FRCS orth course Important papers in Orthopaedics. FRCSOrth.co.uk

Transcription

1 FRCS orth course Important papers in Orthopaedics

2 Scaphoid fracture

3 JBJS Am 2005 oct Should acute scaphoid fractures be fixed? A randomized controlled trial. Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Leicester UK Level 1 evidence N= in each group early internal fixation with use of a Herbert screw without a cast avg 9days post injury vs nonop treatment for eight weeks with immobilization in a below-the-elbow plaster cast with the thumb left free Regular f/u the severity of pain; tenderness; swelling; wrist movement; grip strength; and symptoms and disability+ x-rays Patients returned to work at five to six weeks after the injury in both groups At twelve weeks, grip strength was better in patients who had had surgery. No significant difference was detected between the two groups with respect to any other outcome measure at any other time. 10/44 nonop had not healed radiographically at twelve weeks, and, as a consequence, the treatment was altered. 9/44 operative gp minor complications no clear benefit of early fixation of acute scaphoid fractures over non op Rx. aggressive conservative treatment, carefully assess fracture-healing with plain radiographs, and computed tomography scans, after six to eight weeks of cast immobilization and recommend surgical fixation with or without bone-grafting at that time if a gap is identified at the fracture site. Such an approach should result in fracture union in over 95% of such patients.

4 Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months Prof JJ Dias 2008 JBJS N=71 Non op=36 Op=35 f/u 7 ½ years no statistical difference in symptoms and disability FOR ROM, grip strength, pinch strength or patient rated scores. X-rays: n= 59 patients. OA changes scaphotrapezial (ST)and radioscaphoid (RS)joints no statistical difference. 3/35 patients had asymptomatic lucency surrounding the screw. 1/36 non-operatively treated patient developed nonunion with avascular necrosis. 5/36 scapholunate angle ( > 60 ), 4/5 asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups.

5 Scaphoid fracture Ix J Bone Joint Surg Br Sep Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. Beeres FJ, Rhemrev SJ, Netherlands N=100 with a suspected scaphoid fracture but without evidence of a fracture on plain radiographs using MRI within 24 hours of injury, and bone scintigraphy three to five days after injury. The reference standard for a true radiologically-occult scaphoid fracture was either a diagnosis of fracture on both MRI and bone scan, or, in the case of discrepancy, clinical and/or radiological evidence of a fracture. MRI false negative in four patients and bone scan in eight. MRI sensitivity 80% and a specificity of 100%. Bone scintigraphy had a sensitivity of 100% and a specificity of 90%.

6 CORR 2009 Sep Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis. Level III Yin ZG, China Imaging protocols for suspected scaphoid fractures are inconsistent. bone scan, MRI, and CT for diagnosing suspected scaphoid fractures. 26 studies. The pooled sensitivity, specificity, natural logarithm of the diagnostic odds ratio, and PPV & NPV were, respectively, 97%, 89%, 4.78, 8.82, and 0.03 for bone scan; 96%, 99%, 6.60, 96, and 0.04 for MRI; and 93%, 99%, 6.11, 93, and 0.07 for CT. MRI is more specific and better for confirming scaphoid fracture.

7 Treatment Injury 2009 Mar Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures--a systematic review. Modi CS, Nancoo T, Powers D, Ho K, Boer R, Turner SM. United Kingdom. Included studies were critically appraised using levels of evidence and RCTs were further appraised using a scoring tool. 112 studies, 12 included. Three level 1 RCTs, three level 2 RCTs, two meta-analyses, one economic analysis, and three retrospective studies Percutaneous fixation may result in faster union rates by approximately 5 weeks and an earlier return to sport and work by approximately 7 weeks over cast treatment. This difference is not seen when comparing ORIF with cast treatment. cast treatment results in a higher nonunion rate than ORIF, this needs to be balanced with the 30% minor complication rate. Manual workers require significantly longer time off work than non-manual workers regardless of the method of treatment, ( return to work sooner after ORIF than after cast treatment) Operative treatment should be reserved for patients unable to work in a cast and considered for most manual workers and high-level athletes. CORR2007 Jul Treatment of acute scaphoid fractures: systematic review and metaanalysis. Yin ZG, China 2007 Jul Treatment of acute scaphoid fractures: systematic review and meta-analysis. Yin ZG, China Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.

