The operative procedure begins with minimal excision of the previously excised ulcer. The calcaneocuboid joint and / or the bases of the fourth and fifth metatarsals are identified. Bone fragments and debris that aren't viable should be removed.
The operative procedure begins with minimal excision of the previously excised ulcer. The calcaneocuboid joint and / or the bases of the fourth and fifth metatarsals are identified. Bone fragments and debris that aren't viable should be removed.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
The operative procedure begins with minimal excision of the previously excised ulcer. The calcaneocuboid joint and / or the bases of the fourth and fifth metatarsals are identified. Bone fragments and debris that aren't viable should be removed.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
The procedure can be performed with the patient placed supine
on the operating table under either spinal or general anesthesia as indicated. The initial procedure includes excision of the primary ulcer and debridement to prepare the wound for soft tissue coverage. This stage is typically performed 3 to 5 days before the definitive procedure to limit the potential for postoperative infection. The operative procedure begins with minimal excision of the previously excised ulcer, including the surrounding skin, in a triangular fashion with the base positioned laterally to provide the recipient site for the medical plantar artery flap. At this point, the use of a handheld Doppler ultrasound device is used to identify and outline the three branches of the posterior tibial artery: the medial plantar artery, lateral plantar artery, and the calcaneal artery. The cutaneous portion of the flap is marked out over the nonweight-bearing aspect of the plantar medial foot. The pneumatic thigh tourniquet is then inflated if used in this procedure. The cutaneous portion of the flap that was previously identified and marked or traced is then incised and dissected to a depth that includes the layer of the plantar fascia. The cutaneous branch of the medial plantar artery is then identified between the abductor hallicus and flexor digitorum brevis. The flap is retracted from the wound by placing simple suture from the flap to the medial aspect of the foot. Next, dissection is carried down to the level of bone through the plantar lateral ulcer. The calcaneocuboid joint and/or the base of the fourth and fifth metatarsals at their articulation with the cuboid are identified. In many instances, the anatomy and architecture are distorted by osseous fragments secondary to the Charcot process. Bone fragments and debris that aren’t viable should be removed to prevent recurrent ulceration and infection. The calcaneocuboid joint and/or the bases of the fourth and fifth metatarsals are then resected from a plantar approach. The affected joint resection is performed, using a sagittal saw and/or osteotome, with a plantarly based wedge to elevate the sagittal plane arch of the collapsed lateral column. The resected joints are packed with allogenic bone graft, with or without platelet-rich plasma impregnation and the deformity is corrected and stabilized with 2-mm Steinman pins. Intraoperative image intensification can be used to ensure adequate correction and placement of the Steinman pins. The surgeon will determine if a cutaneous Achilles tendon lengthening is necessary. A percutaneous Achilles tendon lengthening is performed if the surgeon is unable to dorsiflex the foot at the ankle to neutral (for example, the lateral border of the foot is at a 90-degree angle relative to the long axis of the fibula with the knee extended and the calcaneus under the mechanical axis of the tibia. The tourniquet is deflated, and hemostasis is obtained. Once hemostasis has been achieved and viability of the flap is confirmed by the normal color of the skin, the medial plantar artery flap is rotated into the wound. The cutaneous portion of the flap is then sutured to the perimeter of the wound using a simple interrupted nonabsorbable suture. Deep sutures are kept to a minimum to lessen the incidence of infection; they can become a focus for colonization and produced an inflammatory response during degradation. This is also helps prevent necrosis of the wound edges secondary to venous congestion. The fascia overlying the donor defect is excised and covered with a split- thickness skin graft taken from the ipsilateral leg. A bolster-type dressing using sterile sponges soaked in saline and nonadhesive materials is then applied over the split- thickness skin graft. During the next phase of the procedure, the static prebuilt circular external fixation frame is positioned on the foot and lower extremity. Opened towels are stacked under the posterior leg and heel until the surgeon can place two finger breadths anterior and three finger breadths posterior between the frame and the leg. The towels can be removed after the foot and leg are suspended via the frontal plane wires in the frame. To avoid rotational offset, the frame should be positioned aligning the anterior crest of the tibia with the anterior tabs of the tibia rings. Laterally, the external fixator should be positioned approximately 1 cm from the plantar aspect of the calcaneal tuberosity and in parallel alignment with the foot that’s 90 degrees to the leg. Positioning should be maintained until the wires are tensioned to the frame. Frontal plane wires followed by oblique plane wires are then inserted into the calcaneus, proximal tibia and distal tibia. These wires are secured to the frame and tensioned via a mechanical tensioner in a standard manner. Half-pins may also be inserted by the surgeon on the tibia but aren’t usually recommended in patients with poor bone quality and peripheral dense neuropathy to lessen the incidence of stress fractures. Fine wires are then inserted into the midfoot distal to each arthrodesis site and fastened to the external fixator with raised two-or three hole posts, one or two holes proximal on the footplate. Compression across the desired arthrodesis sites is achieved through manual “Russian” tensioning of these prebent wires. Additional wires can be inserted, as needed, across the metatarsals to limit torque created about the forefoot. Wires can also be placed into the digits and attached to the external fixator to prevent digital contractures. Dressings are applied in a standard manner, ensuring access to the medial plantar artery flap for direct monitoring.
Staying a step ahead
Pedicle flaps are useful to close large defects of the foot. They allow the surgeon to replace lost skin with like skin in weightbearing areas of the foot. However, the use of pedicle flaps to close foot ulcers can be beneficial only if the underlying pathology is adequately treated. In the Charcot foot, deformity must be addressed first to ensure the success of a pedicle flap. Advances in external fixation devices have offered the option of correcting severe foot deformity through reduced surgical dissection, while simultaneously performing a pedicle flap for wound closure. The medial plantar artery flap is a well- vascularized mobile pedicle flap capable of closing plantar lateral ulcers. The authors believe that successful limb salvage of Charcot foot can be performed when reconstructive surgery incorporates adequate osseous correction and soft tissue management. Neither component can be overlooked when dealing with the diabetic Charcot foot. The techniques described offer a stepwise approach to salvage a diabetic Charcot foot. The use of a pedicle flap combined with a deformity correction technique for the diabetic Charcot foot represents an advanced concept based on sound, time-honored principles. It also provides a simple, reproducible, and cost-effective means useful in the surgical management of diabetic Charcot wounds involving patients with well- controlled medical comorbities.