Tag Archives: Charcot Foot

Charcot foot management using MASS posture foot orthotics: A case study

by Edward S. Glaser DPM1; David Fleming BS2*; Barbara Glaser2

The Foot and Ankle Online Journal 10 (3): 4

Background: A 62-year old male being treated for Charcot arthropathy of his right foot at the VA Medical Center in Orlando, FL.  The patient was using a knee walker with a below knee cast at onset of treatment.
Methods:  Custom rocker sole walking boot with built in EVA MASS posture orthotic and MASS orthotic Therapy
Results:  Quality of life improvements.  As the Charcot foot remodeled it coalesced into a foot with an increased medial longitudinal arch allowing for return closer to normal gait and footwear.  No ulcerogenesis was noted with aggressive orthotic therapy.  Protective sensation partially returned to feet bilaterally.
Conclusions:  An increase in patient quality of life without introducing ulcers.   More research needs to be done to determine if this treatment protocol contributes to protective sensation returning to patients with DPN.

Keywords: Charcot foot, diabetic neuropathy, orthoses, MASS Posture

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0004

1 – Founder and CEO of Sole Supports, Inc.
2 – Sole Supports, Inc.
* – Corresponding author: dfleming@solesupports.com


The patient is a 62-year old, well nourished, caucasian male with a 12-year history of Type II Diabetes Mellitus. He has experienced neuropathy for 9 years and for the last 7 years he has been profoundly numb bilaterally distal to the ankle. Following a 10-month period of misdiagnosis, he was diagnosed with Charcot foot on November 18, 2015, at the Orlando VAMC. Podiatric treatment for four months prior consisted of ambulating in a BK cast with a knee walker. Casts were reapplied every 3-4 weeks. During the four months of immobilization, the patient noted considerable atrophy of the right gastroc-soleus muscle and loss of his medial longitudinal arch. The patient’s right foot had become a semi-rigid rocker sole foot (Figure 1).

Figure 1 Rocker sole foot.

When the patient was first seen, insensitivity was confirmed with a Semmes Weinstein 5.07 monofilament test bilaterally. No ulcers were visibly present. The patient’s right foot had significant swelling and the patient had gone from a size 12.5 USA (M) shoe to a size 14 USA (M) shoe prior to casting according to the patient.

To prevent amputation of his foot, a prospective protocol was created as the patient progressed.  If at any time the patient developed an ulcer, the project would have been terminated and traditional care would have resumed.

Methods

A Semmes Weinstein 5.07 monofilament was used to determine the patient’s protective sensation.  The locations for monofilament testing were as follows: the plantar aspect of metatarsal heads and distal phalanges 1,3,5. The plantar aspect of the heel, medial arch, and lateral arch. The dorsal aspect of the skin at the base of metatarsal 3, and plantar aspect of the heel, bilaterally [1].

Figure 2 Paper Test shown with MASS Orthotic.

The Paper Test (Figure 2) consisted of the patient weight bearing on the affected foot with a piece of paper placed under both the forefoot and the rearfoot.  The practitioner then attempted to remove the piece of paper by pulling it anteriorly/posteriorly.  If the paper tore then that was a positive result, if the paper slid out it was a negative result.  A positive result meant that part of the foot was providing adequate force to the ground, resulting in the paper being torn.  A negative result meant that part of the foot was not providing adequate force to the ground and slid out un torn.  The paper test was used to determine when it was appropriate to move him from the custom MASS posture rocker sole shoe boot to the MASS orthotic  inside of a diabetic shoe.

Figure 3  Custom walking boot with EVA Shell MASS Posture Orthotic.

Following removal of the  plaster cast, a custom rocker-sole post-op boot with an EVA shell MASS posture orthotic built in (Figure 3) on 1/28/16.  That boot caused irritation and so the design was refined and a new rocker-sole boot with an EVA shell MASS Posture orthotic fitted in the boot (Figure 4) was created and dispensed to patient on 3/4/2016.  The boot (Figure 4) was removed and replaced with a modified golf shoe boot with an EVA shell MASS Posture orthotic fitted into the boot (Figure 5), which was dispensed to the patient on 3/25/2015.  Each change of successive custom boot was modeled from a new, more aggressively captured medial longitudinal arch.  The golf shoe boot (Figure 5) was removed and replaced with an ultrahigh molecular weight polyethylene shell. MASS orthotic (O1) for use with his diabetic shoes.  O1 was dispensed and fitted on 5/6/2016 with use of a full foot lift for his left foot to compensate for the edema on his right foot.   After the edema decreased another MASS orthotic with a polyethylene shell (O2) was dispensed and fitted, for his normal tennis shoes, on 8/25/2016, along with reducing the full foot lift on his left foot.

Figure 4 Refined Custom walking boot with EVA Shell MASS Posture Orthotic.

Figure 5 Modified golf shoe boot with EVA Shell MASS Posture Orthotic.

Results

Our patient initially presented completely insensate with diabetic neuropathy on 1/28/2016.  On 3/25/2016 the patient had regained 6/10 sensation on the right foot and 8/10 on left with the monofilament test.  On 5/6/2016 the patient had a 8/10 sensation on right foot and 10/10 on left.  It should be noted that the patient has been fully compliant keeping his diabetes in control.

Although the patient’s Charcot foot has now fully fused, the foot appears to have remodeled and partially regained the medial longitudinal arch (Figure 6).  The authors believe that this is due, at least in part, to the patient weight bearing in a MASS Posture.  No ulcers developed with the forces applied to the foot.  This is due, at least in part, to the even distribution of body weight across the plantar surface of the foot.  

Figure 6 Clinical view of foot after treatment.

The patient is leading a normal life that includes golf and walking approximating an ideal gait cycle on both hard flat surfaces (hardwood) and uneven flexible surfaces (grass).  

Discussion

For peripheral neuropathy, it is common conventional wisdom that only the levels of Hgb A1C correlate to the presence of neuropathy.  This particular case, along with previous findings of Michael Graham, suggest that there is a secondary biomechanical etiology that may contribute to Diabetic Peripheral Neuropathy (DPN).  Michael Graham showed that reversing neuropathy could be obtained by reducing tension on the neurovascular bundle and the intracompartmental pressures of the posterior tibial nerve utilizing an extra osseous talotarsal implant [2].  This helps explain why some diabetics with equally poor Hgb A1C’s develop DPN but others do not. The biomechanical factor is postulated to involve the mechanical elongation of the perineurium surrounding the posterior tibial nerve.  As the foot drops in posture, the neurovascular bundle is pulled plantarly increasing tension due to elongation [3].  This may cause the perineurium to compress the nerve while increasing fluid pressure within the sheath, contributing to its loss of function.

Conclusion

The authors postulate that using MASS Posture orthotics in combination with controlling diabetes may prevent or, in some cases reverse, diabetic neuropathy by reposturing the foot and thereby decreasing nerve tension and entrapment while evenly distributing the force from the body across the entire plantar surface of the foot.  Additionally, the authors postulate that it is possible during active Charcot to remodel the medial longitudinal arch closer to an idealized foot posture.  Further research is required with an established protocol prior to treatment with a larger sample size to provide more data to verify results.

References

  1. Smieja, M., Hunt, D. L., Edelman, D., Etchells, E., Cornuz, J., Simel, D. L. and For The International Cooperative Group for Clinical Examination Research (1999), Clinical Examination for the Detection of Protective Sensation in the Feet of Diabetic Patients. Journal of General Internal Medicine, 14: 418–424. 
  2. Graham ME, Jawrani NT, Goel VK. The Effect of HyProCure® Sinus Tarsi Stent on Tarsal Tunnel Compartment Pressures in Hyperpronating Feet. The Journal of Foot and Ankle Surgery. 2011;50(1):44-49. 
  3. Graham ME, Jawrani NT, Goel VK. Evaluating Plantar Fascia Strain in Hyperpronating Cadaveric Feet Following an Extra-osseous Talotarsal Stabilization Procedure. The Journal of Foot and Ankle Surgery. 2011;50(6):682-686. 

Charcot Foot Limb Salvage Procedure with External Fixation and Medial Column Lengthening: A Case Presentation

by Mario Cala, DPM1, Beau Willis, BS2, Brian Carbonell, BS3, Scott Boynton, BS4pdflrg

The Foot and Ankle Online Journal 6 (8): 1

Charcot neuroarthropathy is a debilitating disease, which affects nearly a third of diabetic patients with peripheral neuropathy. Many of these cases result in below knee amputation due to secondary complications associated with this condition such as chronic ulceration with subsequent soft tissue infection and osteomyelitis. Previous studies have shown the effectiveness of utilizing external fixation and medial column arthrodesis to achieve a stable plantar grade foot in patients with Charcot neuroarthropathy. In this case we present a patient who has a complex deformity due to a previously shortened and hyper-mobile 1st ray combined with an ankle and forefoot valgus deformity. Through the utilization of previous modalities combined with restoration of 1st ray length, a stable plantar grade foot was achieved preventing below knee amputation.

Key words: Charcot Foot, Limb Salvage, Medial Column Lengthening.

Accepted: July, 2013
Published: August, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0608.001


Address correspondence to: 1Barry University / Mercy Hospital, Miami, FL, Residency Director Jackson North Medical Center, Miami, FL

2,3,4 Submitted as 4th year student, Barry University School of podiatric Medicine, Miami, FL


Charcot neuroarthropathy is a progressive condition that results in the destruction of single or multiple joints characterized by subluxation, dislocation, and osseous destruction[1]. Eventually, the Charcot process proves to be self-limiting and enters a quiescent phase, leaving the patient with an irreversible condition, in addition to an increased risk for secondary ulceration[4]. Complicated by peripheral neuropathy, the syndrome historically left the affected individual with the loss of the affected limb[2]. Pathogenesis is related to stress induced repetitive micro-trauma or acute injury on the affected lower extremity that has a loss of protective sensation[3].

Because of a traditional understanding that management of Charcot neuroarthropathy often resulted in non-practical ambulation, in the past many surgeons would choose to perform an amputation[3]. Charcot affects only 1% of diabetics, however it has been reported in a staggering 29% of diabetic patients with peripheral neuropathy and loss of protective sensation[3]. Take into mind that the survival rates for diabetic amputations at 5 years is only 50%[3], and it becomes evident that a need for alternative treatment modalities is high in demand. Today, an increasing number of surgeons are advocating for earlier intervention of Charcot changes[5].

To reinforce the concept that increased surgical intervention is needed, we present a case in which below the knee amputation was prevented through the use of an autologous bone grafted 1st ray, external fixation and tri-planar deformity correction.

Case Study

A 56-year-old male with a history of diabetes and Charcot joint disease presented with a chief complaint of left foot deformity with severe pain on weight bearing due to pressure under the medial malleolus and medial plantar foot ulcer. The patient had a previous left 1st metatarsal head resection due to chronic osteomyelitis. When the patient initially presented to the Mercy Emergency Department on June 4, 2012, a malodorous, purulent draining ulcer was noted to the left 1st metatarsophalangeal joint with a total area measuring 2.5 cm. The patient was noted to be completely neuropathic. The left foot and ankle were noted to be in severe valgus position, and the 1st metatarsophalangeal joint (MPJ) was dislocated. Infectious disease consults recommended a below knee amputation due to the extent and chronic nature of the condition. However, following podiatry consult, serial incision and drainages (I&D’s) with IV antibiotics, and future limb salvage reconstructive surgery was recommended upon infection control. In the period between June 2012 through to November 2012, six successful I&D’s with bone debridements were performed, resulting in control of infection. At that time, a decision was made to attempt to reconstruct the patient’s left lower extremity utilizing an external fixation frame.

On November 18, 2012, the patient was brought to the Mercy Operating Room for surgical correction of left Charcot joint disease. After general anesthesia was induced, attention was directed to the medial malleolus where a sagittal saw and blade was used to shave down all hypertrophic bone. A transverse cut from posterior to anterior was made with an osteotome and mallet on the medial malleolus to create a varus wedge. The wedge on the medial malleolus was closed for the left tibial correctional osteotomy.

cala1

Figure 1 Left: Postoperative lateral radiograph showing bone graft placement, as well as, 1st ray extended length Right: Preoperative lateral radiograph showing shortened 1st ray.

Next, all cartilage was removed from the ankle in preparation for fusion. Autograft and allograft (Trinity Evolution) was applied to the ankle fusion site and the ankle varus wedge. Attention was then directed to the first MPJ, where all chronicity of the joint was resected, and the bones were fenestrated for fusion of the first MPJ. Autograft measuring 12.8mm x 8.5mm. (Fig. 1) taken from the tibial varus wedge osteotomy was introduced into the site to facilitate fusion, and restore length to the 1st metatarsal. An Orthofix MiniRail was applied to the 1st MPJ.

Two pins were placed proximally on the 1st metatarsal shaft and two distal pins were placed on the proximal phalanx. An elliptical incision was made over the medial and plantar aspect of the 1st MPJ to excise the skin ulcer of this area. Under fluoroscopy, correction of the deformity was achieved and medial arch height of the foot was restored resulting in a better anatomic position. K-wires (.062) were used to fuse the joint, and kept to recreate a high medial arch. An Orthofix external ring fixator was applied to the extremity with 2 olive wires in the proximal tibia, two olive wires in the distal tibia, two olive wires in the calcaneus, and 3 olive wires placed in the forefoot for anatomic correction. (Fig. 2)

cala2a cala2b

Figure 2 Top: Dorso plantar intra-operative radiograph showing placement of external fixator and monorail. Bottom: Lateral intra-operative radiograph showing placement of external fixator.

The ring external fixator consisted of 2 circular rings and 2 foot plates. The case progressed successfully to wound healing and primary fusion after 10 weeks.

cala3a cala3b

Figure 3 Top: Postoperative radiographs showing removal of hypertrophic bone formation as well as fusion of ankle joint. Bottom: Preoperative radiographs showing hypertrophic bone formation.

In follow-up visits, the patient states he is able to ambulate pain free and without assistance. Post-operative x-rays reveal fusion of the ankle joint (Figure 3), and correction of valgus deformity (Fig. 4) as well as fusion of the 1st MPJ with achievement of a more accurate length of the 1st metatarsal.

cala4

Figure 4 Left: Postoperative radiographs showing forefoot valgus correction. Right: Preoperative radiographs showing forefoot valgus deformity.

This case presents a patient with a complex deformity in which chronic ulceration is due to a hyper-mobile first ray combined with a previously shortened 1st metatarsal. Prior studies have shown the effectiveness of external fixator use1, as well as medial column arthrodesis[6], in the management of patients with Charcot neuroarthopathy. By combining these two previous treatment modalities with extension of the 1st metatarsal, through the usage of an autologous bone graft, a stable plantar grade foot can be achieved (Fig. 5).

Conclusion

Below knee amputation is often the recommend procedure in Charcot joint disease patients with chronic non-healing ulceration and significant deformity[3]. The successful utilization of acute tri-planar correction, external fixation and autologous bone graft provides an alternative treatment for those patients with complex Charcot foot deformities.

cala5

Figure 5 Left: Postoperative stable plantar grade L-foot free of ulceration. Right: Preoperative unstable L-foot with ulceration.

References

1. Zgonis T, Roukis T, Lamm B. Charcot foot and ankle reconstruction: Current thinking and surgical approaches. Clin Podiatr Med Surg. 2007 24:505-517. [PubMed]
2. Najafi B, Crews RT, Armstrong DG, Rogers LC, Aminian K, Wrobel J. Can we predict outcome of surgical reconstruction of Charcot neuroarthropathy by dynamic plantar pressure assessment? – A proof of concept study. Gait Posture 2010 31: 87-92. [PubMed]
3. Zgonis T, Stapleton J, Roukis T. Charcot Foot and Ankle Deformity. McGlamry’s Comprehensive  Textbook of Foot and Ankle Surgery. 4th ed, Ch 70. 1008-1021.
4. Jeffcoate W. Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2008; 24(Suppl 1): S62–S65. [PubMed]
5. Burns PR, Wukich DK. Surgical reconstruction of the Charcot foot and ankle. Clin Podiatr Med Surg 2008 25: 95-120. [PubMed]
6. Capobianco CM, Stapleton JJ, Zgonis T. The role of an extended medial column arthrodesis for charcot midfoot neuroarthropathy. Diabetic Foot & Ankle 2010 1: 5282. [PubMed]

Neuropathic Ankle Arthrodesis with Intramedullary Nail Fixation

by Brent Bernstein, DPM FACFAS1, Zachary Ritter, DPM2, Robert Diamond, DPM FACFAS3

The Foot and Ankle Online Journal 5 (7): 1

Tibiotalocalcaneal/Tibiocalcaneal arthrodesis with intramedullary nail fixation is a useful and stable means through which to address complex rearfoot deformities. In this manuscript, we have critically analyzed the modalities and surgical outcomes within existing literature comparing each to our institutional results and have found a critical void in information. In tracking and addressing variables such as smoking cessation, glucose control, weight management, vascular stability, extremity ulcerations and postoperative pedorthics we have observed improved operative outcomes and fusion rates. In reviewing the literature, we have found bone union rates of 79.6%, non-union rates of 7.6%, fracture rates of 1.4% and amputation rates of 4.7%. Those results were then compared to our rates of 88.88%, 11.12%, 0% and 0% respectively. Yet, while our institution noted improved results, a meaningful meta-analysis was difficult to achieve considering that most literature failed to make note of the aforementioned variables. Accordingly, we offer that a strict preoperative regimen of glycemic control, vascular patency, weight management and smoking cessation, in conjunction with strict postoperative non-weight bearing and aggressive wound management will improve overall results. Furthermore, it is our suggestion that future research address these topics.

Key Words: Neuropathic Ankle Arthrodesis, Intramedullary Nail Fixation, Charcot, Ankle Fusion, Diabetes

Accepted: June, 2012

Published: July, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0507.0001


Charcot neuropathic osteoarthropathy is a destructive disease of neurologic origin that contributes to both bone and joint abnormalities.

While its pathogenesis is not completely understood, the Charcot process is thought to be a product of neurovascular and neurotraumatic etiologies with effects reaching far beyond the diabetic community.

In examining the Charcot limb it is important to understand that this deformity will typically present in three anatomic planes–the sagittal, transverse and frontal. The effects of that triplanar deformity are most notable in the Charcot ankle, with severe valgus or varus fixed deformities or occasionally “flail” ankles with the foot being stabilized on the lower extremity by soft tissue alone [1,2].

Figure 1 3-D computed tomography reconstruction of patient 1.

Often, patients also experience postural changes and a grossly unstable bony architecture presenting the need for aggressive surgical correction [3-6].  With that, one mainstay of therapy remains rearfoot fusion with intramedullary nail fixation [2,7]. It is expected that anywhere from 0.1 to 5% of all diabetic patients will develop neuropathic osteoarthropathy during the course of their disease; these odds are increased substantially in patients with end-stage neuropathy [3,4,8-10].  Moreover, diabetic patients with ulcerations are significantly more likely to undergo extremity amputation. With these odds, it is extremely important for the foot and ankle specialist to judiciously approach the Charcot joint.

Our study evaluates the results of bone fusion rates and outcomes with tibiotalocalcaneal/tibiocalcaneal arthrodesis. In order to accomplish this, we have explored our institutions outcomes alongside those of existing literature to demonstrate commonalities and techniques for successful treatment and/or interventional modalities. To this end, it is our hypothesis that meticulous preoperative planning, intraoperative techniques, and post-operative care significantly affect the success of the fusion rates.

Figure 2 Post-operative radiograph of patient 1.

Methods and Materials

An extensive literature review of selected electronic databases including PubMed, the Cochrane Database and OVID was conducted for articles using the key words “Charcot ankle”, “intramedullary nail”, and varied combinations of each. No specific time parameters were set; accordingly, articles were reviewed from inception to present. Studies were excluded if they were not available in English, did not address the use of intramedullary nail fixation for the diabetic Charcot ankle deformity or did not note postoperative weight-bearing, obesity, wound care or union type.  With that, only thirteen articles were found to meet our inclusion criteria. (It should be noted that our original inclusion criteria included monitoring of blood glucose levels, nutritional status, vascular stability and nicotine use, however literature that followed these variables was extremely limited).

Secondarily, a review of our senior authors (B.B.) patient database was conducted.  Nine consecutive patients who had undergone tibiotalocalcaneal/tibiocalcaneal arthrodesis using an intramedullary nail between January of 2005 and 2009 were selected for review. Perioperative data was obtained from our institutions electronic medical record system and wound care facility records.

Figure 3 Pre-reduction radiograph of patient 2.

Of the nine patients followed within our institution, eight were diagnosed with a Sanders IV Charcot deformity, seven had a medical history significant for diabetes mellitus, and seven weighed over 102kg. The average patient age was fifty-five years with eight males and one female.  All diabetics demonstrated a hemoglobin A1c of less than 7.5%. Stable lower extremity arterial studies as per our institutions vascular surgeons were noted along with dopplerable pedal pulses.

All patients had also transitioned from the active phase of neuroarthropathy to the chronic phase as demonstrated by cutaneous infrared thermistor readings being equalized to within 2 degree Celsius of the contralateral unaffected limb [11,12].

Figure 4 Post-operative radiograph of patient 2.

Patients who demonstrated active “hot” joints were managed pre-operatively with protected weightbearing in total contact casts with adjunctive therapy of oral or parenteral bisphosphonates or miacalcin nasal spray and/or non-invasive bone stimulation therapy until temperature readings equalized and edema had resolved.

Patients from our senior author’s practice were refused surgical intervention if at the time of surgery they 1- had an open wound, 2-had not accomplished pre-operative glycemic control, 3- had not undergone tobacco cessation, 4-had not attempted weight management or 5- did not have adequate vascular runoff/perfusion as determined by our facilities vascular testing (ABI/PVR) (Table 1).