8 Conservative treatment of scaphoid nonunion in children and adolescents. Prolonged treatment with cast immobilisation resulted in union of the fracture and an excellent Modified Wrist Score in all patients. D. M. Weber JBJS Br Sep

9 Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. J Hand Surg Eur Vol Apr motion-preserving, salvage procedures for scaphoid nonunion (SNAC) or scapholunate advanced collapse (SLAC). 52 articles SNAC or SLAC for PRC or 4CF. both procedures give improvements in pain and subjective outcome measures for patients with symptomatic and appropriately staged SLAC or SNAC wrists. PRC better postoperative range of movement and 4CF :nonunion, hardware issues and dorsal impingement. PRC:risk of subsequent OA significantly higher Grip strength, pain relief and subjective outcomes similar in both treatment groups.

10 SNAC: scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) fusion Hand Surg Am sept Clinical Outcomes of Scaphoid and Triquetral Excision With Capitolunate Arthrodesis Versus Scaphoid Excision and Four-Corner Arthrodesis. Gaston RG, USA retrospective n=50 patients radiographs, wrist range of motion grip strength; VAS; and DASH questionnaire. Out come same at 3 years f/u. CLA: a lessened need for bone graft harvesting low nonunion rate easier reduction of the lunate following triquetral excision, avoiding subsequent symptomatic pisotriquetral arthritis Screw migration, however, remains a concern with this technique Level of evidence:iii.

11 Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. Cohen MS, USA J Hand Surg Am Both PRC and scaphoid excision and 4-corner arthrodesis are motion-preserving options for the treatment of scapholunate advanced collapse arthritis with minimal subjective or objective differences in short-term follow-up evaluations

12 Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? Tomaino MM USA J Hand Surg Am N=24 for wrists without capitolunate arthritis, PRC avoids the technical demands, lengthy postoperative immobilization, and risk of nonunion associated with LWF (limited intercarpal arthrodesis with scaphoid excision), but for stage III disease (capitolunate arthritis) pain relief may be unsatisfactory, and LWF is recommended. Retrospective

13 Distal Radial Fracture

14 REDISPLACED UNSTABLE FRACTURES OF THE DISTAL RADIUS A PROSPECTIVE RANDOMISED COMPARISON OF FOUR METHODS OF TREATMENT M. M. MCQUEEN, C. HAJDUCKA, C. M. COURT-BROWN Edinburgh, Scotland JBJS Br May 1996 Level 1 A PROSPECTIVE RANDOMISED COMPARISON OF FOUR METHODS OF TREATMENT N=120 ( 30 in each group) 1) remanipulation + forearm cast 6/52 2) open reduction and bone grafting (McBirnie et al 1995) 3) closed re-reduction and application of a Pennig external fixator removed at 6/52 4) closed re-reduction and application of a Pennig external fixator as in group 3 but early mobilisation at 3/52 Radiological results better improvement in angulation of the distal radius Functional results:6/52, 3-6 and 12 months no difference Carpal malalignment :statistically ve effect on functional results.

15 Do young patients with malunited fractures of the distal radius inevitably develop symptomatic posttraumatic osteoarthritis? D. P. Forward, T. R. C. Davis, Nottingham JBJS May years f/u N=106 adults fracture of the distal radius between and who were below the age of 40 years at the time of injury. Clinical and radiological assessment at a mean follow-up of 38 years (33 to 42). No patient required a salvage procedure. there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), (DASH) scores were not different from population norms, and function, significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion imperfect reduction of these fractures may not result in symptomatic arthritis in the long term

16 Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous Fixation A Prospective Randomized Trial JBJS Am 2009 Tamara D. Rozental USA level 1 N=45 22 CR+ k wire 23 volar plate Both closed reduction with percutaneous pin fixation and open reduction with internal fixation with use of a volar plate are effective methods for the treatment of dorsally displaced, unstable, extra-articular or simple intra-articular fractures of the distal part of the radius. Better functional results can be expected in the early postoperative period in association with open reduction and internal fixation, and this form of treatment should be considered for patients requiring a faster return to function after the injury.

