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Orthopaedics
Management of the Charcot Ankle
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
10 sections · 124 slides
Overview
- Scope of this topic
What a Charcot ankle is
- Injury to a neuropathic joint
- Ankle fracture in a neuropathic joint versus Charcot ankle
- Course of joint collapse
- From injury to joint destruction
- Reported incidence of spontaneous Charcot ankle
- The real difficulty in this patient group
- Nerve control of bone repair
- Selective loss of small fibre nerves
- Exaggerated inflammatory response
- Delayed bone formation and joint destruction
- Cellular cascade in Charcot arthropathy
How patients present
- Typical presenting complaint
- History features
- Examination findings
- Differential diagnosis of the swollen neuropathic ankle
- Assessing the likelihood of infection
- Severe deformity at presentation
- Weight bearing radiographs
- Timing the Charcot process from bone appearance
- Timeline read from the radiograph
- Presumptive diagnosis and immediate action
Overall goals of treatment
- Goal of treatment
- Cost of treatment to the patient
- Long-term care after fusion
- Three phases of care
- Baseline diabetic and nutrition labs
- Baseline vascular assessment
- Acting on the vascular findings
Nonoperative management
- Universal initial nonoperative treatment
- Total contact cast with condylar extension
- Strict continuous non-weight bearing
- Duration and patient counselling
- Practical support for non-weight bearing
- Selecting candidates for casting alone
- Fixed deformity as a problem for bracing
- Cast change schedule and soft tissue checks
- Soft tissue ulceration during casting
- Radiographic monitoring during casting
- Two phases of bony healing
- Transition to weight bearing in a cast
- Permanent bracing options
- Nonoperative treatment sequence
- Recognising failure of nonoperative treatment
Operative treatment
- Surgery as salvage
- Indications for surgical stabilisation
- Medical optimisation before surgery
- Two categories of surgical stabilisation
- Choosing between internal and external fixation
- What surgery does not change
- Fixation options in the literature
- Timing of surgical intervention
- Implant failure from ongoing bony resorption
- Proximal dynamization of the nail
- Fixation strategy over time
- Extent of the intended fusion
- Joint surface preparation and malleolar removal
Surgical technique
- Patient positioning on the table
- Bolster placement for exposure and reduction
- Lateral utility approach
- Exposure and fibular transection
- Preserving the distal fibula
- Preparation of the fusion surfaces
- Indications for a medial approach
- Two cuts in the medial malleolus
- Consequences of sectioning the medial malleolus
- Reaming for the retrograde nail
- Consequences of inadequate reaming
- Foot position as the key to success
- Fluoroscopic checks of foot position
- Reshaping the plafond for calcaneal contact
- Screw fixation of the nail
- Static versus dynamic proximal hole
- Supplemental screw fixation
- Purpose of the supplemental screws
- Bone graft from resected bone
- Fibular strut fixation
- Sequence of the operation
Postoperative care
- Immediate immobilisation after surgery
- Postoperative non-weight bearing and casting
- Cast change and radiograph schedule
- Weight bearing trial after surgery
- Transition to permanent bracing
- Criteria for coming out of the brace
- Caution after brace clearance
- Postoperative timeline
Complications and salvage
- Four major complications
- Failure of consolidation with casting
- Failure of stabilisation after surgery
- Bone stimulation and combined fixation
- Salvage after failed internal fixation
- Salvage pathway after failed fixation
- Soft tissue breakdown in the casted patient
- Management of skin breakdown
- Wound healing in the diabetic patient
- Effect of local hypoxia on healing
- Cascade from hyperglycaemia to wound failure
- Risk factors for infection
- Limits of radiographs in detecting infection
- Combined bone and labelled white cell scan
- Treatment of suspected deep infection
- Amputation as a decision point in infection
- Recurrence of the Charcot process
- Recurrence in the surgically stabilised patient
- Response to recurrence
- The vicious cycle of the neuropathic limb
Summary
- Requirements for successful management
- Definition of treatment success
- Key points to remember
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle