Charcot Foot: Potential Pearls from Parkland

Transcription

1 Charcot Foot: Potential Pearls from Parkland Javier La Fontaine, D.P.M., M.S. Professor Department of Plastic Surgery UT Southwestern Medical Center Dallas, Texas

2 Objectives To share the experience from large county hospital To discuss incorporation b/w best evidence and realistic use of it in our population To discuss clinical and surgical pearls Does best outcomes meet patient s expectations?

3 Parkland Experience 33,000 DM patients registered to the system A1c >9.5% Often present through ED ~35 inpatients Dallas County s Diabetes prevalence = 11%, Bexar County 13% Harris County at 11% Tarrant County at 10% Travis County at 8%

4 Parkland Experience Closed system, financial county support classified by tiers Level 1 trauma center ~ 1000 beds First response team No funding support for prosthesis DM shoes are outsourced Bracing depends on tier

5 Getting to the correct diagnosis? Charcot foot vs Osteomyelitis!!

6 Case 1 Osteomyelitis 55 y/o male DM with DFU 2/2 oil burn x 1 wk Afebrile WBC 4.9 CRP 6.5 ESR 79 XR no erosive changes negative PTB test

7 Case 1 Osteomyelitis T1 T2

8 Case 1 Osteomyelitis

9 Case 2 Charcot 42 y/o male DM s/p Charcot recon, now with recurrence Afebrile Wound dehiscence WBC 6.9 CRP 5.2 ESR >130mm/Hr Negative PTB test

10 Case 2 Imaging T1 T2 La Fontaine J, et.al.:wounds Aug;28(8):271-8.

11 Case 2 Imaging La Fontaine J, et.al.: Wounds Aug;28(8):271-8 Neg bone cx and path!

12 Diagnosis Bone Biopsy Acute Osteomyelitis Chronic osteomyelitis Sheets of neutrophils Osteoclasts Bone erosion Plasma cells

13 Diagnosis Bone Biopsy Acute Charcot Chronic Charcot La Fontaine J et.al.: J Foot Ankle Surg Nov-Dec;50(6):

14 Conservative/Surgical Management PAD is more frequent that anticipated Mockenberg s sclerosis is pathognomonic

15 Total Contact Casting 10 patients Stage 1 Charcot treated with WB TCC prospectively Weight range # Average return to CMO 9.2 weeks Level 2 evidence (Pinzur MS, Lio T, Posner M: Foot Ankle Int May; 27(5):324-9)

16 Total Contact Casting 27 pts/34 feet treated with a weightbearing TCC F/U 5.5 years Eichenholtz /34 feet, no ulceration, no recurrence of Charcot Level 2 evidence (Souza LJ: JBJS Am 90 (4), 2008)

17 Removable Walkers Devices (N=219) Median time to resolution Non removable 9 months (3 25) Removable 12 months(3 39) Game FL et.al.: Diabetologia. 2012, Jan;55(1):32-5

18 Charcot Restraint Orthotic Walker (C.R.O.W.) 30 pts ulcers retrospectively reviewed 22/30 ulcers healed (73%) Time to heal=10.3 months 2 ulcers when transfer to shoes Level 4 evidence (Keast, Vair: Adv Skin Wound Care 16, 2013)

19 Patellar Tendon Bearing Brace (PTB) Patellar Tendon Bearing Brace (PTB) 6 pts with midfoot Charcot Decreased mean force to entire foot by 15% With extra padding, 32% Load reduced in hindfoot, not mid/forefoot Not recommended for forefoot or midfoot pressure reduction Level 5 evidence Saltzman CL, et.al.: Foot Ankle Jan;13(1):14-21

20 Surgical Management Limited HIGH risk patients No SNF for rehab

21 Background 80s mid 90s midfoot Charcot with Int Fix Late 90s mid 2000 Ext Fix, Bone Stim Late 2000 Combination of fixation, super construct, all kinds of bone grafting, IM nails, more hindfoot/ankle, less midfoot OUTCOME: Limb salvage, ulcer healing, recurrence, NOT bone healing (rather stable nonunion)

22 Exostectomy 12 patients exostectomy; 1 ulcer recurred Level 5 evidence Brodsky JW, Rouse AM: CORR 296: 21 6, pts (18 medial/9 lateral ulcers) Medial ulcers healing rate 92% Lateral ulcers healing rate 37.5% Level 4 evidence Catanzariti A, Mendecino R, Haverstock B: JFAS 39(5), 2000

23 Laurinaviciene R et.al.: J Wound Care 17(2), Feb 2008

24 Case Initial Bursa like tissue

25 Post op Post op 3 weeks post op

26 6 weeks post op

27 Take home pearls Recurrence is high Not enough bone= recurrence Too much bone= transfer lesion Medial or lateral approach when possible, plantar when needed TAL useful in most cases

28 What is the best fixation technique?

29 Fixation techniques Beaming Internal fixation Intramedullary nail External Fixation

30 Take home pearls Beaming as a single point of fixation is not adequate for fusion; in combination is ok. Beaming maintains deformity, but not fusion Internal fixation decreases recurrence of ulcer and promote union but complications are major External fixation and IM nail have same fusion rates. Ex fix has less severe complications. When infection suspect it, Ex fix is the choice.

31 Clinical Benefit and Improvement of Activity Level after Reconstruction Surgery of Charcot Feet using External Fixation: 24 months results of 292 feet 23% Ulcer Illgner et al. BMC Musculoskeletal Disorders 2014, 15:392

32 What about bone grafting?

33 Sources of Autograft Location Type Complication Availability Outcomes Onlay (local) Distal fibula Tricortical Paresthesias readily 93 96% union in Ankle fusions Proximal tibia Cancellous 1.3% Pain, hematoma, paresthesias 5.4ml 1 study 92% union Distal tibia Cancellous 4% stress fracture 9.1g/8.6ml 97% union rate Calcaneus Cancellous Tricortical 11% incisional sensitivity?? 88% union rate Greater Trochanter Cancellous Cortical 31% hip pain 4% daily pain?? 95% union rate Iliac Crest Cancellous Cortical 10% residual pain 27% more pain than sx site 6.0ml?? % union rate Bone marrow aspirate Needs to be mixed, Cells Postop pain is rare 5 10ml from iliac??

34 Xenograft Shibuya, Jupiter: Clin Pod Med Surg 32, 2015

35 Bone Marrow Aspirate Cell numbers 40 patients with aspirate collection Bone marrow aspirate collected from the iliac crest had a higher mean concentration of osteoblastic progenitor cells compared with the distal aspect of the tibia or the calcaneus (p < ) Hyer C, et.al.: JBJS 95 A July 2013

36 Take home pearls Autograft is the way to go. BMP will be the future with appropriate selective retention technique Allograft is fine when only scaffolding is needed Xenograft is not worth it

37 Patient expectations

38 Clinical Benefit and Improvement of Activity Level after Reconstruction Surgery of Charcot Feet using External Fixation: 24 months results of 292 feet Illgner et al. BMC Musculoskeletal Disorders 2014, 15:392

39 A Retrospective Analysis of 50 Consecutive Charcot Diabetic Salvage Reconstructions Grant W et.al.: JFAS 48(1):30-8, 2009

40 A Retrospective Analysis of 50 Consecutive Charcot Diabetic Salvage Reconstructions Grant W et.al.: JFAS 48(1):30 8, 2009

41 Take home pearls Determine expectations from patients first, then plan your case accordingly.

42 Conclusions Thank you!

43 62 y/o DM male with CC of swelling and ulcer in the left foot x 4 days, bounding pulses, proteinuria, retinopathy

44 The medial column Synthes Midfoot Fusion Bolt is associated with unacceptable rates of failure in corrective fusion for CNA Butt et.al.: Bone Joint J 2015; 97 B:809 13

45 The medial column Synthes Midfoot Fusion Bolt is associated with unacceptable rates of failure in corrective fusion for CNA Butt et.al.: Bone Joint J 2015; 97 B:809 13

46 Internal vs. External Fixation of Charcot Midfoot Deformity Lee D et.al.: Orthopedics 2016; 39(4): e595

47 Internal vs. External Fixation of Charcot Midfoot Deformity Lee D et.al.: Orthopedics 2016; 39(4): e595

48 Internal vs. External Fixation of Charcot Midfoot Deformity Lee D et.al.: Orthopedics 2016; 39(4): e595