Table 1 Preoperative requirements

Post-operatively, our patients were kept strict non-weight bearing until clinical stability was noted. At that time they were transitioned into a total contact cast and finally, as consolidation completed, to accommodative shoe gear or custom-fabricated ankle-foot orthosis. All patients were followed postoperatively at our facility’s wound care center for weekly appointments until that time when independence and function had been restored. Additionally, all post operative wounds were treated at that same facility by certified wound care specialists until the time of their resolution.

Surgical Technique

A hockey stick type incision was made over the fibula and curved distally to the level of the sinus tarsi at the base of the fourth metatarsal. The fibula was then exposed and the distal aspect of the fibula was resected. Typically, the fibula was morselized to be incorporated as bone graft material to fill osseous deficits. An accessory medial ankle incision allowed adequate debridement of devitalized talus and preparation of the joint surfaces. Standard technique included a talectomy and insertion of a wedged portion of bone (autograft from the talectomy or fresh frozen femur) to allow the tibia to seat at 90 degrees to the weightbearing surface in contact with the posterior facet of the calcaneus.  All opposing surfaces of tibia, calcaneus and navicular were denuded of cartilage and multiple subchondral drill holes were created through their articulating surfaces. Additionally, the anterior tibia and bone graft wedge were similarly fenestrated to facilitate bony fusion.

All deficits were back-filled with the morselized fibula graft. Frequently, the Achilles tendon was released at this time. The foot was then assessed for proper positioning and placement of the IM nail. At that time, the guidewire for the nail was placed within the anterior aspect of the plantar heel through the talus–centered into the medullary canal of the tibia. That was then confirmed by intraoperative C-arm guidance in AP, and lateral positions. The bone was drilled, reamed, and placement of the nail was performed utilizing the systems jig. Depending on the system utilized, compression was achieved across the arthrodesis site either externally with tightening of the jig/”top hat” against the external heel pad or plantar calcaneus, via manual compression of the heel, internally through the compression bolts, or externally via external fixation bolts incorporated on the jig. Following insertion of compression screws to fix the nail to the osseous structures, the jig was removed and the IM nail was visualized by C-arm for positioning. Subcutaneous structures were closed with 3.0 vicryl and the skin with staples (Table 2). The incisions were covered with Xeroform™ and a Robert Jones compression dressing. Postoperatively the patient was placed on bedrest with ice, elevation and subcutaneous low molecular weight heparin (Table 3).

Table 2 Intraoperative Techniques

Table 3 Postoperative Management

Results

Osseous fusion, defined as trabecular bridging at the fusion site with disappearance of appositional gapping, was noted in 88.8% of all patients within our institution. Categorically, fusion was seen in 85.7% of diabetics, 87.5% of Charcot limbs, 85.7% of those weighing over 102kg and 88.8% of those placed in a postoperative TCC.

Figure 5 Pre-reduction clinical image of patient 3.

Comparatively, literature has demonstrated fusion rates of 73%, 70.4%, 92.4% and 46.2% respectively [2-4,7,8,13-20].

Moreover, our institution demonstrated significantly fewer post-operative complications when compared to published literature 11.12% non-unions, no amputations and no osseous fractures. Somewhat skewed, however, is the above average number of post-operative wounds encountered within our institution 44.4% as opposed to 18% in literature. Although that statistic could certainly be secondary to the extent of deformity or aggressive tracking, it is hard to draw any correlations due to the lack of detailed information with those articles reviewed.

Figure 6 Post-reduction clinical image of patient 3.

Discussion

In recent years indications for tibiotalocalcaneal/tibiocalcaneal fusion have expanded, likely because of improved fixation methods [2]. Intramedullary fixation is biomechanically more rigid than crossed lag screws when examining flexion and torsional forces [13]. Accordingly, retrograde intramedullary nailing is a good option for complex tibiotalocalcaneal/tibiocalcaneal fusions, especially in patients with Charcot arthropathy [21-24]. The construct does allow for weightbearing six to eight weeks after surgery while demonstrating fusion rates that approach ninety percent.

As with any surgical patient, a thorough preoperative assessment should be performed. It is essential to consider the entire patient and not simply the deformity. Therefore, a complete physical examination and adequate overall health evaluation is essential to choose an appropriate surgical candidate.

In this small retrospective analysis, we propose that the following reasons could account for our improved fusion rate. First, critical preoperative planning, including thorough evaluation of the osseous deformity with a 3-D 64 slice CT scan and long-leg axial radiographs. Second, all patients were followed-up at our institutions wound management center to facilitate aggressive management of pre-operative and post-operative wound complications. Third, evaluation of the patient’s vascular status with non-invasive arterial testing such as toe pressures, ankle/brachial indices and arterial Doppler examination during preoperative evaluation proved to be invaluable when determining inclusion criteria. Fourth, patients were offered enrollment in weight loss and smoking cessation programs preoperatively, deferring surgery until this occurred. Fifth, physical therapy training preoperatively and strict non-weight-bearing postoperatively was maintained for eight weeks after which total contact casting and finally bracing was applied. Sixth, nutritional factors were medically evaluated and patients were under firm metabolic control.

Overall, in reviewing the data offered in our literature review and that of institutional review, it is difficult to do a successful and meaningful meta-analysis given the overall lack of detailed patient information and differentiation. Most publications made little mention of preoperative variables that our authors found exceedingly important to track ABI/PVR, weight management, extent of diabetic control, preoperative wound/deformity, tobacco use, etc. In that void, as previously noted, the authors of this study were required to exclude a majority of papers found. Within the grouping of useful studies (Table 1), patient results were taken individually for correlation accounting for the varying cohort numbers (n=). Meaning, each variable along the x-axis consists of a compilation of data collected from different publications. Accordingly, it is an imperative that future studies more closely follow and account for those variables.

This study demonstrates that, while great strides are being made in the world of reconstructive surgery for neuropathic osteoarthropathy, there remains a void in critical information. Information that will not only lead to better standards in surgical management, but also to a more detailed understanding of the Charcot limb and improved techniques in limb salvage.

References

1. Kile TA, Donnelly RE, Gehrke JC, Werner ME, Johnson KA. Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 1994 15: 669-673. [PubMed]
2. Stone NC, Daniels RT. Midfoot and hindfoot arthrodesis in diabetic Charcot arthropathy. Can J Surg 2000 43: 449-455. [PubMed]
3. Papa J, Myerson M, Girard P. Salvage with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. JBJS 1993 75: 1056-1066. [PubMed]
4. Pinzur MS, Sage R, Stuck R, Kaminsky S, Zmuda A. A treatment algorithm for neuropathic midfoot deformity. Foot Ankle Int 1993 14:189-197. [PubMed]
5. Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. JBJS 2000 82A: 939-950. [PubMed]
6. Wagner FWW. The Diabetic Foot and Amputations of the Foot. Surgery of the Foot, 5th Ed. Mann, PR (ed.), St. Louis, CV Mosby, 421-455, 1986.
7. Pinzur MS, Noonan T. Ankle arthrodesis with retrograde femoral nail for Charcot ankle arthropathy. Foot Ankle Int 2005 26: 545-549. [PubMed]
8. Caravaggi C, Cimmino M, Caruso S, Dalla Noce S. Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rear foot. J Foot Ankle Surg 2006 45: 20-24. [PubMed]
9. Schon LC, Marks RM. The management of neuropathic fracture-dislocation in the diabetic patient. Orthop Clin North Am 2002 26:375-393. [PubMed]
10. Sanders LJ, Mrdjenovich D. Anatomical pattern of bone and joint destruction in neuropathic diabetes. Diabetes 1991 40 (suppl 1): 529A.
11. Eichenholtz SN. Charcot Joint. Charles Thomas, Springfield, IL, 1996.
12. Sanders LJ, Frykberg RG. Diabetic Neuropathic Osteoarthropathy: The Charcot Foot. The High Risk Foot in Diabetes Mellitus. Churchill Livingstone, New York, 1991.
13. Pinzur MS, Kelikian A. Charcot ankle fusion with a retrograde locked intramedullary nail. Foot Ankle Int 1997 18: 699-704. [PubMed]
14. Dalla Paola L, Volpe A, Varotto D. Use of retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: A limb salvage procedure. Foot Ankle Int 2007 28: 967-970. [PubMed]
15. Mendocino R, Catanzariti AR, Saltrick KR. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg 2004 43: 82-86. [PubMed]
16. Moore TJ, Prince R, Pochatko D, Smith J, Fleming S. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int 1995 16: 433-436. [PubMed]
17. Stuart MJ, Morrey BF. Arthrodesis of the diabetic neuropathic ankle joint. Clin Orthop 1990 253: 209-211. [PubMed]
18. Shibata T, Tada K, Kagawa, Chohzo H. The results of ankle arthrodesis of the ankle for leprotic neuroarthropathy. JBJS 1990 72A: 749-756. [PubMed]
19. Stone KH, Helal B. A method of ankle stabilization. Clin Orthop 1991 268:102-106. [PubMed]
20. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int 2006 27: 759-763. [PubMed]
21. Baravarian B, VanGils CC: Arthrodesis of the Charcot foot and ankle. Clin Pod Med Surg 2004 21: 271-289. [PubMed]
22. Fox IM, Shapero C, Kennedy A. Tibiotalocalcaneal arthrodesis with intramedullary interlocking nail fixation. Clin Pod Med Surg 2000 17:19-31. [PubMed]
23. Millett PJ, O’Malley MJ, Tolo ET. Tibiotalocalcaneal fusion with retrograde intramedullary nailing, clinical and functional outcomes. Am J Orthop 2002 31:531-536. [PubMed]
24. Wagner A, Fuhrmann R. Charcot foot treated by correction and arthrodesis of the hindfoot. Oper Orthop Traumatol 2005 17: 554-562. [PubMed]


Address correspondence to: Brent Bernstein, DPM, 303 W. Broad St, Bethlehem, PA 18018

1Director of the Charcot Reconstructive Foot Program and Attending Surgeon, Podiatric Surgical Residency, St. Luke’s University Health Network, Bethlehem, PA
2Chief Resident, Podiatric Surgical Residency, St. Luke’s University Health Network, Bethlehem, PA
3Chief of Podiatric Surgery and Residency Director, Podiatric Surgical Residency, St. Luke’s University Health Network, Bethlehem, PA

© The Foot and Ankle Online Journal, 2012

Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study

by Sarah Shogren, DPM, Sara Zelinskas, DPM, Byron Hutchinson, DPM, Vineet Kamboj, DPM

The Foot and Ankle Online Journal 4 (8): 3

This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Key words: Tibiotalocalcaneal fusions, Charcot Ankle, distal femoral locking plates, ankle valgus

Accepted: July, 2011
Published: August, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0408.0003


Charcot neuroarthropathy when left untreated can progress to combined deformity of the ankle and subtalar joints. The treatment goal in these cases is to produce a stable, plantigrade foot that is braceable.

When conservative treatments such as bracing and shoe gear modifications fail, tibiotalocalcaneal (TTC) arthrodesis is typically the salvage procedure of choice. Bone quality in Charcot patients is often poor due to osteoclastic activity. The decision on the type of stable fixation to use can often be a challenge.