17 Locking plates A revolution in the management of fractures of the distal radius? N. D. Downing, JBJS 2008 A number of clinical and biomechanicalstudies have demonstrated the advantages of restoring normal anatomy, but the number of studies which have used validated patient-derived outcome measures has been few and there are no long-term prospective comparative studies of alternative methods of treatment to guide our management. A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years. J Hand Surg Eur Vol 2007 Barton found no correlation between moderate shortening (up to 8mm) and outcome, as assessed by the Patient Related Wrist Evaluation at a mean follow-up of 29 months

18 Distal radius# 2009 Jul Prospective randomised study of intraarticular fractures of the distal radius: comparison between external fixation and plate fixation. Xu GG, Chan SP, Puhaindran ME, Chew WY. compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. N=35, after a failure of initial conservative treatment. The patients were randomised.patients were followed-up at 1 week, 3, 6, 12 and 24 months. Of the 35 patients, 5 were excluded. Out come not significantly different. Complication rates similar. CONCLUSION: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF. Cochrane database2007 Jul Percutaneous pinning for treating distal radial fractures in adults. Handoll HH, Vaghela MV, Madhok R. Edinburg Adult fracture of the distal radius,compared percutaneous pinning with conservative treatment, or different aspects of percutaneous pinning. CONCLUSIONS: Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use. External fixation versus conservative treatment for distal radial fractures in adults. Handoll HH, Huntley JS, Madhok R. Edinburgh There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.

19 Distal radius fracture JBJS am 2007 Management of Distal Radial Fractures Neal C Chen, J Jupiter Prediction of Instability in Distal Radial Fractures M.M. McQueen JBJS AM distal radial fractures were prospectively recorded over a 5.5- year period. The database was validated by re-examining a sample of it. Complex but fairly accurate in predicting instability

20 Hallux valgus

21 Hallux valgus AHN Robinson : Modern concepts in the treatment of hallux valgus JBJS am 2005 Proximal metatarsal o my for HV: comparison of outcome for moderate and severe deformities Okuda R Foot and ankle 2008 Jul N=54 feet f/u 30 months. Group M (moderate) (24 feet, HVA<= 40 degrees and IMA<18 degrees) and Group S (severe) (30 feet, HVA>40 degrees or IMAof 18 degrees or greater). The prevalence of recurrent hallux valgus (hallux valgus angle of 20 degrees or greater) in Group S was significantly higher than that in Group M (p = 0.013

22 Hallux valgus HV associated with age, female sex & components of generalised OA e.g nodal OA, knee pain, big toe pain & self reported OA Arthritis rheum 2008 Jun Pre op HVA main radiological predictor for correction. Correction rate declines after preop HVA 37. IMA and DMAA have a minor role with HVA< 37 but may contribute to pre op HVA> = 37 BMC musculo skeletal disoders 2008 May Scarf versus proximal closing wedge osteotomy in hallux valgus treatment. Arch orthop trauma surg 2008 apr Paczesny L to evaluate the DMMA as a key factor in choosing between the proximal closing wedge osteotomy and scarf osteotomy. 40 feet: 32 females aged in whom 24 unilateral and 8 bilateral operations had been performed from 24 to 63 months previously. RESULTS: There were statistically significant differences between groups in the postoperative hallux valgus angle and in first metatarsal shortening. inverse correlation betn pre op DMAA and IMA improvement after proximal closing wedge o my and +ve correlation after scarf o my This study confirmed the value of distal metatarsal articular angle assessment.

23 Hallux valgus Scarf o my for correction of HV: midterm clinical outcome: Lipscombe S, Molloy A, Sirikonda S, Hennessy MSJ Foot Ankle Surg Jul-Aug; Prospective study N=22pts (33 feet) Significant improvement in pain scores from preoperative mean of / to / at 5 years (P <.01) was noted and 90.9% of patients remained satisfied

24 Hallux valgus Distal first metatarsal osteotomy for repair of mild to moderate hallux valgus deformity.<14 degrees IMA Tonbul M J Foot and ankle Surg 2008 May

25 Hallux Valgus Foot Ankle Int Sep Proximal first metatarsal opening wedge osteotomy with a low profile plate. Shurnas PS, Watson TS, Crislip TW. Eighty-four patients (90 feet) underwent PMOW osteotomy with distal bunionectomy. There were 78 patients (93%) and 84 (93%) feet available for followup. Mean followup was 2.4yrs. The mean preoperative VAS score was 5.9 (+/- 2.2), compared with a mean postoperative score of 0.5 (+/- 0.8). The mean 1-2 IMA preoperatively was 14.5 (+/-3.3) degrees, postop 4.6 (+/- 2.8) degrees. HVA improved from a mean of 30 degrees to 10 degrees. 1 nonunion, delayed union, mild hallux varus, severe hallux varus (2), recurrent hallux valgus (3) patients (including the nonunion) and no instances of plate Ninety percent of patients reported good to excellent subjective results after the index surgery. a first web space release may result in hallux varus and increased distal metatarsal articular angle (DMAA) was associated with hallux valgus recurrence.

