Revisional Surgery of the Charcot Midfoot
Crystal L. Ramanujam, John J. Stapleton, Thomas Zgonis
Ostectomy has commonly been utilized for midfoot CN to address ulcerations secondary to plantar prominences with reported healing rates of nearly 75%.5–7 Interestingly, a study by Catanzariti et al found that ostectomy was especially successful for ulcers confined to the medial column, while those at the lateral column were less predictable and showed that failed ostectomy often led to complex revisional surgery for limb salvage including arthrodesis and/or flaps.7 A plausible explanation to this was later found in a study by Molines-Barroso et al in which they determined that plantar ostectomy at the lateral column in patients with CN worsens alignment in the sagittal plane deformity, specifically leading to a decrease in calcaneal pitch angle which caused adverse events requiring revisional surgery.5
According to a systematic review on surgical interventions for midfoot CN by Shazadeh Safavi et al, the most common surgical procedures performed for midfoot CN were intramedullary medial column bolt fusion and multilevel external fixation, with mention of hardware failure as the most common postoperative complication.8 Further analyses in the same study revealed an estimated 6% rate of subsequent ipsilateral amputation included any below-the-knee or transtibial amputation; however, overall rate of revisional surgery for the included studies was not specified.8 Through a systematic review by Lee et al comparing clinical outcomes for internal fixation versus external fixation, Lee et al found a 20% increase in the need for unplanned further surgery for internal fixation related to deep infection and wound healing complications.9 For midfoot CN with concomitant osteomyelitis, Ramanujam et al found all studies included some degree of surgical debridement combined with 1 the following: (1) simple exostectomy, (2) arthrodesis with or without internal and/or external fixation, and (3) advanced soft tissue reconstruction including flaps.10 The authors determined revisional surgery was required in 17.9% of the patients.
Reasons for failed surgical reconstruction in CN have been most often associated with missing the correct diagnosis initially, mechanical failure of hardware, recurrent deformity with or without ulceration, lack of consideration to appropriately address the role of Achilles tendon lengthening, and soft tissue infection with or without concomitant osteomyelitis.11 Nearly all existing studies on midfoot CN indicate that successful treatment of the condition requires a highly individualized patient approach both for the index procedure(s) and in the cases of revisional surgery, taking into careful consideration the overall medical status of the patient, clinical presentation, medical imaging of the deformity with or without infection, and the functional expectations of the patient.
Indications and Contraindications
Indications for revisional surgery of midfoot CN include but are not limited to the presence of nonhealing ulcer(s), unstable and/or nonplantigrade residual midfoot deformities, unstable nonunion, malunion, hardware failure, and acute or chronic osteomyelitis recalcitrant to conservative treatment methods such as local wound care and antibiotic therapy. Contraindications for revisional surgery may include the presence of medical comorbidities that preclude optimization for surgical intervention, uncorrectable peripheral arterial disease, severe patient noncompliance, patient’s refusal of reoperation, and those cases in which a proximal amputation may be the best option for management.
A multidisciplinary team approach should be employed in cases of revisional surgery for midfoot CN since these patients frequently require medical optimization of multiple comorbidities prior to surgery. A thorough past medical history is critical to determine the reason(s) for the initial failed surgical reconstruction and to elucidate the best pathway for revisional surgical options. All past surgical interventions of the foot, including details regarding fixation placed, microbiology and pathology results for any soft tissue and/or bone cultures taken with antibiotic resistance patterns, and prior vascular interventions should be reviewed. Information regarding the patient’s compliance and psychosocial issues encountered during the previous surgery is also critical for appropriate patient selection in the revisional surgical reconstruction and subsequent perioperative planning.
A complete physical examination of the lower extremity including biomechanical analysis should be undertaken since failure to address residual equinus deformity may compromise the success of the revisional surgery by influencing peak plantar pressures and by placing stress on adjacent joints.11 Tendo-Achilles or gastrocnemius lengthening are options for those midfoot CN patients which reulcerate or have recurrent deformity following surgical reconstruction. Extended joint arthrodesis procedures produce correction of multiplane deformities to achieve stability while preventing recurrent deformity about the neuropathic foot and ankle.11 Options for internal fixation include traditional plating versus anatomic plates and intramedullary fixation such as axial screw fixation used for beaming the columns of the foot with or without locking plates.12 Wide osseous resection and shortening of the midfoot can be stabilized with bone grafting and application of multiplanar circular external fixation. Combined constructs using both internal and external fixation have also been described for midfoot CN.13
Utilization of nonbiodegradable antibiotic-impregnated cement beads and/or spacers is a surgical adjunct that has become useful for the treatment of midfoot CN with osteomyelitis in order to provide local delivery of antibiotics after surgical resection/debridement and before definitive reconstruction via arthrodesis and/or advanced soft tissue procedures using flaps.10 Other adjunctive procedures include the use of negative pressure wound therapy for preparation of wounds prior to definitive reconstruction and use of autogenous or allogenic skin grafts in the final stages of wound closure.
Detailed Surgical Description and Clinical Cases
One of the most common clinical case presentations with midfoot CN requiring revisional surgery includes reulceration or reinfection to the plantar lateral column of the foot with associated instability and deformity. Patients present with a history of prior multiple surgical debridements and plantar exostectomy of the cuboid and/or lateral column to address an open wound, osteomyelitis, or associated deformity. After a complete history and physical examination, medical optimization, and understanding of the proposed revisional reconstructive surgery, the patient is admitted to the hospital for 1 or staged revisional and reconstructive procedures (Figure 33.1). The initial procedure may include excision of the recurrent ulceration and debridement to prepare the wound for definitive soft tissue coverage. This stage is typically performed 3 to 7 days before the reconstructive procedure to limit the potential for postoperative infection. In the presence of concomitant osteomyelitis, the definitive procedure may be delayed based on the patient’s medical comorbidities, optimization, eradication of underlying infection, and wound characteristics (Figure 33.2).
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