Ahmad et al., described humeral locking plates to have a high rate of fusion at 94.1%. [1] Several forms of stable fixation have been used to achieve TTC arthrodesis, including screws, intramedullary nails, [3] blade plates, [3] external fixation, [4,6] and humeral locking plates, [5] to name a few.

According to Pelton and Carvaggi, intramedullary nails are a good method for TTC arthrodesis with 88% and 92.8% fusion rates respectively. [2,7]

Distal femoral locking plates, like humeral locking plates, are not made specifically for this reconstruction, but are stable with a viable architecture to encompass both ankle and subtalar joints. The locking plate technology allows for a more stable construct in patients with questionable bone quality and combined deformities as in Charcot neuroarthropathy. (Figs. 1A and 1B)

 

Figure 1A and 1B  Pre-operative radiograph (A) and patient (B) with combined Charcot ankle valgus and subtalar deformities.

The purpose of this retrospective chart review was to evaluate the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Methods

A retrospective chart and radiographic review of four patients with Charcot neuroarthropathy with associated ankle valgus was studied. Inclusion criteria for this case series were patients with Charcot neuroarthropathy and a painful deformity at the ankle and subtalar joints. Exclusion criteria included active infections, significant bone loss from trauma and osteonecrosis. All patients failed conservative treatments, including bracing and shoe gear modifications, and all requested definitive treatment. Due to the retrospective review of these patients pain scales were not compared before and after surgery.

All four patients underwent tibiotalocalcaneal arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. Follow-up was obtained for up to 12 months. Frames were removed after approximately three months, after which patients began progressive weightbearing in a postoperative boot.

All four TTC arthrodeses were performed by the same surgeon, including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic and clinical evidence of consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation.

Surgical Method

A linear incision was made adjacent to the course of the fibula. An oblique osteotomy was made at the distal third of the fibula. The fibula was resected and removed from the operative table. The tibiotalar joint was then resected with the sagittal saw. (Figs. 2A and 2B) An ankle arthrotomy was performed medially and the medial malleolar articular surface was resected with a sagittal saw forming a miter at the medial aspect of the tibial surface. (Fig. 3) The subtalar joint was denuded of cartilage using a curette.

 

Figures 2A and 2B  Surgical resection of the fibula (A) is performed prior to resection of the tibiotalar joint. (B)

Figure 3  Application of the distal femoral locking plate to stabilize the Charcot ankle is technically simple.

The tibiotalocalcaneal arthrodesis was temporarily fixated with a Steinman pin placed through the plantar aspect of the foot crossing both joints into the tibia. The distal femoral locking plate was applied to the lateral aspect of the tibia, talus and calcaneus. Multipotential cellular bone matrix as well as platelet rich plasma were added to the autogenous bone graft which was placed in the tibiotalar arthrodesis site.

Accurate placement of the plate was verified using intraoperative fluoroscopy, and the Steinman pin was removed from the plantar foot. The circular fixator frame was then applied to the lower extremity with wires and half pins using standard technique. (Fig. 4) Axial compression was applied through the external fixator.

Figure 4:  Application of external fixator to aid in axial compression of the Charcot Ankle.

Outcomes

All four patients remained non-weightbearing for roughly three months in the external fixator. The fixator was then removed and patients remained non-weightbearing for an additional two weeks in a CAM boot. Patients began progressive weightbearing in a post-operative boot to full weightbearing for 3 additional months.

Once radiographic consolidation was seen, patients were progressed to full weightbearing in a CROW (Charcot Restraint Orthotic Walker) boot or similar device. These patients were ambulating with minimal pain at the end of the postoperative recovery period and able to perform their daily living requirements.

Three patients (75%) had satisfactory outcomes with only minor complications. Two patients (50%) required blood transfusion following surgery, and one (25%) had mild pin tract infections which responded quickly to oral antibiotics. One patient (25%) had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. This patient did not have an active infection at the time of surgery however; this patient had a history of prior osteomyelitis from previous procedures and was in renal failure. These pre-operative factors ultimately could have contributed to the patients post- operative wound dehiscence and ultimate recurrence of osteomyelitis. On average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. (Fig. 5) The patients with successful outcomes were able to ambulate pain free in a CROW boot. Table 1 summarizes the four patient outcomes.

Figure 5  Clinical presentation during 3-month course in external fixators.

Table 1  Tibiotalocalcaneal fusion outcomes for the four patients included in this retrospective case series.

Discussion

Approaching the treatment for a patient with Charcot arthropathy can be very difficult and controversial. These patients generally have multiple comorbidities making healing potential for ulcerations, as well as surgical procedures, more difficult. If ulceration prevention and adequate mobility is achieved using a bracing method this should be done as first line treatment. [8]

Attaining rigid fixation in a tibiotalocalcaneal arthrodeses can be difficult in patients with Charcot neuroarthropathy. Chiodo, et al., in 2003, compared the biomechanical properties of blade-plates and intramedullary rod fixation for TTC arthrodesis, and found the blade-plate to be a more rigid construct. [3] It is important to note that while blade plates do give a more rigid construct, they do not offer multiple planes of fixation. Intramedullary rods have been shown to have high fusion rates however they are technically difficult with risk of stress risers, fractures and neurovascular injury.

Pinzure and Kelikian reported 21 ankles with Charcot arthropathy treated using the intramedullary nail. Ninety per cent of these patients went on to fusion. The authors concluded this as an excellent means of obtaining ankle fusion in Charcot patients. In comparison, another form of fixation are locking plates which are less technically demanding and offer fixation in multiple planes. [5] Fixation in multiple planes is important because it limits rotational forces. Ahmad, et al., proved that using a PHILOS locking plate to achieve TTC arthrodesis does provide bone union and deformity correction. In patients with Charcot neuroarthropathy, greater rigidity is ideal to maintain the correction through the arthrodesis and we believe the locking plate will do this.

The greatest limitation to our case series is a small population size. Further research needs to be done in a prospective manner. This would give the advantage of determining a standardized pre-operative pain score (AOFAS) which is another limiting factor in this retrospective review.

The use of distal femoral locking plates for tibiotalocalcaneal arthrodesis is a viable rigid internal form of fixation. The locking plate technology allows for a stable construct in patients with questionable bone quality. In comparison to other forms of arthrodesis, it has a more rigid construct with better boney apposition and fixation in multiple planes.

In summary, the use of distal femoral locking plates in conjunction with external fixation is an acceptable option to create a plantigrade braceable foot as a limb salvage procedure in Charcot neuropathy patients.

References

1. Ahmad J, Pour AE, Raikin SM. The modified use of a proximal humeral locking plate for tibiotalocalcaneal arthrodesis. Foot Ankle International 2007 28: 977-983.
2. Carvaggi C. Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rearfoot. J Foot Ankle Surg 2006: 45(1), 20-24.
3. Chiodo CP, Acevedo JI, Sammarco VJ, Parks BG, Boucher HR, Myerson MS, Schon LC. Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: A biomechanical investigation JBJS 2003 83A: 2425-2428.
4. Colgrove RC, Bruffey JD. Ankle arthrodesis: Combined internal-external fixation. Foot Ankle International 2001 22: 92-97.
5. Lowery NJ, Alison JM, Burns PR. Tibialtalocalcaneal arthrodesis with the use of a humeral locking plate. Clinics Podiatric Medicine Surgery. 2006 26: 485-492.
6. Misson JR, Anderson JG, Bohay DR, Weinfeld SB. External fixation techniques for foot and ankle fusions. Foot Ankle Clinics 2004 9: 529-539.
7. Pelton K. Tibiocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle International 2008: 27: 759-763.
8. Pinzure M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle International 2004 25: 545-549.
9. Pinzure MS, Kelikian A. Charcot ankle fusion with a retrograde locked intramedullary nail. Foot Ankle International 1997: 18, 699-704.


Address correspondence to: Sarah Shogren, DPM, Franciscan Foot and Ankle Institute, 34509 9th Ave S. Ste 306 Federal Way WA 98003. Email: SarahShogren@fhshealth.org

1-4  Franciscan Foot and Ankle Institute, 34509 9th Ave S. Ste 306 Federal Way WA 98003.

© The Foot and Ankle Online Journal, 2011

Protected Weight Bearing During Treatment of Acute Charcot Neuroarthropathy: A case series

by Jeremy J. Cook, DPM,MPH,CPH, Emily A. Cook, DPM,MPH,CPH

The Foot and Ankle Online Journal 4 (7): 1

Standard of care in the treatment of acute Eichenholtz stage I Charcot neuroarthropathy includes complete non-weight bearing immobilized with total contact casting. This small case series of three patients focuses on patients with acute phase midfoot Charcot neuroarthropathy treated with non-casting immobilization therapy. All patients were male with a mean age of 48.7 (range 46-53) years. Patients were instructed to assume complete non-weight bearing during treatment. Due to financial restrictions, all patients reported fully weight bearing in the non-removable immobilization boot because of work related obligations. Immobilization therapy lasted a mean duration of 90.3 days (range 76 – 133 days) and was discontinued once there was clinical resolution of inflammation and osseous stability. Serial radiographs revealed absence of deformity progression and eventual consolidation in all cases. All patients remained ulcer and callus free during immobilization therapy, without progression of a rocker-bottom deformity, while fully weight bearing and maintaining full-time manual labor employment. This preliminary case series adds to the evidence base that it may be possible to allow protected weight bearing during acute phase Charcot neuroarthropathy with adequate immobilization of the foot at all times.

Key words: Diabetes, Charcot neuroarthropathy, Foot Deformity, Casting, Foot fractures, Diabetic Foot.

Accepted: June, 2011
Published: July, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0407.0001


Charcot neuroarthropathy is an increasingly common clinical entity encountered by foot and ankle professionals. In the early decades of the last century syphilis was the most commonly associated etiology. That has changed with the advent of insulin and the resulting extended survival of patients suffering from diabetes mellitus.

Delay in diagnosis and patient non-compliance can result in severe destruction of the foot and ankle with permanent disability from ulceration, infection, and eventual amputation. [1-14]

The standard of care for treatment of Eichenholtz stage 115 Charcot neuroarthropathy has been immobilization in a total contact cast and complete non-weight bearing. [16-20] The period of non-weight bearing immobilization should last until erythema, edema, and warmth subside and the foot becomes stable and consolidated enough to prevent anatomic destruction while ambulating. This process has been reported to last anywhere from a few months to over two years. [20-26]

Total contact casts (TCC) have been shown in numerous studies to be an effective immobilization device in the treatment of acute Charcot neuroarthropathy. [5,7-14,16-20]

It is recommended that TCCs be changed frequently in order to prevent cast irritation, ulceration and to maintain immobilization as edema subsides. Minor complications such as skin irritation are anticipated with TCC. The risk of major complications such as ulceration and infection can be minimized with proper application techniques, as well as frequent casts changes, which permit careful monitoring, and adequate patient education. [27] Many centers have specially-trained orthotists who apply TCCs on a routine basis. Most studies support changing TCCs for the treatment of Stage I Charcot neuroarthropathy every 1-2 weeks. [11,13,17,19,22,27-31] Some institutions have allowed weight bearing in the TCC due to its inherent stability with success in preliminary reports. [9,27-31]

Although weight bearing during stage I of Charcot neuroarthropathy is controversial, many patients tend to be non-compliant. This is because this period of prolonged non-weight bearing may be detrimental in quality of life and may pose to be an unacceptable disability. [32,33] While the alternative may be amputation, advances in immobilization technology may allow protected weight bearing during the early stages of Charcot without the development of severe deformity. [34,35] The purpose of this study was to report results of acute Stage 1 Charcot neuroarthropathy in individuals immobilized in a vacuum stabilization boot that maintained full weight bearing.

