A Practical Approach to the Management of Charcot

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Dwain Holmes
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Assistant Professor, Department of Orthopaedics University of

1 A Practical Approach to the Management of Charcot APMA Annual Scientific Meeting 2018 Jacob Wynes DPM, MS, CWS, FACFAS Assistant Professor, Department of Orthopaedics University of Maryland School of Medicine Co-Director UMMC Limb Preservation Clinic

2 Charctose Intolerance

4 Agenda Interesting facts Principles of Charcot foot / ankle reconstruction EBM considerations Tips and Tricks Case presentations

Charcot Associations Diabetes Hemochromatosis Alcoholism Antiretroviral Therapy Spina bifida Lyme Disease Myelomeningocele Hansen s Disease Syringomyelia Amyloidosis

5 Charcot Associations Diabetes Hemochromatosis Alcoholism Antiretroviral Therapy Spina bifida Lyme Disease Myelomeningocele Hansen s Disease Syringomyelia Amyloidosis Syphilis Steroid Use Pernicious Anemia Spinal Cord Compression Charcot Marie Tooth Syndrome Multiple Sclerosis Rheumatoid Arthritis 20 patients ( ) Grear et al. FAI 2013

6 Neurotrophic / Neurotraumatic Does it really matter?

7 Eichenholz Stages 1966

8 Sanders / Frykberg *Schon 1998

9 Consider the STJ Brodsky / Rouse 1986

11 Why is Charcot So Devastating? Charcot joints in ~ 0.16% of patients with DM (Glover et al. Adv Wound Care 1997, Larson et al. Diabet Foot Ankle 2012) 0.3% - 7.5% reported incidence 40% Charcot develop ulceration Amputation in charcot patients (4.1%) Charcot + DM Ulceration (12x) vs. DM Ulceration alone (7x) Sohn et al Diabetes Care % higher mortality rate with Charcot + Foot Ulcer (w/ in 5 years) Sohn et al Diabetes Care 2009

12 Charcot or Worse? Crush injury 5 days prior to presentation Recent hospital admission with WBC 20,000 (+) MSSA blood cultures History of bilateral foot deformity bilateral left foot years ago HbA1c 8.9% ESR 97 / CRP 145 / Lactate 1.0

Am J Med 2008 Quality of life poor (low SF 36 scores) Better functional outcome when diagnosed within 3 months (Physical function + General

13 Charcot: More Fun Facts Specialty referral centers have increased cases reported 59% increased risk for Charcot if obese and neuropathic Stuck et al. Am J Med 2008 Quality of life poor (low SF 36 scores) Better functional outcome when diagnosed within 3 months (Physical function + General health > Mental health) Pakarinen et al. JFAS 2009 Wukich et al. Diabet Med 2011 Link btw neuropathy and CV disease CV optimization decreased 5 year mortality in Charcot patients Young et al. Diabetes Care 2008 Gazis et al. Diabet Med 2004 Pitocco et al. Acta Diabetolog 2014

Charcot patients have DM on the Brain Subclinical albuminuria = Nephropathy AND Gray Matter Atrophy Impact on congnitive function Methta et al.

14 Charcot patients have DM on the Brain Subclinical albuminuria = Nephropathy AND Gray Matter Atrophy Impact on congnitive function Methta et al. Metabolism: Clin and Experimental 2014 Pts with DFU decreased cognitive capacity without association of smoking / depression Memory, exec function, reaction time, psychomotor, attention Natovich et al. Diabetes Care 2016 Compliance (un-intentional vs. primary / secondary) Chatteree et al. J Med Ethics 2006 Significantly decreased quality of life scores with presence of wound (Validated Cardiff Wound Impact Scale) Goodridge et al. Foot and Ankle Int Price et al. International Wound Journal 2004

Bone Quality in Charcot is Poor Marked increase in

Decreased osteoid Impaired biomechanical strength of callus

osteoblast response to IGF 1 and increased AGE Loss of Bone

16 Bone Quality in Charcot is Poor Marked increase in osteoclastic activity in DM Decreased collagen synthesis Decreased osteoid Impaired biomechanical strength of callus (stiffness / tensile strength) Hyperglycemia impairs osteoblast response to IGF 1 and increased AGE Loss of Bone Mineral Density Comorbidities Osteoporosis Renal Osteodystrophy La Fontaine et al JFAS 2011

