Bob: Our final speaker, I wanted to present you with someone whoâs new to Desert Foot. A long time friend of mine, but someone who I consider probably one of podiatryâs best foot and ankle surgeon is as critical as I am I think but probably a little bit more and certainly more cynical than I am. Jack Schuberth is the Chief of Foot and Ankle Surgery at Kaiser Medical Center in San Francisco. Heâs got a wealth of experience in very complicated foot and ankle surgical procedures including in diabetes and trauma. Heâs a past President of the American College of Foot and Ankle Surgeons and former Editor of the Journal of Foot and Ankle Surgery. I asked Jack to do a podiatric purpurea [Phonetic], if you will, of problems that heâs noted over the years in operating on diabetic patients or specifically neuropathic patients. One of his first topics is going to be the operating patients with the neuropathic ankles and ankle fractures. Heâs going to take us through a few assorted topics as well since Iâve asked him to fill in for Guido Laporta who could not come. Believe me, when I say I ask him to fill in Jack and easily, easily do that, heâs going to, as I said, a wealth of experience. Iâm really very, very pleased that Jack took time out of his busy schedule to come lecture to us tonight. Letâs finish out the program with a great series of talk with Jack Schuberth.
Jack Schuberth: You have never seen me operate for one but Bob, I do want to thank you. Most of you probably havenât seen me on a luxury shirt [Phonetic] because I recognize very few people in the room but Iâve been operating on diabetics for 29 years. When I started, I have the fear of God putted in to me about ever touching a diabetic with a 15 blade or a 10 blade and I still have the fear of God. And yet as we evolve and we get better fixatives and better biologics and better knowledge, I think weâre able to take care of a lot more difficult problems. Iâve often told people that I donât know a damn thing about diabetes and Bob has forgotten more than Iâll ever know. But I know how to fix some of these things and recognizing that my failure rate is probably not any lower than many people that do this. But one thing Iâve learned is to be honest. Be honest with the patients and be honest with your colleagues about the success rate in some of these more complicated problems. I am going to start out with diabetic ankle fractures, I personally have operated over 3,000 fractures as a surgeon of record in 29 years, and whatever the percentage of the population is diabetic pretty much typifies my experience in the diabetic, which one is which here, in the diabetic ankle fracture. Weâre going to take an overview. We donât have enough time to get in all of the nuances of taking care of the diabetic. Well, clearly, itâs a matter of perspective when see these patients with fractures. We have to ask ourselves what makes these patients so different. Should we be afraid and Iâve already answered that question. We should be afraid but we shouldnât be so afraid that we give them suboptimal care just because they are branded with this diagnosis of diabetes. I think we all come to realize that there is a lot more to it than just fixing the ankle. Many of us know how to put all sorts of stuff on the ankle. In fact, in 3,000 ankle fractures, Iâve yet to use a locking plate and none of them have ever fallen apart. But itâs not to say that we shouldnât use a locking plate in a diabetic or we shouldnât do this or that. We have to realize thereâs a different dimension of complexity just because the patient is diabetic. And so, we have to of course know how to fix the bone as we mention. We have to modulate the biologic metabolism that is clearly compromised in the diabetic. We have to really worry about end stage renal disease as you all know. This is just a harbinger of disaster. We have to worry about Charcot arthropathy. But to this day I donât know a single person that can predict if a patient that are going to develop Charcot arthropathy with an ankle fracture other than the fact that they have neuropathy. The other complicating issue is of course soft tissue complications which are pretty much non-existent in the sensate healthy patient in low energy ankle fractures. And so weâll talk about bone healing and people say all the diabetic doesnât heal.
