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Orthopaedics
Use of External Fixation for the Management of the Diabetic Foot and Ankle
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
14 sections · 152 slides
Overview
- Scope of this topic
- Sections covered
Charcot arthropathy of the foot and ankle
- Charcot arthropathy in peripheral neuropathy
- Consequences of untreated collapse
- Clinical assessment at first contact
- Eichenholtz staging of Charcot arthropathy
- Eichenholtz stages as a sequence
- Nonoperative treatment and its costs
- Barriers to maintaining non-weightbearing
- Deformity despite early treatment
- Anatomic classification of Charcot deformity
- Collapsed neuropathic foot with plantar ulceration
- Ulceration in midfoot Charcot deformity
- Medial column collapse and plantar medial ulcers
- Lateral column disruption and rocker bottom deformity
- Rocker bottom deformity, step by step
- Plantar neuropathic ulcer under the forefoot
- Hindfoot and ankle Charcot
- Threshold for surgical intervention
Indications and preoperative planning
- Primary goal of surgery
- Indications for surgery
- Difficulties in selecting candidates
- Psychosocial assessment and consent
- History and physical examination
- Radiographic evaluation of the deformity
- Full-length limb alignment radiographs
- Cross-sectional imaging and CORA planning
- Supplementary imaging and laboratory tests
- Preoperative work-up sequence
Surgical strategy and soft tissue care
- Traditional open wedge resection
- Minimally invasive gradual distraction
- Open resection versus gradual correction
- Respect for the soft tissue envelope
- Preoperative reassessment of the foot
- Goals of conservative management
- Surgical technique for soft tissue handling
- Inpatient management of postoperative oedema
Equinus correction
- Timing and rationale for equinus correction
- Tendo-Achilles lengthening and the Silfverskiold test
- Gastrosoleal recession over Hoke tenotomy
- Gastrocnemius recession and frame-based correction
- Taylor Spatial Frame for gradual equinus correction
- Options for equinus correction
External fixation: advantages and disadvantages
- Circular external fixator on the lower limb
- Advantages of external fixation
- Weightbearing and wound access with a frame
- Advantages of external fixation, grouped
- Disadvantages of external fixation
- Severity of complications with frames
Construction of a stable external fixation frame
- Host factors that challenge frame stability
- The ring fixation block
- Span of the ring fixation block
- Extra points of fixation in neuropathic bone
- Ring selection and sizing
- Ring materials preferred by the authors
- Extent of tibial fixation
- The foot block or bumper
- Wire choices in the neuropathic foot
- Frame construction principles
- Applied ring frame seen from the front
- Applied ring frame seen from the side
- Mounting the foot ring block
- Safe placement and tension of calcaneal wires
- Midfoot and talar wire placement
- Fluoroscopic control of wire position
- Wire tensions used by the authors
- Connections between tibial and foot blocks
- Pin site care after surgery
- Managing crusting and protecting the frame
Rehabilitation and follow-up
- Role of the patient's support network
- Duration of frame treatment and weightbearing
- Bracing after frame removal
- Postoperative timeline
Management of specific arthropathies
- Static ring fixation in acute Charcot
- Advantages of frame application in stage 1
- Cautions in stage 1 frame application
- Mobile versus nonmobile Charcot joints
- Factors that impair healing
- Acute correction by wedge resection
- Choice of incision
- Performing the biplanar wedge resection
- Bone graft and provisional fixation
- Frame construction for acute midfoot correction
- Bent wire tension technique
- Bent wire technique, step by step
- Metatarsal wires and residual deformity
- Midfoot Charcot deformity before and after frame application
- Reading the preoperative films
- Gradual correction and final fusion of the midfoot
- What the corrected films show
Gradual midfoot correction with external fixation
- The two-stage percutaneous approach
- Advantages of the two-stage approach
- Ligamentotaxis in the first stage
- Osteotomy before gradual correction
- The Taylor Spatial Frame butt construct
- Reference ring selection and mounting sequence
- Postoperative radiographs and computer planning
- Distraction schedule in the first stage
- Gradual distraction of a midfoot Charcot dislocation
- Course of the gradual distraction case
- Temporary transarticular pin after Achilles lengthening
- Minimally invasive arthrodesis in the second stage
- Stabilisation options after joint preparation
- Intramedullary foot fixation technique
- Screw selection and configuration
- Immobilisation after intramedullary fixation
- Advantages of frame plus intramedullary fixation
- Arthrodesis using external fixation alone
- Two routes after gradual distraction
Acute hindfoot and ankle correction
- Indications for frame use in the hindfoot
- Drawbacks of internal fixation in the hindfoot
- Rationale for frame compression in the hindfoot
- Surgical approach for hindfoot fusion
- Frame construct for hindfoot fusion
- Sequence of compression in tibiotalocalcaneal fusion
- Mechanism of subtalar compression
- Compression sequence in tibiotalocalcaneal fusion
- Wire configuration for tibial calcaneal fusion
- Duration and aftercare of hindfoot fusion
- Long-term bracing after hindfoot fusion
- Calcaneal tibial fusion for unstable peritalar Charcot deformity
- Outcome of the calcaneal tibial fusion case
- Reinforced tibial and foot blocks in the applied frame
Problems, obstacles and complications
- Purpose of the classification
- Range of adverse results in frame treatment
- Definitions of problem, obstacle and complication
- Classification of adverse results
- Minor and major complications
- Recurrent equinus after reconstruction
- Function despite recurrent midfoot collapse
Conclusion
- Principles for successful frame treatment
- Training required before using external fixation
- Minimising complication rates
- Determinants of a successful outcome
- Key points
References
- References
- References (continued)
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle