotic bone at the tarsometatarsal areas, notice the dislocation of the second and third digits on the metatarsal.
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Preoperative radiograph demonstrating equinus in second and third toe dislocation.
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Postop radiograph noticed the stability of the tarsometatarsal joints 1 through 5. Fixation was used at the first metatarsal with screws. A plantar plate was applied to the second metatarsal intermediate cuneiform. A third K-wire was applied for extra stability in the fourth metatarsal base into the cuneiforms and K wires were also used to stabilize the dislocated second and third digits.
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Postoperative lateral radiograph.
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This movie demonstrates this patient walking without aid postoperatively.
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This movie demonstrates patient ambulating without aid postoperatively.
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Case presentation #6-RN
A 54-year-old male, IDDM, history of dorsal ulceration first MPJ secondary to an unstable mid foot deformity.
Past medical history: IDDM.
Past surgical history: Multiple debridements right foot x20 years which eventually led to below-knee amputation.
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Vascular: The patient had palpable pedal pulses on his left lower extremity.
Neurologic: Loss of protective sensation left.
Muscular: There was an equinus deformity noted on the left.
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Preoperative clinical examination with an ulceration and osteomyelitis of first metatarsal head secondary to an unstable tarsometatarsal joint.
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Two more preop clinical views of the dorsal ulceration.
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A picture demonstrating the first metatarsal head with bone resection for the osteomyelitis.
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Preoperative radiographs of the left foot notice the fifth metatarsal is more proximal as the patient had a partial fifth ray resection. Notice the bony loss in the cuboid area, it was rotated plantarly, and notice the first metatarsal looks longer, it really is not longer, it just appears longer as there is subluxation at the tarsometatarsal joints, dorsiflexion first metatarsal.
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A postoperative clinical view following the plantar plate.
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A postoperative lateral radiograph demonstrating plantar plate.
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A movie clip demonstrating patientâs gait following surgery.
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Another movie clip demonstrating patientâs gait following surgery.
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Case #7 DS, the foot abducted in the large plantar ______.
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This patient had a previous surgery done by another physician where a medial plate was applied. Consolidation occurred, however the equinus deformity was not addressed and you can see that the abduction was not addressed, so the foot was placed in abducted opposition and there was a sagittal plane deformity still present, and the patient walked on a Rocker bottom foot that was somewhat painful.
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Here a wedge resection was made plantarly and medially closing down the tarsometatarsal area correcting foot in good anatomic alignment with the use of a plantar plate.
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Intraoperative x-rays demonstrating good anatomic alignment of tarsometatarsal areas realigning foot plantar flexing and adducting it.
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Case #8 JR, preoperative pictures, the patient has large plantar ulcer secondary to Charcot deformity.
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Case #8 JR, preoperative radiographs showing the tarsometatarsal subluxation, dislocation with Charcot bone.
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Postoperative lateral radiograph. \
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Case #9, RG alcoholic neuropathy, previous ankle fracture that went on to a nonunion, and tarsometatarsal Charcot disease developing into ulceration of sub lesser metatarsals.
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Preoperative radiographs, nonunion of the fibula and tarsometatarsal, Charcot disease.
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Postoperative views of the plantar plate AP lateral and ankle.
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Case #10 RR, notice the abduction of the forefoot _______ foot, notice the necrotic bone at the tarsometatarsal areas.
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Postoperative view of RR, AP and lateral x-ray.
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Case DM, preoperatively from the AP and posterior view.
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A clinical medial view AP and lateral radiograph demonstrating necrotic bone at the tarsometatarsal area.
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Postoperative views of the AP and lateral x-ray of the patient DM.
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This is the table that we are using to follow our patients at our institution. The table consists of the patientâs age, the patientâs sex, the patientâs diabetes type, whether or not the patientâs uses tobacco, the consolidation of the arthrodesis site, whether we use a bone stimulator, complications, time to ambulation, and length of followup.
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This is a continuation of the same table.
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This table only goes up to patient 18. Up to date, we have 23 patients in our study at our institution. Thus far we are very excited and very pleased with our outcomes.
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Based on our table with 18 patients â 19 feet, average age of 61.5 years, 14 patients were diabetic neuropathic, 1 patient was alcoholic neuropathic, another patient was idiopathic neuropathic. Radiographic consolidation was achieved in 17 feet at the time of the study, 11.5 weeks to ambulation, average followup was 12.5 months, one patient passed away 18 months following the surgery, the foot was well healed, the patient passed away from unrelated complications. Two complications that we experienced, our patient survey at the time of 18 patients suggested that the 16 patients had the procedure done again. There was a need for a long-term followup. Currently we have 23 patients in our institution; unfortunately we do not have data inserted into our table. However, I hope this has been helpful for your educational process of Charcot arthropathy of the Lisfranc joint.
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Thank you!
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