Charcot Arthropathy Syllabus
2014-07-14
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Charcot Arthropathy Patient Evaluation and Indications for Surgery Jeremy J. McCormick, M.D. Assistant Professor - Foot and Ankle Surgery Washington University St. Louis, MO Charcot Arthropathy Patient Evaluation and Indications for Surgery Jeremy J. McCormick, M.D. My disclosures are listed in the AAOS database. I have no potential conflicts with this presentation. The life of a foot and ankle surgeon… Glamourous http://sportsillustrated.cnn.com/nhl/news/20131228/alex-steenblues-concussion-injury.ap/ Not so glamourous… http://www.presentdiabetes.com Each equally important… 1 Charcot Arthropathy Patient Evaluation and Indications for Surgery Overview on Charcot Staging and classification Approach to treatment Charcot Arthropathy Patient Evaluation and Indications for Surgery Overview on Charcot Staging and classification Approach to treatment Jean-Martin Charcot French neurologist 1836 described unique arthropathy in patients with neurosyphilis http://www.sciencemuseum.org.uk/broughttolife/ people/jeanmartincharcot.aspx 2 Definition Progressive, noninfectious, destructive arthropathy in patients with sensory neuropathy Courtesy of Carroll P. Jones, MD Who gets it? Linked with many diseases associated with peripheral neuropathy Described in diabetics in 1936 by William Reilly Jordan Diabetes is leading cause Up to 40% will develop neuropathy in first decade of diabetes http://www.healthisfuture.com/wp-content/uploads/symptoms-of-diabetes.jpg It’s not getting any better… 12.3% (28.9 million) of American adults >20y/o have diabetes 25.9% (11.2 million) of American adults >65y/o have diabetes By 2050, as many as 1 in 3 American adults will have diabetes http://jaxrealestatefacts.com/2012/03/23/anothe r-700k-house-goes-under-contract-inortega/increasing-sales/ www.cdc.gov/diabetes/statistics 3 Why diabetes? Leads to neuropathy Loss of nitric oxide function Vasoconstriction/Ischemia Injury to nerve cells/function Will not protect weightbearing Will not sense a problem Wukich and Kline – JBJS Am, 2008 http://www.mynewtown.co.uk/newsviewer/tabid/1 387/ArticleId/1013/Hot-footing-for-charity.aspx Etiology – Multiple Theories Neurotraumatic Neurovascular Repetitive micro-trauma Autonomic dysfunction that causes increases in blood flow Inflammatory mediated http://www.everyvotecou nts.org.uk/packcontent/politicsworks/factsheets/political -parties.php Increase in cytokines >> osteoclastic activity Baumhauer et al, 2006 Likely a Combination of Events Peripheral neuropathy Unrecognized injury Repetitive stress on injured structures Increased local blood flow http://www.sfmconsulting.co.uk/blog/entry/the_whole_is_great er_than_the_sum_of_its_parts 4 Charcot Arthropathy Patient Evaluation and Indications for Surgery Overview on Charcot Staging and classification Approach to treatment Eichenholtz Classification Radiographic natural history of changes that occur From destructive to consolidation I – Fragmentation II – Coalescence III – Reconstruction A fourth stage (O) has been added Eichenholtz SN (1966) General considerations. In: Eichenholtz SN (ed) Charcot joint. Thomas, Springfield, pp 3–20 http://edtreatmenttoday.com/edtreatment-guide/steps-to-follow-ined-treatment/ Stage 0 Swollen, red, warm foot Normal x-rays Different than infection Elevation decreases swelling No systemic symptoms Courtesy of Carroll P. Jones, MD 5 Stage I - Fragmentation Swollen, warm, red foot Radiographs Osteopenia Fragmentation Subluxation Courtesy of Carroll P. Jones, MD Stage II - Coalescence Clinical: Decreased swelling Decreased redness Decreased warmth Courtesy of Carroll P. Jones, MD Stage II - Coalescence Radiographic: Less bone debris More sclerosis Bone consolidation Courtesy of Carroll P. Jones, MD 6 Stage III - Reconstruction Inflammation resolved Bone fully consolidated Generally more stable foot Courtesy of Carroll P. Jones, MD Anatomic Location of Charcot Sanders and Frykberg: I: Forefoot (least common) II: Midfoot (60%) III: Hindfoot IV: Ankle V: Calcaneus