17 Fracture vs. Dislocation Herbst et al. JBJS (Br) 2004 Dislocation in Charcot = Normal BMD Fracture in Charcot = Decreased BMD

18 How Bone is Affected in Charcot Pleiotropic cytokines Bone resorption TNFα, IL -1, IL-6 Baumhauer et al. FAI 2006 Protection from Bone resorption Offloading Folestad et al. J Foot Ankle Res 2015 Increased IGF-1, IGF-2, IL 6 Millet et al. J Bone Min Res 2004 CGRP, VIP, Substance P Kaishihara et al. J Neuroci 1989

19 Cost comparison: Charcot Limb Salvage vs. Trans-tibial Amputation Gil et al FAI 2013 Level III retro-cohort study n = 67 patients Cost reviewed over 12 months 50% with OM 17/67 DM with BKA $49,251 82% in Rehab Facility 50/67 DM with Reconstruction $56,712 70% in Rehab Facility

20 Charcot Treatment Options Conservative Saltzman et al. CORR 2005: review of non-operative tx of Charcot (large tertiary center) Immobilization 2.7% annual rate of amputation 23% rate of brace wear for more than 18 months Strict NWB 49% rate of recurrent ulceration Smith et al. Int J Evid Based Health 2007 (Southern Australia) Reduction maintained by cast/brace* Bisphosphates decrease temperature / disease activity vs. controls No evidence with reduction ulcerations, hospital admissions, rate of surgical intervention, QOL Bisphosphonates Surgical Plantar Lowery et ostectomy al. FAI 2012 TAL 95 articles reviewed (Level Osseous 4/5 clinical debridement evidence) Realignment Inconclusive: fixation osteotomy / Selective timing arthrodesis Internal fixation External fixation Orthobiologics

22 Can I WB these patients at all? Parisi et al. Diabet Foot Ankle 2013 N=22 DM 2, Mean age 56 years, BMI Eicenholtz 1 / 2 walker boot / immediate WB good functional outcomes No stat sig differences in lateral Meary s angle

25 Goals of Charcot Reconstruction Plantigrade Stable Shoeable / braceable foot Decrease risk for further breakdown / ulceration or infection

26 Charcot Reconstruction: Key Points Heel under mechanical axis of lower leg Metatarsal heads perpendicular to heel weight evenly distributed Adjacent joints stabilized Passive dorsiflexion 5 past neutral Minimally invasive techniques Use of orthobiologics Supplemental external ring fixation

27 N = 15 Charcot (7) Lisfranc (4) Midtarsal (2) NC (1) Perinavicular (1) Multiple N = 19 DM / Neuropathy N=16 unimparied Level 2; NIH Funded Study

28 Radiographic Measures as a Predictor of Ulcer Formation in DM Charcot Midfoot Bevan et al. FAI 2008 Retrocohort investigation Non surgical charcot patients n = 24 feet (25% ulceration) when Lateral Meary s angle > - 27 degrees

29 Catanzaritiet al JFAS 2000 Wukichet al. FAI 2014 Schonet al FAI 1998 Medial column charcot: Lisfranc Schon et al FAI 2002

30 Cuboid Height as a Sole Predictor for Ulceration No direct correlation with plantar ulceration (34.6% vs. 45.2%) Negative correlation with Meary s angle Meyr et al. JFAS 2017

32 Meary s 15 degrees

33 Talar / 1 st Met Angle Improvement > 2 degree loss of correction correlates with non union 75% of nonunions remained plantigrade Calcaneal / 5 th Met Angle Improvement 3-6 months duration for osseous union (73%) No ulcer recurrence

Sammarco (GJ) et al JBJS 2003 Osseous union 83% @ 35 months Must span the Charcot segment Sammarco

31.00 ± 22.97 months maintenance of radiographic correction Wiewiorski et al.

34 Sammarco (GJ) et al JBJS 2003 Osseous union 35 months Must span the Charcot segment Sammarco (VJ, GJ) et al JBJS % 52 months 8/22 broken screws Grant JFAS /- STJ fusion, ± months maintenance of radiographic correction Wiewiorski et al. JFAS 2012 No 27 months (6.5mm fusion bolt) Medial column and CCJ Cullen et al. JFAS 2013 No 18.5 months

35 21 Patients (4 year follow up) Worse complications when > 2/5 high risk criteria observed: 1) Substantial bone deformity 2) Ulcer over infected bone 3) Osteopenia 4) Obesity 5) Immunocompromise Eschler et al. Journal Diabetes Research 2015 Pinzur MS. FAI 2007 Wound healing 21% ; Recurrent ulceration in 13% Richter et al. Foot Ankle Surg 2015 Average of 2.8 complications per patient Lamm et al. JFAS 2010

Can We Predict Who Will do Poorly? Rettedal et al. JFAS 2018 Charcot Reconstruction Preoperative Prognostic Score (CRPPS) Poor prognosis = wound / major amputation at last follow up [4.

