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Charcot Neuroarthropathy

Pages: 38-41

Operative Technique

The procedure can be performed with the patient placed supine

on the operating table under either spinal or general anesthesia as
indicated. The initial procedure includes excision of the primary ulcer
and debridement to prepare the wound for soft tissue coverage. This
stage is typically performed 3 to 5 days before the definitive procedure
to limit the potential for postoperative infection.
The operative procedure begins with minimal excision of the
previously excised ulcer, including the surrounding skin, in a triangular
fashion with the base positioned laterally to provide the recipient site
for the medical plantar artery flap. At this point, the use of a handheld
Doppler ultrasound device is used to identify and outline the three
branches of the posterior tibial artery: the medial plantar artery,
lateral plantar artery, and the calcaneal artery. The cutaneous portion
of the flap is marked out over the nonweight-bearing aspect of the
plantar medial foot. The pneumatic thigh tourniquet is then inflated if
used in this procedure. The cutaneous portion of the flap that was
previously identified and marked or traced is then incised and
dissected to a depth that includes the layer of the plantar fascia. The
cutaneous branch of the medial plantar artery is then identified
between the abductor hallicus and flexor digitorum brevis. The flap is
retracted from the wound by placing simple suture from the flap to the
medial aspect of the foot.
Next, dissection is carried down to the level of bone through the
plantar lateral ulcer. The calcaneocuboid joint and/or the base of the
fourth and fifth metatarsals at their articulation with the cuboid are
identified. In many instances, the anatomy and architecture are
distorted by osseous fragments secondary to the Charcot process.
Bone fragments and debris that aren’t viable should be removed to
prevent recurrent ulceration and infection. The calcaneocuboid joint
and/or the bases of the fourth and fifth metatarsals are then resected
from a plantar approach. The affected joint resection is performed,
using a sagittal saw and/or osteotome, with a plantarly based wedge
to elevate the sagittal plane arch of the collapsed lateral column. The
resected joints are packed with allogenic bone graft, with or without
platelet-rich plasma impregnation and the deformity is corrected and
stabilized with 2-mm Steinman pins. Intraoperative image
intensification can be used to ensure adequate correction and
placement of the Steinman pins.
The surgeon will determine if a cutaneous Achilles tendon
lengthening is necessary. A percutaneous Achilles tendon lengthening
is performed if the surgeon is unable to dorsiflex the foot at the ankle
to neutral (for example, the lateral border of the foot is at a 90-degree
angle relative to the long axis of the fibula with the knee extended and
the calcaneus under the mechanical axis of the tibia.
The tourniquet is deflated, and hemostasis is obtained. Once
hemostasis has been achieved and viability of the flap is confirmed by
the normal color of the skin, the medial plantar artery flap is rotated
into the wound. The cutaneous portion of the flap is then sutured to
the perimeter of the wound using a simple interrupted nonabsorbable
suture. Deep sutures are kept to a minimum to lessen the incidence of
infection; they can become a focus for colonization and produced an
inflammatory response during degradation. This is also helps prevent
necrosis of the wound edges secondary to venous congestion. The
fascia overlying the donor defect is excised and covered with a split-
thickness skin graft taken from the ipsilateral leg. A bolster-type
dressing using sterile sponges soaked in saline and nonadhesive
materials is then applied over the split- thickness skin graft.
During the next phase of the procedure, the static prebuilt
circular external fixation frame is positioned on the foot and lower
extremity. Opened towels are stacked under the posterior leg and heel
until the surgeon can place two finger breadths anterior and three
finger breadths posterior between the frame and the leg. The towels
can be removed after the foot and leg are suspended via the frontal
plane wires in the frame. To avoid rotational offset, the frame should
be positioned aligning the anterior crest of the tibia with the anterior
tabs of the tibia rings. Laterally, the external fixator should be
positioned approximately 1 cm from the plantar aspect of the calcaneal
tuberosity and in parallel alignment with the foot that’s 90 degrees to
the leg. Positioning should be maintained until the wires are tensioned
to the frame.
Frontal plane wires followed by oblique plane wires are then
inserted into the calcaneus, proximal tibia and distal tibia. These wires
are secured to the frame and tensioned via a mechanical tensioner in a
standard manner. Half-pins may also be inserted by the surgeon on
the tibia but aren’t usually recommended in patients with poor bone
quality and peripheral dense neuropathy to lessen the incidence of
stress fractures. Fine wires are then inserted into the midfoot distal to
each arthrodesis site and fastened to the external fixator with raised
two-or three hole posts, one or two holes proximal on the footplate.
Compression across the desired arthrodesis sites is achieved through
manual “Russian” tensioning of these prebent wires. Additional wires
can be inserted, as needed, across the metatarsals to limit torque
created about the forefoot. Wires can also be placed into the digits and
attached to the external fixator to prevent digital contractures.
Dressings are applied in a standard manner, ensuring access to the
medial plantar artery flap for direct monitoring.

Staying a step ahead

Pedicle flaps are useful to close large defects of the foot. They
allow the surgeon to replace lost skin with like skin in weightbearing
areas of the foot. However, the use of pedicle flaps to close foot ulcers
can be beneficial only if the underlying pathology is adequately
treated. In the Charcot foot, deformity must be addressed first to
ensure the success of a pedicle flap. Advances in external fixation
devices have offered the option of correcting severe foot deformity
through reduced surgical dissection, while simultaneously performing a
pedicle flap for wound closure. The medial plantar artery flap is a well-
vascularized mobile pedicle flap capable of closing plantar lateral
ulcers. The authors believe that successful limb salvage of Charcot foot
can be performed when reconstructive surgery incorporates adequate
osseous correction and soft tissue management. Neither component
can be overlooked when dealing with the diabetic Charcot foot. The
techniques described offer a stepwise approach to salvage a diabetic
Charcot foot.
The use of a pedicle flap combined with a deformity correction
technique for the diabetic Charcot foot represents an advanced
concept based on sound, time-honored principles. It also provides a
simple, reproducible, and cost-effective means useful in the surgical
management of diabetic Charcot wounds involving patients with well-
controlled medical comorbities.