http://diabeticfootandankle.net/index.php/dfa/rt/printerFriendly/21884/html Charcot Arthropathy Patient Evaluation and Indications for Surgery Overview on Charcot Staging and classification Approach to treatment 7 Goals of Treatment Reach Stage III with a stable plantigrade foot/ankle Prevent ulceration Avoid infection Ideally achieve these goals without surgery http://blackras.wordpress.com/about/ How should we approach this patient? Needs to be a team approach… Orthopaedic surgeon Medicine Endocrine Vascular Orthotist/prosthetist Physical therapist http://dailystrugglesandupliftingscriptures.blogspot.com/2012/07 Maintain high index of suspicion… How should we approach this patient? History Timing and mechanism Is the patient aware of injury? Systemic illness ? Neuropathy… Understand the patient and possible risk factors… HgbA1c, ulcers, vascular disease, renal failure, etc. 8 How should we approach this patient? Physical exam Protective sensation? Vascular Motor Sensory – neuropathy? Semmes-Weinstein monofilament Associated with risk of Charcot http://www.diabetesindia.com/diabetes/the_feet_diabetes1.htm Look for other signs Claw toes Ulcer/amputation http://shanesfootcomfort.weebly.com/claw-toe.html The Challenge… Majority are morbidly obese Extreme difficulty complying with treatment Medical comorbidities Poor potential for healing Immunocompromised High risk of ulceration http://visionaryfam.com/2014/02 /time-for-a-challenge/ Stage I – Non-op Treatment Total Contact Cast Immobilization is critical Minimize deformity Control swelling Offload foot 2-3 months if possible Follow closely http://www.owm.com/content/total-contact-castsystem-simplifies-application-process 9 Can You Keep Them NWB? Very difficult Probably only 50% compliance Even if WB may still achieve good result De Souza, et al – JBJS, 2008 Err on the side of casting for too long… http://www.confusereviews.com/?p=3729 Stages II – Non-op Treatment Charcot Restraint Orthotic Walker (CROW) Other AFO http://www.mccleveop.com/orthotic s/crow-boots/ http://lermagazine.com/article/evi dence-based-orthotic-managementof-pttd Stages III – Non-op Treatment In-depth shoe Custom insert Life long Educate the patient http://www.valentineorthotics.com/medicare-shoe-program.html 10 Non-op is NOT Easy! 23% required bracing > 18 months 49% risk of recurrent ulceration Ulceration increases risk of amputation 2.7% annual rate of amputation Saltzman – CORR, 2005 http://www.thegodboxproject.com/blog/2012/03/ 16/fun-friday-the-secret-to-saying-no/fingerscrossed-2/ Surgical Indications Unstable, unbraceable deformity Recurrent ulceration Deep infection Deformity at high-risk for ulceration http://www.idlehearts.com/if-plan-a-didnt-work/559/ Charcot Arthropathy Patient Evaluation and Indications for Surgery Overview on Charcot Staging and classification Approach to treatment 11 Take Home Points Understand the natural progression of Charcot Early recognition and treatment Maintain a high index of suspicion Achieve early stability and maintain alignment through casting Thank you… 12 7/14/2014 Charcot Arthropathy: Internal Fixation VuMedi Webinar July 2014 Carroll P. Jones MD OrthoCarolina Foot and Ankle Institute Charlotte, NC Disclosures: AAOS Website. Paid consultant for Wright Medical Technology and have been involved in the development of Charcotspecific implants. Goals of Treatment • Reach consolidation phase with a stable plantigrade foot/ankle • Prevent ulceration/infection • Ideally achieve these goals nonoperatively 1 7/14/2014 • Nonop treatment 70% successful – Clinically plantigrade foot – Radiographically plantigrade • Pinzur et al; FAI 1993 • Fabrin et al; Diabetes Care 2000 • Pinzur et al; FAI 2004 Surgical Indications • • • • Unstable, unbraceable deformity Recurrent ulceration Deep infection Deformity at high-risk for ulceration Clinical Challenge • Limited Level-I evidence • Effective clinical algorithm – Nonop (total contact cast) – Exostectomy – Surgical correction: internal fixation – Surgical correction: external fixation 2 7/14/2014 Algorithm • Plantigrade • Nonplantigrade Total Contact Cast/Brace Low Risk Corrective