26 Hallux Valgus Scarf and Akin osteotomies for moderate and severe hallux valgus: clinical and radiographic results. Garrido IM Foot Ankle Surg. 2008;14(4):

27 Hallux valgus Postoperative Incomplete Reduction of the Sesamoids as a Risk Factor for Recurrence of Hallux Valgus Ryuzo Okuda, MD Journal of Bone and Joint Surgery (American). 2009; level III Proximal Metatarsal Osteotomy with Distal Soft-Tissue Correction and Arthrodesis of the Metatarsophalangeal Joint V. James Sammarco JBJS 2007 Juvenile hallux valgus. A conservative approach to treatment JA Groiso JBJS AM 1992

28 Dysfunction of the tendon of tibialis posterior TREATMENT OF PES PLANUS DEFORMITY Treatment Stage Nonoperative Treatment Operative Treatment I Immobilize (cast, boot, brace); NSAIDs; medial heel and sole wedge orthosis Synovectomy IIA Ankle brace (over-the-counter or custom); UCBL orthosis; short articulated AFO; medial heel and sole wedge orthosis TAL or gastroc slide; FDL to navicular transfer Bone options Medial displacement calcaneal osteotomy Subtalar arthrodesis IIB Ankle brace (over-the-counter or custom); UCBL orthosis; short articulated AFO; medial heel and sole wedge orthosis TAL or gastroc slide; FDL to navicular transfer Bone options Lateral column lengthening with or without medial displacement calcaneal osteotomy Subtalar arthrodesis III Articulated AFO; custom ankle brace Triple arthrodesis; TAL or gastroc slide IV Nonarticulated AFO; custom ankle brace Triple arthrodesis; TAL or gastroc slide; and deltoid ligament reconstruction AFO, ankle-foot orthosis; FDL, flexor digitorum longus; gastroc, gastrocnemius; NSAIDs, nonsteroidal anti-inflammatory drugs; TAL, Achilles tendon lengthening; UCBL, University of California Berkeley Biomechanics Laboratory.

29 Dysfunction of the tendon of tibialis posterior and Rheumatoid foot

30 Dysfunction of the tendon of tibialis posterior Orthopedics. 1996May Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Myerson MS, Coriigan J USA N=32 patients stage-ii posterior tibial tendon dysfunction with calcaneal osteotomy and flexor digitorum longus tendon transfer. These 32 patients (29 F,3 Mnd had been symptomatic for an average of 2.5 years (range, 1 to 8 years) before surgical correction. The indication for surgery was the presence of medial foot pain refractory to nonoperative treatments All patients were examined at a mean of 20 months after surgery. AOFAS score improved from a preoperative mean of 48 points (range, 23 to 76) to a postoperative mean of 84 points (range, 68 to 92). Most patients (94%) experienced pain relief, had improvement in the arch of the foot, and were able to wear regular shoes without orthotic support. In order to correct deformity and provide substantial relief of foot pain and dysfunction, a medial translational calcaneal osteotomy was performed in addition to a flexor digitorum longus tendon transfer for management of stage-ii posterior tibial tendon dysfunction.

31 Dysfunction of the tendon of tibialis posterior Review article: HJ Trnka JBJA Br 2004 Rosenberg reported that MRI is the best method for imaging the tendon because of its multiplanar imaging ability and soft-tissue contrast resolution

32 classification 1989 Johnson and Strom described three clinical stages of dysfunction. Myerson added a fourth to describe the most severe deformity with valgus collapse of the talus within the ankle. Stage I incorporates tenosynovitis. In this stage, the tendon is of normal length and symptoms are usually mild to moderate. Pain and swelling are present on the medial aspect of the foot. Mild weakness and minimal deformity are present. Stage II there is elongation or tearing of the tendon. The limb is weak and the patient is unable to stand on tiptoe on the affected side. There is secondary deformity as the midfoot pronates and the forefoot abducts at the transverse tarsal joint. The subtalar joint remains mobile. Stage III is characterised by a more severe deformity and a fixed hindfoot Stage IV there is a valgus deformity of the talus with early degenerative changes of the ankle.

33 Rheumatoid foot

34 Rheumatoid foot K Trieb: review article: JBJSBr 2005 Management of foot in Rhematoid Arthritis Autoimmune systemic inflammatory disease F>M 3:1 ARA diagnostic criteria T- lymphocyte mediated auto immune response via HLA-II Locus Non op : pressure relieving foot wear. Soft for rigid and rigid for to support and limit joint movement for flexible deformity Op : forefoot: 90% MTP J HV, planter displacement of metatarsal heads, varus little toe, dislocation of PIP J dordally, migration of planter fat pad distally, large bursae, intr-extr imbalanceclawing, + ve Gaensslen test Keller s/ 1 st MTP J fusion / Weil s osteotomy synovectomy+ ext tendon lengthening Modified Fowler s procedure talonavicular fusion /triple fusion/ankle fusion/replacement

35 Rheumatoid foot Long-Term Results of the Modified Hoffman Procedure in the Rheumatoid Forefoot JBJS am 2005 average of five and a half years following thirtyseven consecutive forefoot arthroplasties performed in twenty patients a technique involving resection of all five metatarsal heads. satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was There were no reoperations. Conclusions: Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

36 Ankle :TAR /Arthrodesis

37 TAR BP STAR

38 TAR A randomised, controlled trial of two mobile-bearing total ankle replacements P. L. R. Wood, C. Sutton JBJS Br Jan 2009 Buechel-Pappas (BP) and the Scandinavian Total Ankle Replacement (STAR min 36 months f/u. similar in design consisting of three components with a meniscal polyethylene bearing which was highly congruent on its planar tibial surface and on its curved talar surface. However, the designs were markedly different with respect to the geometry of the articular surface of the talus and its overall shape. six-year survivorship of the BP = 79%,STAR =95% replacement be advised with caution in the presence of varus or valgus deformity and that it should not be performed when the deformity exceeds 15.

39 TAR MEDIUM-TERM RESULTS IN 200 SCANDINAVIAN TOTAL ANKLE REPLACEMENTS P. L. R. Wood, C. Sutton JBJS Br Sept2008 prospective study of 200 total ankle replacements at a single-centre using the Scandinavian Total Ankle Replacement. 24 ankles (12%) revised, 20 by fusion and four by further replacement and 27 patients (33 ankles) died. 5 year survival was 93.3% and 10 year survival 80.3% Subtalar arthritis may continue to progress after total ankle replacement. Brodsky : gait analysis :superior compared to Ankle arthrodesis Schneiderbauer:3.1% infection rate (n=386tar) How Successful are Current Ankle Replacements?: A Systematic Review of the Literature. Gougoulias N, Khanna A, Maffulli N. CORR July 2009 deep infection up to 4.6% Level IV

40 Ankle arthrodesis Arthroscopic ankle arthrodesis. Gougoulias NE, Agathangelidis FG, Parsons SW. Foot Ankle Int Jun N=78 48 ankles had minor deformity (group A), 30 ankles had a varus or valgus deformity of more than 15 degrees (maximum 45 degrees) (group B). 21months Fusion :47 /48 (97.9%) group A and in 29 of 30 (96.7%) ankles group B The outcome was graded as very good in 79.2% (38 feet) in group A and 80% (24 feet) in group B, fair in 18.8% (9 feet) in group A and 16.7% (5 feet) in group B and poor in one ankle in each group (p = 0.68). The arthroscopic technique offered high fusion rates and low morbidity. Deformity correction was achieved with good results. Patients with poor bone quality or post traumatic deformity may require more rigid fixation

41 Ankle arthrodesis Anterior plate supplementation increases ankle arthrodesis construct rigidity. Tarkin. Foot Ankle Int Feb Cadeveric study : Compared to screws alone, anterior plate supplementation increases construct rigidity and decreases micromotion at the ankle fusion interface. Arthrodesis of the ankle in the presence of a large deformity in the coronal plane PLR Wood, R Smith N=23(25 ankles) Open arthrodesis with cannulated 6.5 mm screws 24/25 primary union Rx of choice for severe deformities with arthritis. f/u 20 mths AOFAS pain score 10 pre op 35.2 post op.

