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Orthopaedics
Exostectomy for Charcot Arthropathy
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
9 sections · 91 slides
Overview
- Scope of this presentation
Charcot arthropathy and bony prominences
- Definition of Charcot arthropathy
- Goal of Charcot foot treatment
- Role of exostectomy in the stable Charcot foot
- Principal concerns with exostectomy
- Regions affected by Charcot arthropathy
- Anatomy of the foot skeleton
- Origin of bony prominences in Charcot arthropathy
- Bone bridging and soft-tissue calcification
- Development of a Charcot plantar ulcer
- Clinical appearance of the collapsed Charcot foot
Staging and classification
- Two classification systems in common use
- Eichenholz stages of Charcot arthropathy
- Interpreting the Eichenholz stages
- Brodsky anatomic classification
- Brodsky types by region
Indications and contraindications
- Initial conservative management
- Long-term protection after stabilisation
- Management of an established ulcer
- Neuropathic plantar ulcer
- Indication one: stable, shoeable deformity with ulceration
- Indication two: unstable foot with osteomyelitis
- Imaging before surgery for suspected osteomyelitis
- Indication three: the medically high-risk patient
- Absolute contraindication to exostectomy
- Relative contraindications to exostectomy
- Decision path in the ulcerated Charcot foot
Preoperative evaluation
- History taking before exostectomy
- Assessing patient satisfaction and function
- Clinical examination of the Charcot foot
- Definition of instability
- The lateral plantar ulcer trap
- Evaluating suspected infection
- Vascular assessment of the limb
- Radiographic and CT assessment
- Choice of imaging for osteomyelitis
- Culture technique and antibiotic route
Surgical approaches
- Principles of incision planning
- Excising the ulcer with the exostosis
- Avoiding iatrogenic destabilisation
- Adjunctive Achilles tendon lengthening
- Achilles tendon and its insertion
- Forefoot involvement: the MTP joints
- Mechanism of forefoot ulceration
- Approach to the second to fourth metatarsals
- Authors' preference for forefoot ulcers
- Approach to the first and fifth metatarsals
- Midfoot prominences in Charcot arthropathy
- Other midfoot prominences
- Sites of midfoot prominence
- Technique for plantarmedial exostoses
- Plantar ulcer over a subluxed medial cuneiform
- Level of resection at the Chopart joint
- Reading the resection line
- Exostosis after midfoot fixation
- Prominence following previous fixation
- Technique for dorsal exostoses
- Technique for lateral exostoses
- Lateral column exostectomy from ulcer to healing
- Hindfoot involvement in Charcot arthropathy
- Mechanism of hindfoot ulceration
- Technique for hindfoot exostectomy
- Ankle involvement in Charcot arthropathy
- Mechanism of ankle ulceration
- Principles of exostectomy about the ankle
- Impingement and osteophytes around the ankle
- Regional approaches at a glance
Postoperative care
- Immediate postoperative management
- Weight-bearing progression
- Long-term footwear and rehabilitation
Outcomes
- State of the evidence
- Brodsky and Rouse series
- Catanzariti and colleagues series
- Rosenblum and colleagues series
- Laurinaviciene and colleagues series
- Reported healing rates across the series
- Medial versus lateral ulcer outcomes
Conclusion and key points
- Conclusions from the chapter
- Persisting difficulties and adjuncts
- Key points for revision
- References
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle