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Orthopaedics
Plate Fixation Techniques for Midfoot and Forefoot Charcot Arthropathy
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
11 sections · 128 slides
Overview
- Scope of this topic
The disease and why it needs surgery
- Definition of Charcot arthropathy
- Factors required for neuropathic arthropathy
- Mechanism of progressive destruction
- Consequences of untreated disease
- Clinical presentation
- Distribution of Charcot changes within the foot
- Midfoot versus forefoot involvement
- Goals of treatment
- Conservative management and its limits
- Reported outcomes of nonoperative intervention
- Rationale for surgical fixation
Classification of the deformity
- Eichenholtz staging
- Radiographic features by Eichenholtz stage
- Timing of surgery relative to the active stage
- Anatomic classification of affected regions
- Midtarsal deformity patterns on anteroposterior and lateral views
- The Schon midfoot classification
- Clinical stages of midfoot deformity
- Rocker-bottom deformity
- Radiographic types I and II
- Radiographic types III and IV
- Alpha and beta subdivision
- Radiographic criteria defining the beta stage
- Prognostic meaning of the alpha stage
Deciding on plate fixation
- Factors determining treatment
- Typical surgical candidates
- Limitations of the current evidence base
- The superconstruct concept
- The four factors of the superconstruct model
- Indications for plate fixation
- Reduction and fixation versus arthrodesis
- Absolute contraindications to plate fixation
- Relative contraindications to plate fixation
- Bone quality as a limiting factor
Hierarchy of fixation
- Principle of the fixation hierarchy
- Hierarchy of fixation from weakest to strongest
- Why dorsal plating alone fails
- Tension and compression sides of the midfoot
- Minimum acceptable fixation
- Biomechanical comparison of crossed screws and dorsomedial plating
- The ideal construct
- Biomechanical evidence for plantar plating
- Disadvantages of plantar plating
- Dorsal versus plantar plate position
Surgical management of the midfoot
- Bone quality and implant selection
- Advantages of locking plate constructs
- Limitations of locking plates
- Choosing between anatomic reduction and wedge resection
- Indications for anatomic reduction
- Clinical results of reduction and fusion
- Results of primary arthrodesis in Eichenholtz Stage I
- Indications for wedge resection
- Effects of the bony resection
- Principles guiding the surgical approach
Medial column fixation
- Rationale for the medial incision
- Placement of the medial incision
- Exposure of the abductor hallucis muscle
- Reflection of the abductor hallucis
- Creating the capsular periosteal flap
- Tendon structures to protect
- Assessing intraoperative mobility
- Subluxation of the first and second metatarsocuneiform joints
- Stress radiograph showing midfoot instability
- Reduction of the medial cuneiform
- Compression before fixation
- Provisional guidewire placement
- Screw placement across the prepared joints
- Screw construct across the medial cuneiform, first metatarsal and navicular
- Supplementary plate fixation of the medial column
- Steps of medial column anatomic reduction
- Radiographic findings when anatomic reduction is not possible
- Tarsometatarsal dissociation with dorsal subluxation of the lateral rays
- Planning the wedge with Kirschner wires
- Siting the resected wedge
- Amount of bone to resect
- Orientation of the two guide wires
- Protecting soft tissues during the osteotomy
- Completing the wedge resection
- Reduction of the lateral rays
- Lateral guidewire and screw placement
- Holding the medial column after wedge closure
- Final plate application after wedge resection
Lateral column fixation
- Anatomy of the lateral column
- Concerns with lateral column arthrodesis
- Indications for lateral midfoot arthrodesis
- Outcomes of lateral midfoot arthrodesis
- Choice of fixation on the lateral column
- The dorsolateral approach
- Protection of the sural nerve
- Reduction manoeuvre for the lateral joints
- Joint preparation on the lateral column
Closure, releases and postoperative care
- Wound closure technique
- Gastrocnemius recession and tendo-Achilles lengthening
- Early postoperative protocol
- Progression of weightbearing
Complications and salvage
- Major complications of midfoot and forefoot reconstruction
- Prevention of nonunion and hardware failure
- Revision of failed plate fixation
- Revision technique in nonunion
- Supplementary and alternative fixation
- Role of external fixation
- Stress transfer to adjacent joints
- Management of adjacent joint Charcot progression
- Risk to the contralateral limb
- Preoperative and postoperative wound infection
- Management of infection without bony involvement
- Management of deep infection and osteomyelitis
- Management of ulceration over a bony prominence
- Symptomatic hardware after midfoot reconstruction
Summary
- Key principles of plate fixation in Charcot midfoot
- Key operative and aftercare points
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle