Medial column arthrodesis for a midfoot Charcot rocker-bottom deformity: Wright Salvation system
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Charcot neuro osteoarthropathy is a devastating complication of peripheral neuropathy, primarily effecting the lower limbs. Its commonest cause in western populations currently is Diabetes Mellitus. Its acute presentation is characterised by a combination of destructive features including fracture, dislocation, severe loss of bone density and associated soft tissue swelling and often ulceration. It has a complex etiopathogenesis. Neuro-traumatic mechanisms with activation of complex biochemical pathways coupled with autonomic dysfunction on a background of cumulative microtrauma are generally thought to be the precipitating factors. If neglected, patients eventually present with severe deformity which is either fixed or unstable. This can lead to ulceration due to an abnormal weight bearing profile of the sole of the foot and can be a cause of loss of limb. Observational studies following Charcot patients recurrently reflect that limb loss is a poor prognostic indicator.
The traditional classification for the stages of Charcot arthropathy has been Eichenholtz’s system which is based on clinical and radiological evaluation of the limb in question. Originally described in 1966 by Eichenholtz in 3 stages (Eichenholtz SN. Charcot Joints. Springfield, IL, USA: Charles C. Thomas; 1966), a third stage, 0 ,was added in by Shibata et al(The results of arthrodesis of the ankle for leprotic neuroarthropathy. Shibata T, Tada K, Hashizume CJ Bone Joint Surg Am. 1990 Jun; 72(5):749-56.)
Treatment of Charcot disease is complex difficult frustrating and unpredictable. The deformities caused by this disease are often multi-level and multi-axial and operative planning is difficult upon the background of ulceration, osteomyelitis and bone destruction. The importance of timing of the operation cannot be overemphasised as in the earlier phases of the disease operation can have devastating sequlae secondary to almost unfixable bone and unclosable soft tissues.
It is generally accepted that any surgical intervention for stabilisation or deformity correction is best done after the stage of repair and remodelling are complete (Eichenholtz stage 3). It is also of paramount importance that the deformity correction is done when any ulcers are rendered infection free or healed for fear of devastating infection which can often lead to loss of limb. Earlier operation is though on occasion required, in particular in the context of an uncontrollable and progressing deformity or impending soft tissue breakdown.
Choosing the method of stabilisation is equally important as conventional methods of treating these deformities fail regularly both due to altered bone healing with the production of abnormal collagen as well as non-compliance with non weight bearing by patients who can’t feel their feet.
The choice of hardware in fixing these difficult fusions is also of significance as conventional hardware, such as small fragment plates and screws, are almost sure to fail. Specially designed implants are now available for use which utilises robust designs with highly secure fixation screws, low profile yet strong and malleable plates as well as the use of intra-medullary beams and bolts which allow compression as is found with the Wright Medical Salvation system of fixation. It is also essential to use bone stimulation techniques including the use of osteogenic materials such as bone graft, bone marrow aspirate concentrates, Bone Morphogenic Protein, external and internal bone stimulators. The success of the operation depends on thorough preparation, robust fixation and protracted protection postoperatively.
External fixation is also used with innovative techniques such as minimally invasive surgery to create a treatment algorithm that is specifically of use in patients with poor skin or peripheral vascular disease. It is the case that many of these procedures are refusions of failed operations and the quality of skin is often compromised with multiple previous incisions where external fixation techniques with fine wires can be of great use.
Author:Kartik Hariharan FRCS
Institution: Aneuran Bevan University Health Board, Wales.