[05:01]
Well, who says they donât heal? Whatâs the difference between diabetic bone and your bone? Well, no one really knows the metabolism per se. We appreciate that itâs probably a little bit more brittle, particularly in the diaphysial areas. But whether itâs more brittle in the metaphyseal areas which is really the business end of the tibia and fibula with respect to ankle fractures, Iâm not so sure about that. Remember that these patients have more body mass and so the same maneuvers or shifts in body weight in the diabetic patient versus the average patient made of in part more force to the diabetic bone and yet we extrapolate that and say, well, the bone is weaker. Iâm not so sure about that. Certainly, the healing rate is going to be compromised if you have nutritional deficits or glucose metabolism deficits as youâre all well aware of here. But we have yet to define a concrete difference in the way diabetic bone heals or breaks compared to the normal population recognizing that just because youâre diabetic doesnât mean your blood sugar is in the 400s and your hemoglobin A1c is over 6. And so, we have to sort these things out and recognize that they are not necessarily universally applied to the entire diabetic population. Yet, we appreciate that the local biology does change. Although we canât necessarily define it, we have to take it into consideration when we apply our fixatives. Now, Iâm going to talk a little bit about Charcot after this talk here. Nothing makes my blood pressure go up more than somebody who comes up and gets on the lecture and says, âIf you operate on a diabetic foot, youâre going to cause Charcot arthropathy.â Thatâs just simple fiction. It can but it can also be just a straightforward ankle fracture culminate in the disastrous complication without anybody ever laying a knife on it. And so, Iâm always wary of Charcot arthropathy. I like to watch for it but until someone can come up concretely with predictors that are going to make a difference in taking care of the diabetic population, Iâm not going to change the way Iâm doing things realizing that I probably among the far left end of taking care of these patients which for reasons which should become clear in a second. We do appreciate as Dr. Navone [Phonetic] has just pointed out, there is a higher incidence of infection. Bob Fiebergâs [Phonetic] paper pointed this all very nicely. Weâve known this empirically. Bobâs proved it and there is not a damn thing we can do that about that other than practice good surgical technique here. What are these myths? Well, the bone is soft. Well, we donât know that. We donât know that the bone is soft at the distal metaphysis. It wonât heal. Many of these diabetics have excellent circulation. If they donât have good circulation, weâre not going to operate on them. Itâs that simple in my mind. The circulation is poor. Well, they do. Some of these patients do have poor circulation and they just donât heal any operation that we provide for them. And anesthesia says no. This is the one that just kills me. Any numbskull can put a patient to sleep if theyâre healthy. But we need an anesthesiologist to put people that arenât so healthy to sleep. I trained in Seattle as some of you know. And in the days where the trauma world was evolving, and Ted Hansen [Phonetic] used to say this patient is too sick not to operate on it. And I think that thatâs very, very true in the diabetic patient when you get these 300 plus patients which primary their fractures that are just incapable of being non-weightbearing, theyâre confined to bed. There is tremendous physiologic cause and cardiopulmonary cause to someone thatâs bedridden. We try to mobilize these patients whether or not we let them walk on this with personal preference. But we need to get them functional instead of just plopped them in the bed and say, âHey lady, weâll get you up when your fracture heals.â That may be six or eight weeks for now and they may not survive it. And so, we also have been told, well, she canât be non-weightbearing. Well, canât and wonât are two completely different verbs. People can be non-weightbearing if they break both tibias, they will be non-weightbearing. And so we have to get pass all of these stuff thatâs kind of been propagated is the can and wonât, and should and wouldnât. Because it does come into play when we take care of the diabetic patient and I already talk about that. So whatâs the real deal here? The basic difference is the complications are more common, we all know that. No one is going to dispute that. The dilemma is how to stratify the risk over the long-term. What I mean by the long-term is from the time the patient breaks their ankle until the time they assume their pre-injury functional levels.
[10:02]
Thatâs how morbidity is measured in hip fractures, tibia fractures, and every other orthopedic injury in the world and thatâs how we need to do this. Pre-injury function, post-injury function, thatâs the long-term. It may not be years, it may be a matter of weeks or months, but we have to appreciate that the mortality of these patients is clearly not zero just like it isnât zero in a total hip. When my residents come up here and Iâve heard some of these fiction, I said, âYou should ask if patient how fast and or how soon and how do you want to die? Do you want to die laying in bed or do you want to die from an anesthetic complication?