Case Series

Three consecutive patients presented with acute Stage I Charcot neuroarthropathy over a three month period (November 2009 to January 2010). All three patients had Brodsky type I deformity involving the tarsometatarsal and naviculocuneiform joints. [18] Patients were referred for examination and treated within two weeks of symptom onset. Clinical examination revealed erythema, warmth, and edema involving the midfoot with gross instability, crepitation with midfoot range of motion, and bounding pedal pulses. One patient had diabetic neuropathy while the other two were diagnosed with alcoholic neuropathy. Peripheral neuropathy was confirmed by the absence to detect the Semmes-Weinstein 10gm monofilament.

Two of the three patients reported a minor injury preceding the Charcot event. The third patient had had previous amputations of digits two and three for localized osteomyelitis secondary to contiguous digital ulcerations. All three patients were male with a mean age of 48.7 (range 46-53) years. All patients presented within two weeks of first symptoms and were ulcer free at the time of initial presentation with this being their first occurrence of Charcot neuroarthropathy. Radiographs were obtained with findings consistent with early signs of Charcot neuroarthropathy. (Fig. 1A and 1B) Magnetic resonance (MR) imaging further confirmed the diagnosis with diffuse bone marrow edema adjacent to the Lisfranc joint.

 

Figure 1A and 1B  Initial anterior posterior (AP) (A) and lateral (B) radiographs demonstrating soft tissue edema with early signs of osteolysis, cortical thickening, fragmentation, and osseous destruction within the tarsometatarsal and naviculocuneiform joints.

All three patients were treated with immobilization in a vacuum stabilization boot (VACOcast®, OPED Inc, Framingham, MA) with instructions to remain strictly non-weight bearing. (Fig. 2) Despite these recommendations, all three patients reported bearing weight on the affected limb in order to prevent loss of their job. All three patients were sole providers in their household with jobs that required extensive manual labor. The patients were compliant in wearing the boot at all times as this was verified through inspecting the undamaged compliance locks on the boot.

Figure 2   In this boot, by removing air from a vacuum cushion, small beads contour around the lower limb and create vacuum stabilization.

Serial monitoring was conducted by clinical examinations and plain radiographs. Patients were kept immobilized in the vacuum stabilization boot until resolution of edema, warmth (examined by palpation with back of hand and fingers and comparing to contra-lateral limb), and clinical stability was achieved. Successive radiographs were taken to ensure the absence of deformity progression every 3-4 weeks. (Fig. 3A, 3B and 3C) Throughout the treatment period each patient maintained normal full weight bearing in the conduct of their full-time jobs.

  

Figure 3A, 3B and 3C  Progression of acute phase of Charcot neuroarthropathy.  AP (A), Oblique (B) and lateral (C) views demonstrate increased osseous destruction and osteolysis.

Patients wore the vacuum stabilization boot for a mean of 90.3 days (range 76 – 133 days). One patient developed a superficial abrasion on the dorsal proximal interphalangeal joint of the second digit. This healed after two weeks of wound care and the additional of padding to the boot in this area. There were no other complications experienced. During the treatment of acute Stage I Charcot neuroarthropathy, all three patients remained ulcer and callus free while ambulating in the immobilization boot. Once the Charcot events had progressed to the consolidation phase, patients were transitioned to accommodative shoes or boots with supportive inserts.

Two of the three patients were compliant with accommodative shoes and molded insoles. After 16 months from the initial presentation, both patients have not developed ulcers, callus, or progression of deformity. (Fig. 4A, 4B and 4C) During the 12 weeks that the third patient was wearing the immobilization boot, the deformity did not progress and the patient remained ulcer and callus free.

  

Figure 4A, 4B and 4C  AP (A), Oblique (B) and lateral (C) views showing progression into chronic Charcot neuroarthropathy with maintenance of anatomic alignment with consolidation of osseous destruction.

However, the third patient did not obtain prescribed accommodative shoes or inserts citing financial limitations. He was subsequently lost to follow-up for five months after completing 12 weeks of immobilization therapy. His Charcot neuroarthropathy had developed a rocker bottom foot deformity and plantar midfoot ulcer after five months of interrupting care.

Discussion

Management of Charcot neuroarthropathy is a complex process which requires flexibility and constant attention. This small case series demonstrates that despite the overt disregard for non-weight bearing management instructions, all patients were able to maintain employment and prevent progression of rocker bottom midfoot deformities during acute Eichenholtz stage I Charcot neuroarthropathy as there was continuous utilization of the vacuum immobilization boot.

Patients were continuously immobilized in a vacuum stabilizing below-knee boot with compliance confirmed by boot locks. There were minimal complications during the acute phase treatment with one patient developing a superficial digital abrasion from the boot. This was identified immediately and rectified by adjusting the boot. Despite fully weight-bearing, a rocker bottom deformity was prevented with adequate and constant immobilization.

Standard of care for acute Eichenholtz stage I traditionally includes total contact casting and complete non-weight bearing to prevent progression of deformity. This has been recently challenged by allowing weight bearing in the total contact cast in combination with frequent cast changes and close monitoring. Two prospective case series have reported successfully preventing deterioration of osseous alignment from acute phase Charcot deformity with weight-bearing total contact casts. [28,29]

The amount of non-restrained cumulative load forces across acute Charcot joints is also believed to increase the amount of deformity progression. By immobilizing the foot with a walking total-contact cast, the acute phase resolved and further progression towards a rocker bottom foot was prevented. [30]

The immobilization boot reported in this study was chosen for several reasons. Total contact casts require frequent changes and proper construction to prevent complications related to this casting technique. This immobilization boot had the advantage of clinical efficiency as no time was necessary beyond properly sizing and fitting the patient and providing instructions on its use. The vacuum boot can be adjusted to accommodate changes in edema. The removable sole allows patients to sleep with the boot without dirtying the linens. It also has a radiolucent frame that permits radiographic evaluation without removal. Finally, the compliance locking straps prevent unknown patient removal. Although none of the affected limbs had an open ulcer necessitating daily care, had local wound care been necessary by a visiting nurse an additional key would have been provided.

Limitations of this study include its retrospective nature. The initial treatment plan did not permit patients to weight bear during acute phase Charcot neuroarthropathy, however, weight bearing did not adversely impact the treatment outcome. Both mechanical and comparative studies are needed to further investigate the ability of nontraditional immobilization devices to effectively prevent osseous deformity in a disease which can cause permanent disability and eventual amputation. Future prospective studies with a larger sample size are needed to assess the long-term outcomes of this immobilization technique. Comparison studies of different immobilization techniques would also be very useful. Finally, the definition of adequate immobilization needs further investigation in order to achieve a balance of prevention of serious Charcot-related complications and quality of life.

Conclusion

Patients with acute Eichenholtz stage I midfoot Charcot neuroarthropathy were able to fully weight bear and maintain manual labor employment without development of a rocker bottom foot deformity while wearing a vacuum stabilization below-knee boot. Advances in immobilization therapy may allow improvement in the quality of life in acute phase Charcot neuroarthropathy.

References

1. Holewski, J, Moss KM, Stess RM, Graf PM, Grunfeld C. Prevalence of foot pathology and lower extremity complications in a diabetic outpatient clinic. J Rehab Res and Devel 1989 26: 35-44.
2. Sohn MW, Stuck RM, Pinzur M, Lee TA, Budiman-Mak E. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care 2010 33: 98-100.
3. van der Ven A, Chapman CB, Bowker JH. Charcot neuroarthropathy of the foot and ankle. J Am Acad Orthop Surg 2009 17: 562-571.
4. Sohn MW, Lee TA, Stuck RM, Frykberg RG, Budiman-Mak E. Mortality risk of Charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone. Diabetes Care 2009 32: 816-821.
5. Boulton AJ, Jeffcoate WJ, Jones TL, Ulbrecht JS. International collaborative research on Charcot’s disease. Lancet 2009 J373 (9658): 105-106.
6. Shibuya N, La Fontaine J, Frania SJ. Alcohol-induced neuroarthropathy in the foot: a case series and review of literature. J Foot Ankle Surg 2008 47: 118-124.
7. Nielson DL, Armstrong DG. The natural history of Charcot’s neuroarthropathy. Clin Podiatr Med Surg 2008 1: 53-62.
8. Frykberg RG, Belczyk R. Epidemiology of the Charcot foot. Clin Podiatr Med Surg 2008 1:17-28.
9. Pinzur MS. Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int 2007 8: 952-959.
10. Sanders LJ. What lessons can history teach us about the Charcot foot? Clin Podiatr Med Surg 2008 1: 1-15.
11. Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications 2009 23: 409-426.
12. Jeffcoate WJ. Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2008 24 (Suppl 1): S62-65.
13. Petrova NL, Edmonds ME. Charcot neuro-osteoarthropathy-current standards. Diabetes Metab Res Rev 2008 24 (Suppl 1): S58-61.
14. Chantelau E. The perils of procrastination: effects of early vs. delayed and treatment of incipient Charcot fracture. Diabet Med 2005 22: 1707–1712.
15. Eichenholtz SN. Charcot Joints. Springfield, Illinois: Charles C. Thomas, 1966.
16. Shaw JE, His WL, Ulbrecht JS. The mechanism of plantar unloading in total contact casts: implications for design and clinical use. Foot Ankle Int 1997 18: 809-817.
17. Pinzur MS, Shields N, Trepman E, Dawson P, Evans A. Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 2000 21: 916–920.
18. Brodsky JW. The diabetic foot. In: Coughlin MJ, Mann RA, editors. Surgery of the Foot and Ankle. Vol 2. 7th ed. St. Louis, Mosby. 1999, 895-969.
19. Pinzur MS, Shields N, Trepman E, Dawson P, Evans A. Current practice Patterns in the treatment of Charcot foot. Foot Ankle Int 2000 21: 916-920.
20. Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot’s arthropathy in a diabetic foot specialty clinic. Diabetic Med 1997 14: 357-363.
21. Molines L, Darmon P, Raccah D. Charcot’s foot: newest findings on its pathophysiology, diagnosis and treatment. Diabetes Metab 2010 36: 251-255.
22. Pinzur, MS. Surgical vs. accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int 2005 25: 545-549.
23. Myerson MS, Henderson MR, Saxby T, Short KW. Management of midfoot diabetic neuroarthropathy. Foot Ankle Int. 1994 15: 233-241.
24. Alpert SW, Koval KJ, Zuckerman JD. Neuropathic arthropathy: review of current knowledge. J Am Acad Orthop Surg. 1996 4: 100-108.
25. Fabrin J, Larsen K, Holstein PE. Long-term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care 2000 23: 796-800.
26. Schon LC, Easley ME, Weinfeld SB. Charcot neuropathy of the foot and ankle. Clin Orthop Relat Res 1998 349: 116-131.
27. Wukich DK, Motko J. Safety of total contact casting in high-risk patients with neuropathic foot ulcers. Foot Ankle Int 2004 25: 556-560.
28. Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int 2006 27: 324-329.
29. de Souza LJ. Charcot arthropathy and immobilization in a weight-bearing total contact cast. JBJS 2008 90A:754-759.
30. Kimmerle R, Chantelau E. Weight-bearing intensity produces charcot deformity in injured neuropathic feet in diabetes. Exp Clin Endocrinol Diabetes 2007 115: 360-364.
31. Chantelau E, Kimmerle R, Poll LW. Nonoperative treatment of neuro-osteoarthropathy of the foot: do we need new criteria? Clin Podiatr Med Surg 2007 24: 483-503.
32. Pakarinen TK, Laine HJ, Mäenpää H, Mattila P, Lahtela J. Long-term outcome and quality of life in patients with Charcot foot. Foot Ankle Surg 2009 15: 187-191.
33. Sochocki MP, Verity S, Atherton PJ, Huntington JL, Sloan JA, Embil JM, Trepman E. Health related quality of life in patients with Charcot arthropathy of the foot and ankle. Foot Ankle Surg 2008 14: 11-15.
34. Verity S, Sochocki M, Embil JM, Trepman E. Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole. Foot Ankle Surg 2008 14: 26-31.
35. Stöckle U, König B, Tempka A, Südkamp NP. Cast immobilization or vacuum stabilizing system? Early functional results after osteosynthesis of ankle fractures. Unfallchirurg 2000 103: 215-219.


