Update in Charcot Arthropathy Reconstruction Utilizing the Ilizarov Method with Combined Internal Fixation

Authors:Byron Hutchinson, DPM,1 FACFAS;Edgardo Rdoriguez, DPM;2

R. Jordan Mechell, DPM;3

Scott Berg, DPM;4 Megan Wilder, DPM4

Key:1. Director of Franciscan Podiatric Medicine and Surgical Residency

Program with Rearfoot/Reconstruction Accreditation, Federal Way, WA

2. Director, Chicago Foot and Ankle Deformity Correction Center, Chicago, IL; Associate Director of St. Joseph Hospital/Chicago, IL Podiatric Medicine and Surgical Residency Program with Rearfoot/Reconstruction Accreditation, Chicago, IL

3. Resident Phsician,PGY-3, St. Joseph Hospital/Chicago, IL Podiatric Medicine and Surgical Residency Program with Rearfoot/Reconstruction Accreditation, Chicago, IL

4. Resident Physician, PGY-2, Franciscan Health System-St Francis Hospital Podiatric Medicine and Surgical Residency Program with Rearfoot/Reconstruction Accreditation, Federal Way, WA

5. Resident Physician, PGY-1, Franciscan Health System-St Francis Hospital Podiatric Medicine and Surgical Residency Program with Rearfoot/Reconstruction Accreditation, Federal Way, WA

References:1. Petrova NL, Foster AV, Edmonds ME. Calcaneal bone mineral

density in patients with Charcot neuropathic osteoarthropathy: differences between Type 1 and Type 2 diabetes. Diabet Med. Jun 2005;22(6):756-761.

2. Myerson MS, Henderson MR, Saxby T, Short KW. Management of midfoot diabetic neuroarthropathy. Foot Ankle Int. 1994;15(5):233–24

3. Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint Surg Am. 1993;75(7):1056–1066.

4. 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. J Bone Joint Surg Am. 2000;82(7):939–950.

5. Sammarco VJ. Superconstructs in the treatment of Charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin. 2009;14:393–407.

6. Assal M, Stern R. Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg Am. 2009;91:812–20.

7. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse. Foot Ankle Int. 1996;17:325–30.

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Diabetic Charcot neuroarthropathy is a progressive, debilitating condition characterized by joint dislocation, pathological fracture, and wide-spread osseous destruction. Salvage arthrodesis in an attempt to avoid amputation with external fixator frame modifications according to the Charcot joint level of involvement has led to better stabilization and improved outcomes.

Controversy exists in the literature regarding surgical

intervention on Charcot arthropathy foot and ankle

deformities. Most authors advocate intervention in the

coalescent or consolidative stages,(1,2) but early arthrodesis

and open reduction and internal/external fixation during

the developmental stage have been reported.(1,3,4) In order

to restore a stable plantigrade foot that is amenable to

functional ambulation and not prone to future skin

breakdown reconstructive surgery of the Charcot foot will

need to be undertaken. This typically entails stabilization

and/or arthrodesis of multiple collapsed joints. This can be

performed in a number of ways: intramedullary rod fixation,

locking plate fixation, and external fixation or a

combination approach. Recently, the literature on the

reconstruction of unstable Charcot arthropathy of the

midfoot has focused on the so-called superconstructs. The

application of an external fixation device in the

superconstruct allows for stress shielding of the affected

arthrodesis sites and augmentation of the bending stiffness

and torsional resistance of the overall

plate and screw construct. More over, the presence of the

external fixator may also act as an additional deterrent

for inappropriate weight bearing on the operative limb.(5)

The choice of fixation is often dependent on cortical

integrity, presence of bone defects and dislocations,

health of the soft tissue envelope, history of deep infection,

blood glucose control, and body mass index of the patient.

More often than not the bone is predictably osteopenic,

comminuted, and because the occurrence of dysregulated

hyperemia, construct stiffness for Charcot reconstruction

is key no matter which fixation construct one chooses.

Moreover, the absence of a normal pain feedback loop in

neuropathic patients frequently results in premature and

inappropriate weight-bearing post-operatively, which must

be anticipated when choosing operative fixation

approaches.(6,7)

We present a case series where external fixation alone

and in conjunction with internal fixation consisting of:

distal femoral locking plates, medial column locking plate,

fusion bolts and intra-medullary nails were used for

correction of Charcot joints.

Institution: St. Joseph Hospital Chicago, ILClassification: Rearfoot and Ankle ReconstructionCategory: InstitutionFormat: Case StudyPresented: American College of Foot & Ankle Surgeons Scientific National Meeting 2013

A retrospective chart and radiographic review of 109 cases was performed. Each case had an Ilizarov circular external fixator applied. Circular external fixation with or without internal fixation were used in each case depending on the severity and location of the Charcot joint collapse.

Case StudyIn our combined results we had a total of 109 cases. Of that 109, eighty-six were

male and twenty-three were female. 31 patients have type 1 Diabetes mellitus

and 78 of the patients have type 2 Diabetes mellitus. The average follow-up

was 47.9 months (range: 12 month - 60 months). Thirty-seven had ulceration

at the time of surgery with surgical primary closure of the wound. Eighteen

required a below the knee amputation. Fifty-six required an additional visit

to the operating room for frame adjustments. Nine had recurrence with

additional fracture and dislocation. Eleven had Charcot only at the ankle joint.

Eighty had Charcot at the ankle, subtalar and midtarsal joints. Eighteen had

Charcot at the midtarsal and tarsometatarsal joints.

Results

The goal for reconstructive Charcot surgery is to achieve and maintain a

plantigrade orientation foot to avoid development of ulceration, infection,

and amputation. Many options are available for the surgical treatment of

Charcot fracture dislocation including circular external fixation with or without

internal fixation. Reconstruction utilizing external fixation and in combination

with internal fixation based on Charcot level of joint involvement represents a

promising alternative to amputation, allowing for decreased patient morbidity.

Analysis & Discussion

Statement of Purpose

Literature Review

5. Oblique view showing post-operative results of bolting and ex-fix application.

6. Lateral radiogrpah showing pre-operative with Charcot changes to the midfoot.

7. Lateral radiogrpah showing post-operative results of bolting and ex-fix application.

4. AP view with Charcot changes of the midfoot.

Podiatric Surgical Residency ProgramSaint Joseph Hospital/ Chicago, IL. PMSR+RRA

Program DirectorFrank W. Zappa, DPM

1. Clinical pre-operative photo showing the rocker bottom type of deformity secondary to Charcot arthropathy.

2. Preoperative lateral radiograph showing midfoot fragmentation with cuboid subuluxation plantarly.

8. Series of radiographs showing preoperative radiographs of Charcot changes involving the ankle joint and post-operative results utilizing distal femoral locking plate (DFLP) and application of ex-fix.

3. Post-operative radiograph status post external fixation application with plantarflexory wednge osteotomy from the midfoot to restore the talar declination angle.