SLR - February 2011 - Mark Co
Reference: Bradley M. Lamm, DPM, H. David Gottlieb, DPM, Dror Paley, MD. (2010). A Two-Stage Percutaneous Approach to Charcot Diabetic Foot Reconstruction. Journal of Foot and Ankle Surgery, 49, 517-522.
Scientific Literature Review
Reviewed by: Mark Co
Residency Program: Kaiser Hayward/Fremont Residency Program
Podiatric Relevance:
Diabetic Charcot neuroarthropathy affects up to 2% of neuropathic diabetic patients. The goals of deformity correction are to restore osseous alignment, regain pedal stability, and prevent ulceration. Traditional reconstructive methods involve large, open incisions and the use of internal fixation to fuse dislocated joints. These authors present a two-stage technique using external fixation for gradual distraction and minimally invasive arthrodesis using internal fixation.
Methods:
This is retrospective case series of 8 patients who underwent minimally invasive Charcot reconstruction at the Rubin Institute for Advanced Orthopedics over a 3-year period. All 8 patients (11 feet overall) had midfoot Charcot deformity in various Eichenholz stages. Lisfranc and ankle joint deformity were excluded from the study as an alternate technique not involving external fixation was used to address this pathology.
The surgical technique involved gradual relocation of forefoot on a fixed hindfoot with Taylor spatial frame (TSF). An Internet-based software loaded with deformity and mounting parameters as well as surgeon’s weekly updates was used to produce a daily schedule of TSF adjustments performed by the patient. A posterior muscle group lengthening procedure was used to acquire a neutral hindfoot position. Coalesced deformities required percutaneous osteotomy using a Gigli saw technique at three levels – 1) Talar neck and calcaneal neck, 2) cubonavicular osseous level, and 3) cuneocuboid osseous levels. The majority of deformities underwent distraction without osteotomy. Once correction was achieved, rigid internal fixation was inserted percutaneously.
A complete review of medical charts and radiographic angular measurements were performed pre- and post-operatively. Stage and location of Charcot deformity, time in external fixation, time to fusion, time to return to normal shoe gear, and complications were recorded. Post-operative radiographs were used to assess osseous union and various radiographic angular measurements were compared from pre-operative levels to evaluate for deformity correction. Complications such as non-unions, additional surgery, pin tract infections, deep infections, recurrent ulceration, and hardware failure were calculated.
Results:
Eight patients ranging from 41-79 years old underwent minimally invasive Charcot realignment surgery of 11 feet. Three feet had midtarsal and subtalar joint deformity and eight feet had solely midtarsal joint deformity. All patients had gastroc-soleus equinus, with 3 undergoing gastoc-soleus recession and 8 undergoing Z-lengthening of Achilles tendon. The average pre- to post-operative changes showed statistical significance in the transverse plane talar-first metatarsal angle, sagittal plane talar-first metatarsal angle, and calcaneal pitch angle. The average time in external fixation ranged from 5-30 weeks and time for radiographic fusion ranged from 6-28 weeks.
With respect to complications, no non-unions were noted, 3 additional operations were required, 6 instances of external fixation hardware failure were noted, no deep space infections, and 11 pin tract infections.
Conclusions:
The authors’ two-stage minimally invasive Charcot reconstruction technique shows promise as an alternative to traditional methods of Charcot surgery for specific Charcot deformity. Gradual distraction allows incremental adjustments during the entire post-op period, avoids large incisions, neurovascular compromise, reduces risk of infection, reduces loss of bone mass, affords partial weightbearing, and offloads wounds. The most notable result was that none of the 11 feet underwent recurrent ulceration, with all feet plantigrade and with no deep space infection at average follow-up of 22 months.