36 Can We Predict Who Will do Poorly? Rettedal et al. JFAS 2018 Charcot Reconstruction Preoperative Prognostic Score (CRPPS) Poor prognosis = wound / major amputation at last follow up [4.33 ± 1.07] Score of [2.96 ± 1.23] consistent with better prognosis Score > 4 consistent with poor outcome Regression: anatomic location (ANKLE) / CRPPS Sensitivity of 75% ; Specificity of 71%

43 Lamm et al. JFAS 2016

63 Lamm et al. JFAS 2010

64 Anterograde? Assal et al JBJS 2009 / 2010 Technique Guide n=15 DM / Charcot Average 42 Month Follow up 6.5mm - 8mm X 150mm screw Recommendations: -TAL / GR +/- STJ Fusion - Autograft - Thread purchase > 50% of 1 st met Ulceration NOT Contraindicated

65 2 Ring Pedal Block 2 Ring Tibial Block 2 Half pins proximal tibia ring 1 Half pin distal tibia ring Axial wire distal tibia Axial wire proximal tibia Axial wire calcaneus Oblique calcaneal wire Axial wire talus (+/- additional oblique wire) 2 metatarsal wires

66 External fixation with greater odds of success (systematic review of 616 procedures) (Dayton et al. JFAS 2015) 8x more nonunion with ex fix ; 1.5 X amputation with internal fixation with higher rate of overall complications (Lee et al. Orthopaedics 2016)

67 13 Steps

Immediately after procedure Hibbiclens soaked gauze or sponge Bolster tight against the skin No change for 1 week Perioperatively until removal Q3 day change with

68 Immediately after procedure Hibbiclens soaked gauze or sponge Bolster tight against the skin No change for 1 week Perioperatively until removal Q3 day change with chlorhexidine wipes 4x4 gazue ABD and ACE Treat PRN with dicloxicillin, cephalexin, or doxycyline Recognition of the CONTINUUM: Pin site irritation Pin site infection Pin tract infection

70 No two feet are created equal 25 degrees varus / 8 degrees varus

71 6 weeks Camasta 2010 PI Update

72 Post Operative Clinical 8 months

77 Development of neuropathic ankle after midfoot charcot: 5 / 171 feet Pinzur MS. FAI 2012

78 7/28/2016

79 Post op

81 11/ /2015

83 Intra Op: 3/2016

84 Reduction of exuberant scar tissue and promoting neurogenic support to bone growth (Wei et al. J. Biol Chem 2009, Kassemm et al. Acta Opthalmol 2013) Downregulation of TNF-alpha and IL-1 (He et al. J Biol Chem 2013, Romero et al. J. Obstet Gynecol 1994)

85 8/2016

86 Post op Clinical

88 1/21/2016

90 3/2016

91 Intra Operative Fluoroscopy

92 5/5/2016

93 6/2/2016

94 6/2016

95 6/21/2016

96 3 Months Post op

100 5/9/2017

101 CT Scan 11/2017

102 Presentation to UMOA: 12/21/2017

103

104 Pre Op Ceretec Scan No evidence of osteomyelitis

105 Surgery #1: 1/30/2018

106 3/29/2018

107 5/10/2018

108 Surgery #2: STJ Arthrodesis / ROH / Exchange HW DOS: 5/30/2018

109 Last Follow Up: 6/14/2018

Summary Prognostic influence: Lateral Talar First Met alignment + Tibiocalcaneal alignment Assessment of physiology preoperatively and preservation perioperatively Influence of hindfoot

110 Summary Prognostic influence: Lateral Talar First Met alignment + Tibiocalcaneal alignment Assessment of physiology preoperatively and preservation perioperatively Influence of hindfoot alignment on midtarsal joint Influence of bone mineral density on deformity Potential for cascade of HW failure in midfoot (serial radiographs important) Hindfoot stability >> Midfoot Obtain then Maintain

111 Thank You

112

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