Resection Arthroplasty for Limb Salvage of the Unreconstructable Charcot Foot & Ankle

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1 Resection Arthroplasty for Limb Salvage of the Unreconstructable Charcot Foot & Ankle Michael Greaser MD and James Brodsky MD Baylor University Medical Center Dallas, TX

2 Resection Arthroplasty for Limb Salvage of the Unreconstructable Charcot Foot & Ankle Michael Greaser MD My disclosure is in the Final AOFAS Program Book. I have no potential conflicts with this presentation.

3 Rationale & Materials/Methods Arthrodesis is impossible in some Charcot ankles & feet with severe bone loss, especially fragmentation of talus or calcaneus We investigated resection arthroplasty as a limb salvage alternative to amputation in very severe Charcot joints Retrospective analysis of 10 patients with resection arthroplasty for severe, unreconstructable Charcot foot and ankle deformity Variables Analyzed: Primary diagnosis Medical co-morbidities Ulcer status Vascularity of the limb Pre-operative ambulatory status Surgical procedures Subsequent reoperation Post-operative ambulatory status

4 Results - Demographics Patient Age /Sex Primary Diagnosis Medical Comorbidities Insulin Dependent Pedal Pulses R.G. 82F Idiopathic Neuropathy Psoriasis, Venous Stasis, COPD N Y A.T 44F DM Neuropathy Kidney/Pancreas Transplant, Cardiomyopathy Y Y J.B. 61M DM Neuropathy CRI, CABG N Y R.D. 37M DM Neuropathy Kidney Transplant Y Y R.S. 49M DM Neuropathy ESRD, Kidney Transplant Y Y R.C. 43M DM Neuropathy CAD, CRI Y Y Y.M. 52F DM Neuropathy ESRD, Obesity Y Y E.S. 63F DM Neuropathy Morbid Obesity N Y M.O. 59M DM Neuropathy CABG, Throat Cancer Y Y W.V. 48M DM Neuropathy Kidney Transplant, Morbid Obesity Y Y

5 Results - Indications Indications for Surgery: 8pt with severe deformity and history of recurrent ulcers 2pt with severe deformity preventing weightbearing 7pt with ulcers at the time of surgery 7 of 10 patients were not able to weightbearing at time of surgery

6 Results - PreOp Patient PreOp Deformity X-Ray Class History of Ulcer Ulcer at Surgery PreOp Amb Status R.G. Valgus Hindfoot, Fixed 2 Y Y WC Transfers A.T Valgus Hindfoot, Rocker Midfoot, Fixed 2 Y Y NWB, Crutches J.B. Forefoot Abd, Rockerbottom, Fixed 1 Y Y Walking R.D. Varus Hindfoot, Unstable 2 N N NWB, Crutches R.S. Varus Ankle, Unstable 3a Y Y NWB, Roll-About R.C. Varus Ankle, Unstable 3a Y N NWB, Crutches Y.M. Varus Ankle. Unstable 3a Y Y Household Amb E.S. Valgus Hindfoot, Fixed 2 Y Y WC M.O. Valgus Ankle, Unstable 3 N N NWB, Crutches W.V. Varus Ankle, Fixed 2/a3 Y Y Community Amb

7 Charcot Resection Illustration Pre Op Charcot Deformity Post Op Charcot Resection Talectomy, Midfoot Resection,Malleolar Resection 5 Year Follow Up Radiographs

8 Results - Technique Each patient underwent radical resection of the bony architecture causing the deformity. The most frequent procedure was talectomy, but partial resections also included the tibia, fibula, hindfoot, and midfoot. Post operatively patients were placed in a total contact casts (TCC) for a minimum of 3 months - one patient had initial immobilization with an external fixator, with subsequent TCC. After soft tissue healing, patients were allowed to weight bear in bivalved AFO (BAFO) braces.

9 Results Post Op The average follow up - 56 months (range 9-90). 5 patients required a subsequent reoperation for further resection to achieve an ulcer-free, braceable limb. 6 of 10 patients had instability at the resection site All 10 patients had a braceable plantigrade foot and ankle. At final follow up 9 of 10 patients were ambulating in a BAFO. 1 patient after 5 years of ambulation, required a BKA for osteomyelitis due to an acute deep infection.

10 Conclusion In selected patients with very severe, non-braceable CN, who are not candidates for arthrodesis, resection arthroplasty can produce a plantigrade and braceable foot and ankle which allows ambulation, and which can be a functional alternative to below-knee amputation