R . S P R I N G F E L D F U S S C H I R U R G I E
K L I N I K D R . G U T H , H A M B U R G
M A I L : D R . S P R I N G F E L D @ D R G U T H . D E
Charcot Arthropathy (CN):
Principles of Surgery
Danish Foot & Ankle Society, Copenhagen May 2016
1 . I S T H I S C N ?
2 . W H A T A B O U T W A L K E R O R B O O T ?
Questions to CN:
1 . 1 . N O T E V E R Y B O N E M A R R O W E D E M A R E P R E S E N T S C N ! 1 . 2 . I S T H E R E A P O L Y N E U R O P A T H Y ?
2 . 1 . I S C O N S E R V A T I V E T R E A T M E N T A N O P T I O N ? 2 . 2 I F Y E S , I T I S T H E T R E A T M E N T O F C H O I C E ! !
Wukich, D.K.; et.al.: Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes.
Diabetes/metabolism research and reviews; VOL: 32 Suppl 1; p. 292-6, 2016
Surgical Intervention in an active CN
QUESTIONS:
Indication for Surgery?
What about the incision?
Reconstruction of Soft Tissue and Foot
Gehling, D.J.; et.al.: Orthopedic complications in diabetes. Bone; VOL: 82; p. 79-92, 2016
Active Charcot caused by Surgery
(missed Neuropathy )
Trauma and Charcot IV
McEwen, L.N.; et.al.: Foot Complications and Mortality Results from Translating Research Into Action for Diabetes (TRIAD).
Journal of the American Podiatric Medical Association; VOL: 106 (1); p. 7-14, 2016
Osteomyelitis and Charcot
Labovitz, J.M.; et.al.:The impact of comorbidities on inpatient Charcot neuroarthropathy cost and utilization.
Journal of diabetes and its complications. print electronic 2016
S T A G E ( E I C H E N H O L T Z ) 0 - 3 B E S S E R 1 A , 1 B , 2 , 3 ( A C T I V E O R I N A C T I V E )
L O C A L I S A T I O N ( S A N D E R S ) 1 - 5
M A L U M P E R F O R A N S I N F E C T I O N
( S O F T T I S S U E , T E N D O N S , J O I N T S , B O N E ) V A S C U L A R S T A T U S
Aspects of
Charcot Arthropathie CN
Bony Anatomy
Links aus Mc Minn: Anatomie des Fußes
Classification?
BRODSKY Typ I,II, III, IV
SANDERS Typ I, II, III, IV, V
SCHON Mittelfuß Typ 1- 4
SOMMEREY, 2004
(P1-3, F0-3, D0-2, S0-4, L 1-10, M0-4)
Chantelau, 2014
Abb. Schon, L.: Midfoot Charcot, 1998
Charcot Sanders II
Pat. male, 36a PNP by M. Fabry acute CN I/12 TCC for 5 month MRT: Osteomyelitis
Pinzur, M.S.: Surgical treatment of the Charcot foot. Diabetes/metabolism research and reviews; VOL: 32 Suppl 1; p. 287-91, 2016
Are there typical Destruction Patterns?
N O N O F T H E E X I S T I N G C N C L A S S I F I C A T I O N S A R E S U F F I C I E N T
T R E A T M E N T R E C O M M E N D A T I O N S A R E B A S E D O N P A R T L Y A S P E C T S
W E D O K N O W :
I N F E C T I O N / O S T E O M Y E L I T I S I N S T A B I L I T Y
N O N P L A N T I G R A D E F O O T / R O C K E R B O T T O M
ClassifiCationen
Surgical Planning
• unknowen:
• classification?
• fixation
• cancellous bone, tricortical bone graft
• grafting itself
• stemm cells/bone marrow
• subtractive correction
• skin plastic for plantar defects
• recommendation for Implants
• recommendation of external
fixation or Ilisarov type
Reposition or Resection
Reposition of acute luxation
Resection for reposition
CN Sanders II
CN Sanders II
Pat. H.B., Charcot II with Malum perforans
Morbach, S.; et.al.: The German and Belgian accreditation models for diabetic foot services.
Diabetes/metabolism research and reviews; VOL: 32 Suppl 1; p. 318-25, 2016
Pat. H.B., Charcot II with Malum
Inactive CN
CN II: unstabil, no fusion
Pat. R. E., * 1979, DM I, PNP
MRSA Infection
Fusion CN Sanders II
Arthrodesis of both columns, when?
Correction, subtractiv (always?)
Amount of correction (3 dimensions)
ATL (when and how)
post OP protocoll (off loading, duration, reloading)
CN Sanders III, EH II, III
• Eichenholtz III (inactive CN)
• stabil, plantigrad: custom made boots > conservativ
• unstabil, not plantigrad, Rocker bottom:
mediale and lateral approach, Chopart arthrodesis, fixation intern
• unstabil, not plantigrad, Rocker bottom, Malum:
plantare debridement , Chopart arthrodesis, Fixation: intern u/o extern
• subtalare Fusion needed?
• Fixation time: 3 month
• reloading of the foot: (2 x 15 min week 1, 2 x 30 min week 2,…)
• Custom made boots acc. to diabetic guide lines
• Check up every 4 weeks with x- ray
• MRI in doubt
Charcot Sanders III
Dislocation Typ bilateral
Markakis, K.; et.al.: The diabetic foot in 2015: an overview. Diabetes/metabolism research and reviews; VOL: 32 Suppl 1; p. 169-78, 201
6
Stabile Internal Fixation:
2- Column Stabilisation
Sanders III > subtalare fusion
> Fusion laterale column
Surgical Technique Midfoot Reconstruction
Petrova, N.L.; et.al.: Acute Charcot neuro-osteoarthropathy. Diabetes/metabolism research and reviews; VOL: 32 Suppl 1; p. 281-6, 2016
Sanders III
• Not solved:
• Subtalar Fusion needed
• recommended osteosynthesis
• internal +/o external
• ATL?
• Gastroc or AT
• surgicaly demanding:
Talo- Naviculare- Fusion
Problems with Internal Fixation
Nonsurgically after failed Fusion
S T A G I N G C O R R E C T ?
T Y P E O F F I X A T I O N S U F F I C I E N T ? T I M E O F F I X A T I O N ?
O R T H E T I C S T A B I L E N O U G H T ( C O M P L I A N C E O F T H E P A T I E N T )
Analysis of failed Sugery
Pat. R. E., * 1979, DM I, PNP
Pat. R. E., * 1979, DM I, PNP
MRSA Infection
Instability: CN Sanders IV
CN Sanders V
Charcot disease of the heel
CN V
conservative therapy if possible
CN Sanders V
conservative therapy (duration)
custom made boots
VI- 15 VIII- 15 II- 16
Charcot: Problems
classification of serveral CN‘s of different location
Different course of CN in correlation to different types of PNP?
Differentiation: Charcot<> Osteomyelitis <> AVN
strategy infected CN: MRSA, ESBL, MRGN
DRG(German Reimbursement System):
Classification CN- Reconstruction vs. Amputation
stemm cell therapy to modify bone biologie?
Ruotolo V; et.al.: A New Natural History of Charcot Foot: Clinical Evolution and Final Outcome of Stage 0 Charcot Neuroarthropathy in a Tertiary Referral Diabetic Foot Clinic .Clinical nuclear medicine /2013