Address correspondence to: Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
Email: jeremycook@post.harvard.edu

1,2  Clinical Instructors in Surgery at Harvard Medical School, Division of Podiatric Surgery, Department of Surgery.
185 Pilgrim Road, PB Span 3, Beth Israel Deaconess Medical Center, Boston, MA. 617-632-7098

© The Foot and Ankle Online Journal, 2011

Reconstructing Limb Deformities using the VCAM™ External Fixator: A series of 3 cases

by Michael P. DellaCorte, DPM, FACFAS , Panagiotis Panagakos, DPM ,
Tarika Singh, DPM , Howard Goldsmith, DPM, AACFAS

The Foot and Ankle Online Journal 4 (1): 2

External fixation was used almost exclusively for fracture management. It is also used for arthrodesis, management of lower extremity deformities such as Charcot neuroarthropathy, limb lengthening, osteotomy stabilization, osteomyelitis, nonunion or pseudoarthrosis. It has proven extremely useful in the treatment of a number of conditions because it can provide distraction, compression, stabilization and neutralization as needed. Traditional external fixators involve driving pins through the tibia and fibula. The VCAM™ is a unique below the ankle external fixator. The VCAM™ can avoid possible disruptions and complications that are often seen with traditional Ilizarov fixators. The indications for the VCAM™ external fixator are identical to the Ilizarov fixators, such as off-loading, fracture reduction and reconstructive procedures. In our institution, we have used the VCAM™ device to off-load ulcerations and correct limb deformities. In the cases presented in this paper the VCAM™ was used to off-load wounds secondary to Charcot arthropathy and transmetatarsal amputations, as well as to gradually correct a rearfoot deformity such as seen in a Chopart’s amputation. The VCAM™ can be constructed into an Ilizarov type frame or a hybrid frame which can be used to achieve gradual triplanar correction. We have seen good results using the VCAM™ for wound care and limb deformities and recommend this approach when tibia and fibula intervention is not necessary.

Key words: Limb deformity, Charcot foot, ulceration, VCAM™, wound, external fixation.

Accepted: December, 2010
Published: January, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0401.0002


External fixators have proven very versatile in treatment as they can be used with open, closed or limited open surgical techniques. They provide access to the involved limb for wound healing and dressing changes and can be designed to correct complex deformities such as Charcot joint. They allow for gradual, precise correction over the postoperative course rather than a single intra-operative correction by osteotomy or fusion.

Ring fixators are typically used to treat complex Charcot neuroarthropathy. [1] External fixators provide multiplanar correction including angulation, translation, rotation, stabilization, compression, distraction and neutralization while allowing for surrounding soft tissue adaptation; this also helps to minimize wound complications and vascular compromise that may result from overcorrection in a single-stage procedure. [2,4,5,6] In general, external fixators can be used to correct coexisting deformities separately, successively or simultaneously. [3]

The VCAM™ fixator allows for adjustment and alteration as needed during the post-operative period. Full immediate weight bearing postoperatively is also possible with the external fixator. [2] This is extremely important in Charcot reconstruction with concomitant ulcerations that require offloading. Additionally, external fixation is the only treatment option for Charcot with associated osteomyelitis or in Eichenholtz stage I and II, where internal fixation is contraindicated. [4]

There are two main types of fixators. The monolateral fixator which consists of threaded half-pins attached to a bar which allows for axial compression or distraction. The other main type is the ring fixator which was made popular by G.A. Ilizarov. The ring fixators use trans-osseous wires and pins placed under tension for bone fixation; they are more versatile and complex than the monolateral fixators. The hybrid fixator is a combination of these two main types and may be more appropriate for certain indications. [2,3]

Lower limb deformities secondary to trauma, diabetes or any other pathological cause can be devastating to patients and frustrate foot and ankle surgeons treating them. Charcot arthropathy is one of the limb deformities discussed in this paper that can lead to ulceration. Treatment of Charcot foot may require internal as well as external fixation. Ilizarov type fixators have been used for surgical reconstruction of this deformity. Surgery is indicated for treatment of Charcot arthropathy if chronic or recurrent ulcers are associated with the deformity, if the deformity is unstable and if there is an acute fracture in a neuropathic patient with good circulation. [1,2]

There is limited mention in the literature of external fixation devices that do not extend proximal to the ankle. The purpose of this paper is to introduce the VCAM™ external fixator and present its various uses and construct designs.

The VCAM™ has been available for nearly a decade. In our opinion it is an underutilized external fixator because it has not been previously reported in the literature which has lead to an ignorance of the device in the orthopaedic community.

It has mainly been used in locations where ankle privileges are not available to podiatrists. The VCAM™ consists of a leg portion with a boot construct similar to a CAM walker with Velcro straps lined along the leg sleeve, plastic upright Velcro extensions attached to posts, various size threaded rods, half rings, foot plates and a rocker bottom with rubber treads with Velcro straps. We believe this unique external fixator has many advantages over traditional Ilizarov frames. It reduces the number of pins or wires placed across the tibia and fibula, therefore decreasing pin site infections, calf edema does not become an issue, fractures of the tibia and fibula when inserting, removing and/or tensioning the wires and decrease in thermal necrosis of neurovascular and muscular structures in the leg. The VCAM™ cannot be used for limb lengthening procedures, ankle fractures, pilon fractures, or any other surgical procedure involving the tibia or fibula

Technique

When all ancillary pedal procedures are complete and the half rings and wires have been applied to the operative site and tensioned, the VCAM™ leg sleeve is first applied over cast-padding. Next, the plastic extensions are attached by velcro and are secured. Then three or four hole posts are secured to the plastic extensions to which various sized rods are attached spanning from the leg down to the foot. These rods are connected to the foot plate and half rings with the use of posts, if needed. Note that the foot plates and half rings are secured in place with nuts and bolts to the smooth olive transfixation wires during the surgical reconstruction. Lastly, the rubber rockerbottom foot attachment allows protection and partial weight bearing. Constructs are designed based on the pedal pathology present.

Once there is clinical and radiographic evidence of consolidation at the fusion site, or there is clinical correction of a specific limb deformity the external fixator may be removed. The frame is often removed after 8 to 12 weeks and the patient is fitted for a Charcot Restraint Orthotic Walker (CROW) and remains in this device for 6 months.

Thereafter, patients are fitted for ankle foot orthoses (AFO) and custom extra depth shoes with appropriate fillers if necessary.

Case Report 1

This diabetic male patient presented to the Emergency Department with an infected 2nd toe leading eventually to a proximal Chopart’s Amputation. The patient had multiple debridements and fasciotomies of the leg over a 6 month period. He developed a lateral ankle ulcer and an adducto-varus foot type as a result of muscle imbalances. (Figs. 1A and 1B)

Figure 1A and 1B Case 1: Lateral aspect of the lower extremity with adducto-varus deformity and ulceration over the fibular malleolus before VCAM™ application. (A)  A superior view of the lower extremity with adducto-varus deformity. (B)

He had the VCAM™ external fixator applied to offload the ulcer and to gradually correct the adducto-varus deformity. The pins were placed distally through the amputation site to create a more stable frame. He had an adjunctive Achilles tenotomy. Weekly adjustments consisted of tightening the lateral aspect of the frame and loosening the medial components to bring the foot perpendicular to the leg. (Figs. 2A, 2B and 2C) After six weeks of weekly adjustments clinical correction of the deformity was achieved and the lateral ulcer healed. The VCAM™ was then removed. (Figs. 3A and 3B) He was then placed in a CROW Walker to weight bear.

Figure 2A, 2B and 2C Case 1:  Day of VCAM™ application. (A)  1 week after the VCAM™ application with the first adjustment after VCAM™ application. (B)  4 weeks after VCAM™ application with the fourth adjustment. (C)

Figure 3A and 3B Case 1:  6 weeks after VCAM™ application and there is clinical correction of deformity.  The VCAM™ was then removed. (A) The lateral view shows clinical correction of deformity and healed ulceration. (B)

Even though the VCAM™ is primarily a below ankle frame it can be designed to imitate a Taylor Spatial™ external fixator, as it was for this case. A half ring was able to be applied above the ankle without any pins inserted into the leg and six struts were fashioned to help achieve gradual triplanar correction of the lower extremity deformity.

Case Report 2

A 60 year-old male with history of Diabetes Mellitus with peripheral neuropathy and ESRD, presented to wound care center with a chief complaint of chronic non-healing plantar ulcers of six months duration. The patient had a previous left foot trans-metatarsal amputation (TMA) with an ulcer on the distal plantar lateral aspect of the TMA site and a plantar heel ulcer. Local wound care with weekly debridements failed to heal the ulcers. The plantar heel ulcer measured 5cm x 6cm and probed to bone.

It was then decided to proceed with surgical debridement of the ulcer and VCAM™ application. On March 3rd, 2008 a percutaneous tendo-Achilles lengthening (TAL) and tenotomy of the anterior tibial tendon were performed to relieve forefoot pressure on the distal plantar lateral TMA site ulcer. The Versajet Hydrosurgery System™ (Smith & Nephew) was used to debride the plantar ulcers of all necrotic tissue and then application of Apligraf® (Organogenesis) skin substitute was applied to the heel ulcer. At this point, a VCAM™ external fixator was applied to offload the plantar ulcerations and help maintain angular correction after TAL and anterior tibialis tenotomy. The pins for the frame were thrown distally through the TMA site exiting posterior to the heel to help create a more stable construct. The VCAM™ in this case is a standard Ilizarov type frame and was primarily used to offload the ulcers. (Fig. 4A and 4B) The ulcers were progressing well and had decreased in size significantly until the patient tripped and fell while ambulating which ultimately led to several pin tract infections. (Figs. 5A and 5B) The causative organism of the pin site infections was MRSA. The patient was started on Zyvox® (Pfizer) and the VCAM™ fixator was removed on April 17, 2008.