osteotomy: Internal Fixation High Risk Thin-wire Fixation Ankle/Hindfoot Charcot • Arthrodesis provides the most reliable and durable correction and stability • Most deformities can be corrected intraoperatively • Typically include both ankle and ST joints for levels of fixation • Internal fixation reserved for relatively “clean” cases Case Example • 70 yo diabetic neuropathy • 4 month h/o ankle deformity • Unable to ambulate 3 7/14/2014 Transfibular Approach Joint Preparation Reduced Mortise 4 7/14/2014 TTC Intramedullary Rod • Load-sharing device (vs plate/screw fixation) • Bridge ankle and ST joints • Percutaneous insertion • Soft-tissue friendly • Low metal/hardware exposure (intraosseous) • Frame can be added if necessary Midfoot Charcot 5 7/14/2014 Technique Closing-wedge osteotomy Technique Remove wedge and close Low Risk Charcot -32° 6 7/14/2014 Surgical Approach Surgical Approach Video 7 7/14/2014 Internal Fixation How Much Fixation? Charcot-Indicated Plates 8 7/14/2014 What About Beaming? • Relatively new technique for Charcot (1997?) • Similar to rebar in construction • Concrete has very poor tensile properties • Rebar + concrete: magnitudes stronger What is Beaming? • Intraosseous fixation bridging one or multiple joints • Screw, rod , or bolt • Most commonly used in the medial column 62 yo Recurrent Ulceration 9 7/14/2014 62 yo Recurrent Ulceration 6 Months Postop My Technique • Evolving… • 6.5 mm solid bolt stainless steel system • Retrograde 1st ray/talus bolt • Retrograde lateral column bolt • Rarely augment with plate fixation 10 7/14/2014 55 yo Painful Charcot 9 Months Postop Caveats • • • • • TAL critical Prepare all joints that the bolts cross Bone graft defects (typically allograft) NWB in TCC for 8-10 weeks Transition to extra-depth shoe/insert 11 7/14/2014 Results Charlotte experience • 6 patients • Minimum 6 month f/u • All clinically/radiographically healed • No deep infections • One required plantar lateral exostectomy 4 months postop Conclusions • Consider internal fixation for unstable ankle and mid/hindfoot Charcot in absence of deep infection • Adjunctive external fixation should be considered • Beaming very promising for midfoot – need for greater variety of sizes Thank You! 12 Charcot Foot Treated with a Static Circular External Fixator Michael S. Pinzur, MD Professor of Orthopaedic Surgery Loyola University health System Disclosure Consultant Small Bone Innovations Wright Medical Lecturer Smith-Nephew Stryker Favorable Outcome Ulcer and Infection-Free Able to ambulate independently with commercially-available therapeutic shoes custom accommodative foot orthoses 1 Who needs surgery? 1. Non-plantigrade foot with overlying ulcer and osteomyelitis 2. Clinically and radiographically nonplantigrade foot 3. Painful neuropathic non-union Principles of Static Ring Able to OBTAIN correction of deformity Obstacles to MAINTAIN correction: vitamin D deficient / poor quality bone poor host Motor Balancing Gastrocnemius muscle lengthening or Tendon Achilles lengthening 2 3 4 5 6 Static Ring Fixation Obtain correction at surgery Difficulty with maintaining correction 7 7/12/2014 Richard Gellman, MD Summit Orthopaedics Portland, OR Dynamic = gradual deformity correction using Ilizarov multiplanar external fixation Most corrections with Taylor Spatial Struts Simple lengthenings or distraction with threaded rods Some ankle equinus corrections in lighter patients with universal hinges Create a stable, plantigrade, ulcer-free foot below an aligned leg 1 7/12/2014 Unbraceable, unstable deformity + Recurrent ulceration Non ambulatory patients wanting alternative to amputation Patients need to understand that this is limb salvage surgery. Risk of amputation or need for future reconstructions 20% Deformities that can’t be acutely corrected Too severe ▪ plantigrade foot not obtainable despite heroic attempts at soft tissue release, bone shortening, Poor soft tissue, unsafe to make requisite surgical dissections Acute correction would lead to unwanted arthrodesis such as a pantalar or TCC Safe to operate on contracted or previously operated soft tissue