Charcot joint and methods of arthrodesis

Charcot joint and methods of arthrodesis

1. Charcot Joint & Methods of Arthrodesis Presented by: Ibrahim S. Al- Shaygy R2

2. What to do?

3. Interoduction Charcot neuropathy is a progressive deterioration of weight-bearing joints, usually in the foot or ankle. Historically, neuropathy of the knee was most frequently caused by syphilis, and neuropathy of the shoulder was usually caused by syringomyelia .

4. Today, the Charcot foot occurs most often in patients with diabetic neuropathy; other predisposing conditions include alcoholic neuropathy, cerebral palsy and congenital insensitivity to pain. The first description of neuroarthropathy occurring with diabetes mellitus was published in 1936.

5. Objectives Pathogenesis Epidemiology Classification Evaluation Treatment options Surgical treatments

6. Pathogenesis Two theories: Neurotraumatic Attributes bony destruction to the loss of pain sensation and proprioception combined with repetitive and mechanical trauma to the foot. Neurovascular suggests that joint destruction is secondary to an autonomically stimulated vascular reflex that causes hyperemia and periarticular osteopenia with contributory trauma.

7. Pathogenesis Intrinsic muscle imbalance can produce eccentric loading of the foot, propagating microfractures , ligament laxity and progression to bony destruction. In DM, the cause is high concentrations of glucose with altered osmolarity . Micro vascular damage can also occur. Associated with increased risk of ulceration. Skin integrity becomes abnormal due to neuropathy.

8. Epidemiology 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. Most of those patients have uncontrolled DM for 15 to 20 years.

9. Epidemiology The ( Lisfranc’s ) joint is the most common site for arthropathy . Initial involvement usually occure on the medial column of the foot. Distribution: 70% at the midfoot . 15% at forefoot or rearfoot .

10. Learning Point Charcot osteo-arthropathy must occur in the presence of a neuropathy. It rarely occurs in the presence of arterial insufficiency as high blood flow is required for osseous resorbtion . Charcot ankle is considered the worst among the other Charcot because the difficulty to control the instability.

11. Classification Neuropathic arthropathy is either atrophic or hypertrophic. Atrophic: localized to the forefoot and causes osteolysis of the distal metatarsals. The metatarsal heads and shafts have a radiographic deformity that resembles a pencil point or “sucked candycane ” .

12. Hypertrophic: usually occurs at the midfoot , rearfoot or ankle, and is traditionally defined according to the Eichenholtz classification system.

13. STAGE 1 The first stage is the developmental, or fragmentation, stage (acute Charcot) Associated with: periarticular fracture and joint dislocation leading to an unstable, deformed foot

14. Charcot Foot: Stage I [Fragmentation] Initial presentation = hot, swollen, painless foot ! Early radiographs negative ! No fever, malaise; normal WBC ! Patient usually walks into clinic Hyperemia precedes bony destruction

15. STAGE 2 “ coalescence stage “ Patients in the ( subacute Charcot) present with resorption of bone debris. STAGE 3 “consolidation stage” Reparative, stage (chronic Charcot) is associated with re-stabilization of the foot with fusion of the involved fragments . This leads to the return of a stable, although deformed, foot.

16. consolidation stage Rocker-bottom foot deformity

17. Revised Eichenholtz Classification:

18. Diagnosis 50 percent of patients with Charcot foot remember a precipitating, minor traumatic event. Diabetic patients with neuropathy, erythema , edema, increased temperature of the foot and normal radiographs most likely has an acute Charcot process. Role out INFECTION!!!

19. Diagnosis Brodsky method! Decreased sensation light touch or vibration Semmes-Weinstein 10-g monofilament wire. Decreased or absent sensation in 4 out of 10 is an abnormal test.

20. If a neuropathic ulcer is present, it is graded using the Wagner classification: Grade Description 1 Superficial diabetic ulcer 2 Ulcer extension to ligament, tendon, joint capsule or deep fascia without abscess or osteomyelitis 3 Deep ulcer with abscess or osteomyelitis 4 Gangrene to portion of forefoot 5 Extensive

21. Treatment Stage 1: Immediate weight bearing protection ! Severe/bilateral = bed rest! Wheelchair mobility! Crutch walking [if good balance]! Total Contact Casting [TCC]

22. Goal: Prevent multiple fractures of foot/ankle ! TCC changed q 1-2 wks Unweighting for 2-3 months, or until symptoms resolve and radiographs show bony stability

23. Charcot Foot: Stage II [Coalescence] Maintain external foot contours while bone Reconstitutes. Controlled weight bearing believed to facilitate healing. Wean from TCC to AFO Custom shoe, if foot is deformed

24. Charcot Foot: Stage III Consider surgical intervention Arthrodesis for severe deformities Exostectomy for local prominences with recurrent ulceration

25. FURTHER TREATMENTS Alternative: C.R.O.W or PTB Preferred when control of coronal plane ankle instability is needed Usually after erythema and swelling subside

26. TOTAL CONTACT CASTING: The gold standard of treatment when pt are picked early. Most cases can be treated by pressure-relieving methods. Serial x ray every 6 weeks conversion to a Charcot restraint orthotic walker (CROW) after the active phase of the condition is complete

27. PREFABRICATED PNEUMATIC WALKING BRACE: An alternative to TCC, which decrease forefoot and midfoot plantar pressure in the treatment of neuropathic plantar ulceration . 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.