Figure 4A and 4B Case 2:  Clinical appearance the day of VCAM™ application. (A) The lateral view 1 week after VCAM™ application. (B)

Figure 5A and 5B Case 2:  2weeks after VCAM™ application showing ulcer healing with associated pin tract infections. (A)  4 weeks after VCAM™ application with progressive closure of the ulcers.

The distal plantar ulcer healed before the fixator was removed and all wounds healed with continued off-loading after removal. Pin site infections are the most common complication with external fixators. In this case, patient selection was appropriate. He could ambulate without any significant issues prior to VCAM™ application that would deter a foot and ankle surgeon from applying an external fixator. In our opinion the result of the patient falling was accidental.

Case Report 3

A 51 year-old diabetic female with history of Hypertension, Hypercholesterolemia, Charcot Neuroarthropathy and a non-healing Wagner Grade 3 ulcer measuring 2.4 cm x 2.5 cm x 2.4 cm present for more than 1 year duration, was seen in the Wound Care Center. (Figs. 6A and 6B) Radiographs revealed a Charcot foot deformity with dislocation at the LisFranc and Chopart joints. (Figs. 7A and 7B) After 17 hyperbaric oxygen treatments helped to resolve cyanosis of the digits, it was decided that surgical intervention would be necessary to realign the midfoot and to offload the ulcer.

Figure 6A and 6B Case 3:  The Initial clinical appearance; plantar view of the foot. (A)  The Initial clinical appearance demonstrating the depth of the ulcer. (B)

Figure 7A and 7B Case 3:  The initial radiographic lateral view. (A) The initial radiographic dorsoplantar view. (B)

The patient had a wound debridement, left talar osteotomy, percutaneous Tendo-Achilles lengthening and VCAM™ application. This frame was constructed to offload the ulcer and to compress and realign the midfoot to the hindfoot. One half ring was placed on the dorsal aspect of the foot and another half ring placed posterior to the heel to aid with compression. Realignment of the dislocated joints is evident on the immediate post operative radiographs. The frame was adjusted on a weekly basis. The VCAM™ was successful in producing a more plantigrade foot and offloading the ulcer long enough for it to decrease greatly in size. The frame was removed after 8 weeks and the patient was subsequently put into an ankle foot orthosis. Conservative wound care continued for approximately 2 months until the ulcer healed successfully. (Figs. 8A, 8B and 8C)

Figure 8A, 8B and 8C Case 3: Day of VCAM™ application. (A)  The foot is placed in a more plantarflexory position to promote ulcer closure. (B)  The immediate post-op lateral radiograph. (C)

Discussion

External fixators are now almost exclusively used for arthrodesis, management of lower extremity deformities such as Charcot neuroarthropathy, limb lengthening, osteotomy stabilization, osteomyelitis, nonunion or pseudoarthrosis. [1,2] In wound and ulcer management it provides offloading and potentiates healing. It has proven extremely useful in treatment of these conditions because it can provide distraction, compression, stabilization and neutralization as needed. [2]

There is limited mention in the literature of external fixation devices that do not extend proximal to the ankle. Herbst uses two types of external fixation devices for the treatment of Charcot Arthropathy. One is a foot frame and the other a tibiocalcaneal frame. He uses the foot frame for the correction of midfoot deformity. The main characteristics are a hindfoot ring and a forefoot ring in the coronal plane. The two rings have a spanning device between them to provide compression across the midfoot. [7] Malizos, et al., described an Ilizarov below the ankle circular frame to treat displaced calcaneal fractures. There are 2 rings both confined to the foot.

The proximal ring serves a stable ground through the talus and midfoot bones and supports the distal ring. The 2 rings are distracted to withstand the deforming forces of the Achilles tendon, the plantar musculature, aponeurosis and peroneal retinaculum. Ligamentotaxis can be used for reduction of fragments. Reduction of the shape and height of the calcaneus is easy with the use of gradual distraction. They concluded that rings attached to the distal tibia are not necessary.

Possible complications associated with the external fixator include: uncontrollable edema with drainage exiting at the pin tract sites, pin tract infections, pin loosening, pin irritation, pin/wire breakage, thermal necrosis, non-union, delayed union, malunion, osteomyelitis, joint contractures/subluxation, wound dehiscence, compartment syndrome, reflex sympathetic dystrophy and fracture after frame removal. [2] Many of these complications can be avoided with post-operative compliance and follow-up care. Edema can be alleviated by elevation and partial weight-bearing immediately post-op. Another potential complication is severe pain and damage due to pins or wires compromising muscles, tendons or neurovascular structures.

This complication is decreased with the use of the VCAM™, as no pins are passed through the leg. Major complications such as infection and wire breakage alter the postoperative course and often require removal of the external fixator. [9]

In the cases presented it is evident that the VCAM™ can be constructed in many configurations and therefore be used to treat a variety of lower limb deformities that could lead to ulcerations. In the first case the VCAMTM was applied to achieve gradual correction of a triplanar deformity. It was successful in doing so without the use of leg pins or wires. In the second case it was used a traditional Ilizarov frame to simply offload the extremity to assist in healing two plantar ulcers. In the third case it was again constructed as an Ilizarov type frame to offload a plantar ulcer and to provide compression of the midfoot to the hindfoot. In all three of these cases the VCAM™ was successful and proved to be a useful device to heal ulcerations and correct deformities without the use of leg pins or wires. One of the disadvantages of the VCAM™ as seen in the second case was the development of pin tract infections. This is the most common disadvantage with any external fixator, but the absence of leg pins in our opinion decreases the chance of pin tract infections with the VCAM™. More case studies and research should be explored with the VCAM™ in the areas of trauma especially Lisfranc fractures since it is a midfoot deformity and other lower limb deformities.

In conclusion we feel that the VCAM™ is an excellent modality when managing limb deformities that have lead to the development of ulcerations. It provides a means of realigning the foot in all necessary planes while simultaneously offloading ulcerations. The benefits greatly outweigh the risks associated with use of this device. We have seen good results using this device and recommend it for offloading ulcerations secondary to limb deformities. More case studies and research should be explored with the VCAM™ in the areas of trauma especially Lisfranc fractures since it is a midfoot deformity and other lower limb deformities.

References

1. Hamilton GA, Ford FA. External fixation of the foot and ankle Elective indications and techniques for external fixation in the midfoot. Clin Podiatr Med Surg 2003 20:45-63.
2. Baker MJ, Offutt SM. External fixation Indications and patient selection. Clin Podiatr Med Surg 2003;20:9-26.
3. Vito GR, Talarico LM, Kanuck DM. Use of external fixation to correct deformities of the lower leg. Clin Podiatr Med Surg 2003 20:119-157.
4. Cooper PS. Application of external fixators for management of Charcot deformities of the foot and ankle. Foot Ankle Clin N Am 2002 7:207-254.
5. Cooper PS. Application of external fixators for management of Charcot deformities of the foot and ankle. Semin Vasc Surg 2003 16: 67-78.
6. Jolly GP, Zgonis T, Polyzois V. External fixation in the Management of Charcot Neuroarthropathy. Clin Podiatr Med Surg 2003 20:741-756.
7. Herbst, S. External fixation of Charcot Arthropathy. Foot Ankle Clin N Am 2004 9:595-609.
8. Malizos KN, Bargiotas K, Papatheodorou L, Dimitroulias A, Karachalios T. The below-the-ankle circular frame: A new technique for the treatment of displaced calcaneal fractures. J Foot and Ankle Surg 2005 45(5):295-299.
9. Bevilacqua NJ, Rogers LC. Surgical management of Charcot midfoot deformities. Clin Podiatr Med Surg 200825:81-94.


Send correspondence to: Michael P. DellaCorte, DPM, FACFAS, Director of Podiatric Medical and Surgery Program at NorthShore Forest Hills LIJ; 5901 69th street, Maspeth, NY 11378. (718) 639-3338

1 Director of Podiatric Medical and Surgery Program at NorthShore Forest Hills LIJ; 5901 69th street, Maspeth, NY 11378.
2 PM&S 36 Resident; Hahnemann University Hospital.
3 PM&S 36 Resident; Hahnemann University Hospital.
4 Private Practice New York, NY.

© The Foot and Ankle Online Journal, 2011

Divergent Lisfranc’s Dislocation and Fracture in the Charcot Foot: A case report

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1

The Foot & Ankle Journal 1 (6): 3

A case report discusses the presentation, diagnosis and treatment of a 45 year old diabetic man with a divergent, Lisfranc’s dislocation of the first metatarsal in a Charcot foot. The patient also presents with associated laterally subluxed lesser metatarsals and multiple fractures. Conservative treatments such as TTC or total contact casting, prefabricated pneumatic walking brace (PPWB), patellar-tendon brace and CROW custom orthosis are discussed.

Key words: Charcot foot, Lisfranc’s dislocation, fracture

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: May 2008
Published: June 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0106.0003

Charcot joint in the foot typically refers to painless fracture and dislocation of the foot in patients without normal sensation or feeling in their foot. Loss of sensation in the foot for any reason can be responsible for developing a Charcot fracture, although this is most commonly seen with neuropathy. Neuropathy of the nerves that affect the foot is most commonly seen with diabetes, but is associated with other diseases as well. Treatment depends on the severity of the condition and the amount of deformity that is present.

We present a 45 year old diabetic man with Lisfranc’s dislocations along with fracture of 2,3,4,5 metatarsals. These patients frequently present complaining of a deep, aching, non-descript pain in the ankle joint that worsens with activity.

Case Report

A 45 year old man came to our out patient department with complaints of swelling in the left foot for 20 days duration. There was no history of trauma, fever or constitutional symptoms. The patient is a non-insulin dependent diabetic on oral hypoglycemic drugs. The swelling was diffuse, red, warm, non tender on palpation. (Fig. 1)

Figure 1   Diffuse swelling is noted to the left foot in a typical, Charcot presentation.  The swelling is diffuse and non-painful.

There was no sinus or active discharge. Radiographs of the foot showed fractures at the neck of 2,3,4, and shaft of 5 metatarsal along with divergent type of Lisfranc’s dislocation, bony destruction, fragmentation, joint subluxation and bony remodeling. (Figs. 2,3)

Figure 2   Oblique views reveal a divergent, Lisfranc dislocation of the first metatarsal with associated lesser metatarsal fractures.

Figure 3   Dorsoplantar view reveals complete dislocation of the first metatarsal at the medial cuneiform articulation.  Typical TMT joint fracture, fragmentation, joint subluxation and bone remodeling is seen.

Random blood sugar was 201mg/dl. C-reactive protein was negative; Erythrocyte sedimentation rate was 12mm/hr. Other blood parameters were normal. The patient was treated with a total contact cast.

Casts were replaced approximately every 2 weeks. The foot was inspected, and cutaneous temperature measurements were done. Serial plain radiographs were taken approximately every month. Casting lasted for 3 months. We used a patellar tendon¬ bearing brace in addition to custom-molded footwear after the cast. The brace was eliminated from the regimen after six months. Thereafter, continued use of custom footwear to protect and support the foot was given.

Discussion

Charcot neuropathy is a progressive deterioration of weight-bearing joints, usually in the foot or ankle. It is a condition of acute or gradual onset and, in its most severe form, causes significant disruption of the bony architecture of the foot. It often results in foot deformities and causes abnormal pressure distribution on the plantar surface, foot ulcers and, in some cases, requires amputation. The exact pathogenesis is unknown, but underlying sensory neuropathy is nearly universal. Arteriovenous shunting due to autonomic neuropathy is also thought to play a role. Repeated unrecognized microtrauma or an identifiable injury may be the inciting factors of Charcot foot. Approximately 50 percent of patients with Charcot foot will remember a precipitating event such as a slip or a trip, or they may have had unrelated surgery on the foot as an antecedent event. In approximately 25 percent of patients, a similar problem ultimately develops on the other foot. [1,2]

The process is characterized by pathologic fractures with an exuberant repair mechanism and is associated with mixed peripheral neuropathies. The common denominator in these various conditions is that motor function is not as severely affected as are sensory modalities in the patient. [3,4,5] The Charcot foot in the diabetic patient is a progressive condition that is not confined to bones but affects all of the tissues in the lower extremity. It is often confused with osteomyelitis and massive infection of the foot necessitating early identification and management to prevent amputation of the lower extremity. With the advent of advanced surgical techniques and a better understanding, the physician may be optimistic with the treatment of this condition. By thoroughly understanding the etiologic factors and deforming forces, treatment can be planned for each specific patient.

The etiology of Charcot joints has been argued by many authors. Two theories (neurotraumatic and neurovascular) explain the pathogenesis of Charcot foot. [4]
The neurotraumatic theory attributes bony destruction to the loss of pain sensation and proprioception combined with repetitive and mechanical trauma to the foot. The neurovascular theory suggests that joint destruction is secondary to an autonomically stimulated vascular reflex that causes hyperemia and periarticular osteopenia with contributory trauma. Intrinsic muscle imbalance with increased heel and plantar forces can produce eccentric loading of the foot, propagating microfractures, ligament laxity and progression to bony destruction. [6] Neuropathic arthropathy is prevalent in 0.8 to 7.5 percent of diabetic patients with neuropathy; 9 to 35 percent of these affected patients have bilateral involvement. [7,8] The higher prevalence is seen in referral-based practices. Most patients with neuropathic arthropathy have had poorly controlled diabetes mellitus for 15 to 20 years. Clinical findings in patients with an acute Charcot process include warmth, erythema and swelling. [13,14,15] Pain and tenderness are usually absent because of sensory neuropathy, which is universal and is probably a component of the basic pathogenesis of the Charcot foot. Cellulitis should be considered in any patient with diabetes. Missing the diagnosis of Charcot foot can be disastrous since failure to initiate proper treatment of the Charcot foot exacerbates the problem. We strongly recommend that the diagnosis of acute Charcot foot be considered in any patient with diabetes and unilateral swelling of the lower extremity and/or foot. The existence of little or no pain can often mislead the patient and the physician.

The tarsometatarsal (Lisfranc’s) joint is the most common site for arthropathy, with initial involvement usually occurring on the medial column of the foot. The distribution of neuropathic arthropathy is 70 percent at the midfoot and 15 percent at the forefoot or rearfoot; it is usually contained in one area.

Nearly 50 percent of patients with neuropathy had an associated plantar ulcer. [8,9]

Bony destruction, fragmentation, joint subluxation and bony remodeling are considered radiographic hallmarks of the disease. These radiographic changes take time to develop, however, and may be absent at the time of presentation. The initial radiographic findings can be normal, making the diagnosis difficult but, if a Charcot foot is strongly suspected from the clinical presentation, treatment should be initiated and serial radiographs should be taken. Biopsy is the definitive test for the diagnosis of Charcot joints. The specimen will demonstrate the presence of multiple shards of bone and cartilage embedded within the deeper layers of the synovium. If osteomyelitis is of concern then a bone biopsy is essential for proper and accurate diagnosis.

The proper treatment for a hot, swollen foot in a patient with sensory neuropathy is immobilization. We believe that the best form of immobilization is a total contact cast, when available. Strict immobilization and protection of the foot (most often in a total contact cast) is the recommended approach to managing the acute Charcot process. [11,12,13,14,15] We used the total contact cast for our patient which allowed some measure of ambulation for the patient and prevented the progression of deformity. (Fig. 4)

Figure 4   Total Contact Cast is used for immobilization and protection of the Charcot foot.  It is commonly used as initial conservative treatment in the acute Charcot episode.

Charcot fractures that are not treated progressively, typically lead to marked deformity and skin ulceration over the new bony prominence. Casts should be replaced approximately every one to two weeks. The foot should be inspected, and cutaneous temperature measurements should be made. Serial plain radiographs should be taken approximately every month during the acute phase. Casts should be kept on until the active phase of the Charcot process is complete, as evidenced by temperature normalization and radiographic stability. Casting usually lasts from three to six months. The initial post-cast phase usually includes the use of some sort of a brace to protect the foot.

We used a patellar tendon¬ bearing brace in addition to custom-molded footwear. The brace can sometimes be eliminated from the regimen after six to 24 months. Thereafter, continued use of custom footwear to protect and support the foot is essential.

An alternative to TCC is a prefabricated pneumatic walking brace (PPWB), which has been found to decrease forefoot and midfoot plantar pressure in the treatment of neuropathic plantar ulceration. [11,12,13,14,15] (Fig. 5)

Figure 5   The alternative to the total contact cast is the PPWB or prefabricated pneumatic walking brace.  (Courtesy Aircast Corp.®)

Benefits include easier wound surveillance, ease of application and the ability to use several types of dressings. Use of the PPWB is limited in patients who have severe foot deformity or who are noncompliant. After swelling and erythema resolve and radiographic stability has been achieved, the TCC can be changed to a CROW, an ankle foot orthosis or a patellar tendon-bearing brace, depending on residual anterior edema. If anterior edema persists, the CROW full-enclosure system is used. (Fig. 6) This device is used for six months to two years, until a stable foot is obtained.

 

Figure 6   The CROW or Charcot Restraint Orthotic Walker (A) and the patellar tendon-bearing brace (B).  The CROW is a custom molded device that when properly constructed can improve plantar off-loading up to 50 percent.  It can be used for 6 months to 2 years until the foot is stabilized.  The patellar tendon-bearing brace can reduce offloading pressures of up to 90 percent. [16]

Patients can then be fitted for extra-depth shoes with custom insoles or orthotics to accommodate any residual deformity. Return to conventional foot gear may not be possible in all cases.

Other treatments for the Charcot process have included electrical bone stimulation or low-intensity ultrasonography during the acute phase to enhance healing. [11,12] Another study found that use of a bisphosphonate (pamidronate) resulted in decreased erythema, decreased temperature and decreased Charcot activity. [12,13,14] Additional controlled studies are needed to further evaluate the effectiveness of these treatments.

While it is still unknown why some patients with diabetes develop a Charcot process and others do not and more interestingly why some patients only develop this condition in one of their feet, an introspective review is necessary.

The literature on Charcot foot is huge and refers, not specifically, to every joint and metatarsals. The fact that 2,3,4,5 metatarsal involvement has not been extensively described, does contribute a base for our observation.

In summary, the Charcot foot commonly goes unrecognized, particularly in the acute phase, until severe complications occur. Early recognition and diagnosis, immediate immobilization and a lifelong program of preventive care can minimize the morbidity associated with this potentially devastating complication of diabetic neuropathy. If unrecognized or improperly managed, the Charcot foot can have disastrous consequences, including amputation. A lifelong program of patient education, protective footwear and routine foot care is required to prevent complications such as foot ulceration.

With proper planning, timing and knowledge of all facets of diabetic neuropathy, many patients may retain their foot and benefit from its function.

References

1. Gregory M. Caputo, M.D, Jan Ulbrecht, M.D., Peter R. Cavanagh, Ph.D., and Paul Juliano, M.D., The Charcot Foot in Diabetes: Six Key Points American Academy of Family Physicians, Vol. 57/No. 11 (June, 1998)
2. Cavanagh PR, Young MJ, Adams JE, Vickers KL, Boulton AJ. Radiographic abnormalities in the feet of patients with diabetic neuropathy. Diabetes Care 17:201-9, 1994.
3. Johnson JTH: Neuropathic fractures and joint injuries J Bone Joint Surg 49A: 1, 1967.
4. Brower AC, Allman RM: Pathogenesis of the neurotrophic
joint: neurotraumatic vs neurovascular. Radiology 139: 349, 1981.
5. Banks AS, McGlamry ED: Charcot Foot. J Am Pod Med Assoc. 79: 5, 1989.
6. Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the foot and ankle. Clin Orthop 349:116-31, 1998.
7. Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot’s arthropathy in the diabetic foot specialty clinic. Diabet Med 14: 357-63, 1997.
8. Harrelson JM. The diabetic foot: Charcot arthropathy. Instr Course Lect 42:141-6, 1993.
9. Eichenholtz SN. Charcot joints. Springfield, Ill.: Thomas, 1966.
10. Kelikian AS. Operative treatment of the foot and ankle. Stamford, Conn.: Appleton & Lange, 153, 1999.
11. Caputo GM, Ulbrecht J, Cavanagh PR, Juliano P. The Charcot foot in diabetes: six key points. Am Fam Physician 57:2705-10, 1998.
12. Brodsky JW. The diabetic foot. In: Mann RA, Coughlin MJ, eds. Surgery of the foot and ankle. 6th ed. St. Louis: Mosby, 1993.
13. Giurini JM, Chrzan JS, Gibbons GW, Habershaw GM. Charcot’s disease in diabetic patients. Correct diagnosis can prevent progressive deformity. Postgrad Med 89(4):163-9, 1991.
14. Holmes GB Jr, Hill N. Fractures and dislocations of the foot and ankle in diabetics associated with Charcot joint changes. Foot Ankle Int 15:182-5, 1994.
15. Sinha J, Thomas EM, Foster A, Edmonds M. Fractures in the neuropathic diabetic foot. Foot 4:28-30, 1994.
16. Pupp, G., Wilusz, P.M. Reassessing The Impact of Diabetic Footwear. Podiatry Today, online article. ISSN: 1045-7860 – 17:3, March 2004.


 
Address correspondence to: Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho)
Registrar in Orthopedics, Dept. of Orthopedics
St. Stephen’s Hospital, Tiz Hazari, Delhi 54, India
E-mail: terrencejose@gmail.com

1Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.

© The Foot & Ankle Journal, 2008