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 ofCharcot 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. Fabryacute CN I/12TCC 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, tricorticalbone graft

• grafting itself

• stemm cells/bone marrow

• subtractive correction

• skin plastic for plantar defects

• recommendation for Implants

• recommendation of externalfixation or Ilisarov type

Reposition or Resection

Reposition of acuteluxation

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 IIIDislocation 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, 2016

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

• recommendedosteosynthesis

• 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

DRG System

wüsthoff

E X I S I T I N G C L A S S I F I C A T I O N S A R E I N S U F F I C I E N T

D E S T R U C T I O N P A T T E R N S W I T H R E L E V A N C E T O T R E A T M E N TP L A N N I N G S A R E N O T R U L E D O U T

T R E T A M N E T O F C N I S B A S E D O N R E C O M M E N D A T I O N O F S I N G L E S U R G E O N S

L E V E L I V : G O O D M E D I C A L P R A C T I C E

Conclusion