42 Diabetic foot Surgical aspects of the diabetic foot AHN Robinson JBJS Br )DM with complications ulcer infection charcoat neuroarthopathy 2) Routine problem with coincedental DM

43 Diabetic foot

44 Diabetic foot Neuropathy: The cause is thought to be an ischaemic insult secondary to damage to the vasa nervorum. the sensory neuropathy, and not vascular disease, is the primary cause of most foot conditions in diabetic patients Sensory/ motor / autonomic Assessment by 128Hz tuning fork, 10g Semmes Weinstein monofilament Vasculopathy: large, small vessels and microcirculation affected: arteriosclerosis 45%after 20yrs DM -nt pulse further Ix should be requested.

45 ulceration Wegner /Brodsky : classification Treatment protocol for the diabetic foot as based on the depth-ischaemia classification Classification Definition Treatment Depth 0 At-risk foot, no ulceration Patient education, accommodative footwear, regular clinical examination 1 Superficial ulceration, not infected Off-loading with total contact cast, walking brace or special footwear 2 Deep ulceration exposing tendons or joints Surgical debridement, wound care, off-loading, culture-specific antibiotics 3 Extensive ulceration or abscess Debridement or partial amputation, off-loading, culturespecific antibiotics Ischaemia A Not ischaemic B Ischaemia without gangrene Non-invasive vascular testing and vascular reconstruction with angioplasty/bypass C Partial (forefoot) gangrene Vascular reconstruction and partial foot amputation

46 neuroarthropathy

47 Diabetic foot Total contact cast Exostectomy Arthrodesis Avulsion of TA: non op Rx

48 Diabetic foot Lengthening of the Achilles Tendon in Diabetic Patients Who Are at High Risk for Ulceration of the Foot DAVID G. ARMSTRONG, JBJS am 1999 peak pressures on the plantar aspect of the forefoot are significantly reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. Effect of Initial Weight-Bearing in a Total Contact Cast on Healing of Diabetic Foot Ulcers J. Bone Joint Surg. Am. Dec 2004 Charles L. Saltzman, Moderate early weight-bearing retards healing of plantar ulcers only minimally in patients with diabetes mellitus treated with total contact casts. Allowing patients to walk immediately after placement of a total contact cast may improve their acceptance of this form of therapy. Only excessive walking during the first twenty-four or forty-eight hours after cast application is likely to prolong the duration of cast treatment. Arthrodesis as an Early Alternative to Nonoperative Management of Charcot Arthropathy of the Diabetic Foot Sheldon R. Simon J. Bone Joint Surg. Am., Jul 2000

49 Ankle fractures in DM Mc Cormack RG,Leith JM J B JS Br, Jul 1998; N=26 Ankle fractures in diabetics: COMPLICATIONS OF SURGICAL MANAGEMENT Level III Complications : >40% Six major complications Johnson : NWB 3/12, PWB with cast 3/12 then brace upto 1 year for ankle # K. B. Jones, K. A. Maiers-Yelden, USA Ankle fractures in patients with diabetes mellitus J B J S Br, Apr 2005 N=42 21 DM / 21 DM comorbidities DM comorbidities 47% complication rate DM without comobrbidities : no diff with control Longer immobilization reqd the comorbidity of a history of Charcot neuroarthropathy was independently associated with every complication measured

50 Kienbock s

51 ASPECTS OF CURRENT MANAGEMENT Kienböck s disease F. Schuind,S.Eslami,P. Ledoux JBJS Br 2008 There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck s disease and negative ulnar variance. Anatomical difference (TFCC and joint with capitate /hamate)and blood supply: Y/I/Xpattern : single volar/dorsal, several volar / dorsal no central anastomosis, with anastomosis.(lee) Hulten noted increased incidence (74% wrists with ulnar ve variance ) 1/3 rd load thru Radiolunate jt. Adult male manual worker 20-40yr,-ve ulnar variance Lichtman classification aetio: exact cause not known?the consequence of impaired venous outflow.

52 Kienbock s Rx: non op / op Radial shortening/ ulnar lengthening Vascularised graft:ulnar plus hand (dorsal metacarpal arteriovenous Pedicle)or by dorsal aspect of the radius via pedicles from the fourth and fifth extensor compartments.(icsra) PRC/Fusion Assessment of the different published studies indicates that radial shortening offers durable pain relief and may improve grip strength, but does not offer a cure. Radial shortening: less satisfactory results in patients over the age of 30. J Hand Surg Am Jan Vascularized bone grafting for treatment of Kienböck's disease. Elhassan BT, Shin AY

53 Thank you