Maintains bone length, may limit need for arthrodesis Lower deep infection rate Ability to allow limited weight bearing due to strength of frames 2 7/12/2014 Best to have applied quite a few static Holding Frames before attempting dynamic frames Ankle Combined Foot Deformity = hindfoot and midfoot deformities Midfoot Examples: ankle equinus contracture, neuropathic ankle fx/dx, AVN talus, distal tibia collapse Apply standard 2 ring tibial base frame, one long foot ring and connect lower tibial ring to foot ring with Taylor Spatial struts If deformity at tibiotalar joint, insert a talar neck wire and attach to foot ring. This focuses distraction, correction across ankle joint 3 7/12/2014 Always perform percutaneous achilles lengthening or tenotomy first in equinus corrections Set up TSF program as apex anterior deformity with origin at center of talar dome Hold in corrected position of at least 10 degrees dorsiflexion for 6 weeks to prevent recurrence 4 7/12/2014 Ideal for contracted longstanding ankle/hindfoot dislocations For a more rapid correction, especially with infected cases, I perform talectomy, antibiotic bead placement, deformity correction Stage Tibia-Calcaneal fusion in 4-6 weeks Frames can be set up to allow insertion of 16 cm hindfoot fusion nails 5 7/12/2014 59 yom DM Morbid obesity Longstanding lateral peritalar dislocation (PTTD gone wild) Active MSSA infection over ulcer breakdown on talar head, I&D site by his podiatrist Not able to walk 6 7/12/2014 7 7/12/2014 8 7/12/2014 Severe valgus peritalar dislocation, rigid equinovarus foot Hindfoot and midfoot both in varus or valgus Set up like Ankle equinus frame except talar neck wire attaches to distal tibia by long hinges. This stabilizes the ankle joint (talus in the mortise) so that correction occurs through the subtalar, talonavicular, calcanealcuboid joint complex Forefoot deformity of aDduction or aBduction can be acutely corrected with “drag” olive wires May need to pin toes In severe deformities, may need to prevent weight bearing for first 1-2 weeks until the sole of the foot is more plantigrade 9 7/12/2014 10 7/12/2014 Apply tibial base frame Place U-ring along posterior aspect of distal tibia on lateral view Attach full ring that encircles the forefoot Place at least 3 wires into metatarsals for sufficient strength of fixation Attach struts after insertion of first forefoot wire to make strut attachment easier May need to first distract (lengthen) 10-15 mm in order to disengage midfoot bones prior to correction of angular or translational deformity TSF software pretty good for midfoot correction Option to set up as tibia but have forefoot correlate to proximal tibia 11 7/12/2014 57 yom with DM. Chronic midfoot ulceration over 10 years Failed debridements and CROW MR negative for deep bone involvement Teaches nursing at local college 25 degree Talo-1st Met 40 degrees Talo-1st Met No significant hindfoot malalignment Debridement and closure of ulcer Gradual correction of midfoot rocker bottom and abduction contracture with frame Safer for lateral skin 12 7/12/2014 3 weeks after frame application Staged triple and 1st TMT arthrodesis Frame modification to correct equinus contracture 13 7/12/2014 Plantigrade, ulcer healed 14 7/12/2014 Stretched the soft tissue, incomplete reduction 15 7/12/2014 16 7/12/2014 Lack of experience with static frames prior to attempting dynamic frames Challenges of placing sufficient number of wires to create a stable and strong frame in small areas of the foot Challenge of working around struts Experience in running TSF programs Experience in applying frames in a manner to allow strut application and decrease strut changes Keeping wire fixation away from osteotomies and internal fixation Aggressively managing pin site infections Planning frame modifications in the OR to replace broken or loose wires before catastrophic failure occurs Need to perform staged arthrodesis to maintain correction Gradual transitions after frames are removed with walking casts and AFOs 17 7/12/2014 gellman@summitdocs.com 18
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