28. PROPOSED TREATMENTS: Electrical bone stimulation Low-intensity ultrasonography Bisphosphonate

29. SURGICAL TREATMENT: Exostosectomy : Stable chronic charcot Arthrodesis : Unstable or joint with subluxation .

30. Arthrodesis AIM: To provide a solid, painfree fusion of the ankle in the optimum position. Minimise risk of complications.

31. Pre Operative Vascular study. Previous scars. Medical history, diabetes, smoker. XRs ? arthritis of subtalar jts or midfoot Increased movement in remaining joints in foot

32. Results 80-90% fusion rates Most patients satisfied with pain relief Hindfoot motion limited – uneven ground difficult Most can wear normal shoes Rocker bottom shoe may help gait Gait velocity slowed 16% 3% increase oxygen consumption Shortened stride length Increase ER at hip

33. Complications Non-union ( pseud-arthrosis ) Mal-union Infection Neurovascular injury, neuroma Skin necrosis

34. Non Union

35. Optimum Position The foot should be externally rotated 20 to 30 degrees relative to the tibia, with the ankle joint in neutral flexion (0 degrees) 5 to 10 degrees of external rotation, and slight valgus (5 degrees). Neutral to slight posterior displacement of talus under tibia ( minimise midfoot loading) Match to normal side

36. Surgery General or regional supine Antibiotics Prep for bone graft, sandbag under buttock +/- tourniquet Drape above knee (for alignment)

37. Surgical Techniques As a general rule, External fixators are preferred for patients undergoing arthrodesis for a preexisting septic joint and for those with severe osteopenia . Arthroscopic arthrodesis or the “ miniopen ” arthrodesis should be used only for patients with minimal deformity. Open arthrodesis is appropriate for patients with significant ankle deformity and foot and ankle malalignment .

38. Approaches to Ankle Anterior Transmalleolar ( transfibular ) +/- medial ”utilitarian” approach Posterior behind fibular, hinged calcaneal osteotomy or TA divided if done for tibio-talar-calcaneal fusion Mini-incision (Myerson) Arthroscopic

39. Fixation INTERNAL FIXATION: Screws Wires Steinman pins Plates Intramedullary rods ( tibiocalcaneal ) Bioabsorbable screws

40. INTERNAL FIXATION PROS Patient convenience Ease of insertion Good to excellent results

41. TRANSMALLEOLAR (Mann) Incision 10cm above the tip of fibula to base 4 th MT Full thickness skin flaps Subperiosteal dissection fibula and and tibia

42. Oblique fibula osteotomy 2cm above joint Fibula removed (+/- as graft) Distal tibia and talar neck exposed Distal tibia cut – 2mm Talar cut 3-4mm Avoid excess bone removal – loss of height

43. Resect articular surface medial malleolus (may require medial incision) Position, temporary Kwires 2 screws – sinus tarsi to medial tibia, lat talus to medial tibia Transcortical screws

44. Practically , most of the cases with Charcot ankle have severely deformed talus . Most of them need Pan talar arthrodesis .

45. Post OP Routine closure POP slabs initially Below knee POP & NWB 6-8weeks Then WB in cast further 6-8weeks

46. Screw fixation 6.5 – 7mm cancellous screws +/- cannulated 2 or 3 – ( 3 screws stronger than 2 in testing) Anterior, medial and central placement Posterior “home-run” screw , (inside-out technique)

47. Tibiotalocalcaneal arthrodesis Angled blade-plate: Posterior approach Prone position. Achilles tendon is osteotomized at its insertion into the calcaneus . Curetting and Bone grafting 95 degree blade plate placed posteriorly Achilles tendon is reattached.

48. Tibiotalocalcaneal arthrodesis

49. Tibiocalcaneal Arthrodesis with Intramedullary Nailing Medial and lateral skin incisions. B ody of the talus removed, and fixation of the head and neck of the talus to the anterior tibia Posterior approach used for wide exposure.

50. Calandruccio device I & II Triplanar – more control 2 pins in talus, 2 in tibia Series II more versatile and allows XR of arthrodesis site

51. Arthroscopic Entire articular surfaces denuded using shavers, burrs, currettes ,etc Cannulated screws placment Good results: ? quicker union time Less morbidity / recovery time Union rates comparable to open Takes longer More difficult

52. Bone graft Some reports indicate faster and higher union rates Adaptable to different situations, esp with bone loss Iliac crest or fibula/ tibia

53. Long term Coester et al –JBJS am 2001(mean 22 yr FU on post traumatic OA arthrodesis ) Increased risk of arthritis in subtalar and midfoot areas No increased risk of knee OA

54. Foot Arthrodesis Mostly for Lisfranc’s joint. Two dorsal insicion medial and lateral. Fixation with screws or LP plates. Most of the cases will need BG. Long time needed till complete healing

55. Summary Charcot osteo-arthropathy is a potentially catastrophic complication of neuropathy. However it most commonly presents in the foot and ankle in the diabetic population. Early recognition and prevention of deformity make a lot of difference. Arthrodesis is meant for unstable severely deformed and painful ankle.

56. That’s All Folks