â Iâll take the anesthetic complication any day because I know that thatâs very, very uncommon. That people arenât going to get off the table. So what are we trying to do? Well, we are trying to preserve life. You may say that sensationalistic but Iâve had a number of patients die. In fact, in 2012, Iâve had three people die on my service after taking care of fractures. Itâs not much fun, believe me, to go tell the family that auntie, Auntie Lee [Phonetic] is no longer with us. So we are in a sense trying to preserve life. Weâre trying to preserve the limb. The next slide is behind it. Weâre trying to restore to stable plantigrade platform. It can be an insensate plantigrade platform but it has to be stable and it has to be plantigrade as you all well know. It may be up the expense of anatomic reduction. So if a patient is insensate, all I want is the foot under the leg. I donât care if the ankle has arthritis or not. If it moves a little bit, great but thatâs a good result in many of these patients because they still have their leg and they still can assume their pre-injury levels. So someone ask, âWell why even operate on this patient that theyâre diabetic? Whatâs wrong with non-operative care?â Well, not a lot is wrong with it except if youâre 300 pounds, got cardiopulmonary compromised and there is no way that you can transfer from bed to wheelchair without walking on that ankle. So closed reduction cast in a hotel stay used to be modus operandi. When I was a resident here, we just put these patients in a cast, put them in bed for six weeks. And we recognize there was a fair amount of morbidity. And so the problem in my mind is weightbearing. If we can get that patient to bear some sort of weight after we treat their ankle fracture, whether itâs operative or not, then we have basically circumvented some of the cardiopulmonary compromise thatâs inevitable in these patients. And we all understand that weightbearing in a diabetic patient is difficult. And we can argue for hours whether itâs because their brain isnât working or whatever, but I donât think itâs that. I think itâs because theyâre just physically incapable of being non-weightbearing and so I donât fight it. I just assume that Iâm going to fix this fracture so that you can get out of bed and put some weight on it immediately after the injury. We all know that even though they may last or, you know, while theyâre in the hospital or not and weight bearing, when they get home, theyâre going to pounce on it. What are the mechanical issues? Well, the bigger they come, the harder they fall, as you know. And it not only affects the severity of the fracture but the postoperative management. Obviously, energy in equals energy out. We have to deal without that. We canât control but we can control the postoperative management. And so, is there a correlation of diabetes in the ability to be non-weightbearing. I donât think so. I think thereâs clearly a relationship with body habitus and overall health which we appreciate is different. But certainly, we have to understand that weightbearing doesnât potentiate Charcot. Weâve seen Charcot in non-operative and operative. If we do get Charcot and we recognize it and it doesnât go on to collapse, we can take care of it. I personally believe the answer to this question is yes. I do believe that these patients will decompensate over the six to eight week period. And in my mind, thatâs the real issue. Can we prevent that decompensation that we see in the elderly sick patient after trauma? As I mentioned, the model in the orthopedic world is hip fractures and yet we have to study this in more detail. Letâs look at some of the things here. Upper arms strength, as we talk about cardiopulmonary restraints, immediate weight bearing. And Iâve been told that Iâve committed malpractice. Well, I probably committed it 3,000 times because out of the 3,000 fractures Iâve done, Iâve operated well over 2900 of them within two weeks of surgery. Iâm not including Pilon fractures. And knock on wood, havenât been accused of malpractices yet.
[15:04]
So we look at how the ankle breaks and we have to realize it taluses the weapon of insult. This is what causes the fracture of the malleoli because of the morbid motion within the mortis. We appreciate that itâs a rotational sequence, alright? The PABs and [indecipherable] [15:21] SADs are extremely uncommon. These are rotational injuries and we have to keep that in mind. And so when the foot rotates on the leg or the leg rotates on the foot, weâre going to cleave off the malleoli in a fairly recognized pattern and we need to put it back together. Of course, we all like to put in screws and plates and all sorts of paraphernalia here. Itâs a lot of fun to do this. My point is it doesnât matter what you do, you have to make a stable construct. You can use screws and plates. You can use locking plates and waste our money but the point is you need to get the forces of the foot up through the tibia and have it absorbed by the long axis of the tibia. And thereâs lot of fixation alternatives as I mentioned here. Iâve been told that you can never put tension bands in oblique fractures. Iâve been doing that for years and this lady got three of them or two of them, and a plate, and this is a very, very stable construct. Itâs called miss-a-nail technique where you bolster the screws on either side. And this woman was diabetic. We got her out of bed the next day when she did remarkably well. I saw her 20 years later, she was senile as I am. After fixing her ankle fracture, she broke the other side but she never had a single problem with this and there it is on the side there. And so, we have to modify our technique sometimes. We canât just look in the book and say, well, that needs a semi-tubular plate and the interfrag screw here. This bone may or may not be any good. And there is no law that says we canât just fire Steinmann Pins in there or whatever it takes. Thereâs just a couple of other options here. Two K-wires that are buried under the skin or poke into the skin or two transsyndesmotic screws. And this is the technique that I favor the most which is called the fibula pro-tibial technique where a simple little rotational fracture that I deem unstable. Iâm just going to fire several transsyndesmotic screws through the plate, tighten them down and get the patient up. Thereâs no place for that bone to go. The fibula cannot escape because itâs incarcerated by the fibula. And so regardless of how we fix it, if we can dampen the rotational forces, then we can allow the patient to put some weight up through the tibia. In rare instances, I will supplement my construct with an external fixer if a patient is polytraumatized, Iâll usually put a fixator on it so we can get them out of bed and get their lungs functioning better and everything else functioning better. But it is probably even five times in 29 years where I put a fixator on a diabetic fracture just to allow them to walk. We try to minimize the exposure if we can because we donât necessarily need anatomic reduction. We can capitalize on the neuropathy and modulate the biology if it all possible. So you say, well, big deal, rotational fractures, any sort of fixation, weâll take care of it if we can dampen the rotatory torque. How do we do that? Well, we can neutralize the disruption by simply transferring the weight up the tibia, one of the simple, short leg cast. There is no way that that foot can rotate and put pressure on the fibula or the medial malleolus when itâs incarcerated in the cast, itâs impossible. If you hold the ankle still, the fibula will absorb very, very little if any load with full weight bearing up the tibia. And thatâs pretty been the premise of my thought process for many, many years. Transfer the weight up the fibula. This is the only one that Iâve ever had fall apart in 29 years Iâve operated on these patients. And it fell apart in a manner that I still defies me to this day, whether I missed the interfrag or whatever or she had distal lateral osteonecrosis of the distal tibia, I donât know but this is the only one that fell apart. Here is just a couple of other techniques here. This guy was numb as a brick and I didnât even open the fracture. I just put this plate on through a percutaneous corridor and fired three transsyndesmotic screws, put him in a cast. And itâs not perfect but he loves it. He has absolutely no pain and he was non-weightbearing. Exactly, that hour it took me to put the hard wiring [Phonetic]. So does this always work? Well, of course not. We always have complications. And when these complications occur, theyâre often catastrophic.
[20:02]
And as I mentioned, I had three deaths on my own service this year. And I lost a lot of sleep over this and still just dizzy by this whole thing here. And many of these patients end up with amputation but not as many as you think whether sound and judicious approach to these ankle fractures. Weâve talked about soft tissue complications, you all know how to take care of this far better than I do. I donât know very much about wound care. My residents take care of it all and they donât even bother. They ask me anymore because I donât know. They just do what they do and most of these things heal. This is another woman that got out of bed before we even got the cast on him and busted this one apart, but that one I donât count. And she ended up in another emergency room. And I could have strangled the surgeon that did this putting these two Steinmann Pins up right through the heel. This is his way of fixing it. Obviously, this lady is going nowhere with those two pins that were protruding through the plantar aspect of the heels. So I finally wrestled her back into my clinic and put a fixator on her, centralized the tibia, excuse me, the talus and let her walk. This guy, he was a model. He built airplanes and you can see that he probably wasnât very good at it, diabetic, bilateral Pilon fractures from a plane crash that he built. This is from Southern California and this was just a mess. And we ended up doing a fusion on him. This is probably about 15 years ago. And so we canât saw all with these patients if they have good blood flow. Is it pretty? No, itâs ugly. But the point is these patients still have their limb and they can get back into their pre-injury levels. Iâm not sure what that one is there for. Anyway, remember the foot of stone [Phonetic], thatâs our goal in the diabetic fracture. The last case Iâm going to show you was catastrophic. This is another woman that did not make it out of the hospital. Simple little rotational fractures, end stage renal disease, closed reduction once, closed reduction twice. Finally, I gave up and I stuck a pin right through the heel just to hold it there. Sheâs about 120 pounds, soak and wet, 40 years old, with a creatinine in double digits. And this is her first post-op visit and thatâs what her leg look like and she went under a DIC and died within about three days of this ankle fracture. It was just a tragic situation. So these are difficult patients as you all know and you all have your horror stories on how this happened. And so in my mind, the ideal practice protocol is the chief stable fixation, immediate short leg walking cast with careful surveillance for any migration of the hardware. And whether or not you let him bear a full weight or partial weight, itâs up to you. But get them out of bed and get them moving so that they donât decompensate and improve or graduate their physiologic stress whether itâs weightbearing or cardiopulmonary, and decide what the patient needs for the best functional outcome. Donât be pigeonholed into taking care of this by the book. You canât deal corrupt the physiology, itâs what it is. But if youâre uncomfortable of having a non-weightbearing, at least mobilize him. So again, you take care of their entire patient rather than just the fracture. What have we resolved? We resolved that the diabetic will break their ankle and there is clearly no cookbook approach. We have to discard many of the traditional mentalities and I donât want to get diabetes and I certainly donât want to get an ankle fracture because of the morbidity. So weâll stop there with this and then go on.