On behalf of AOFAS, I want to welcome you to the sixth webinar of the 2021 Foot and Ankle Focus Series. Tonight's program, Chakra Neuropathy, Complications of Surgical Management, will be moderated by Dr. Vinod Punjabi. Dr. Punjabi will be joined by Drs. Jessie Doty, Richard Laughlin, Celine Parekh, and Philip Kaiser. You can find their full biographies and disclosures in the program document posted in the chat box and on the PRC. The 2021 webinars are provided free to AOFAS members and orthopedic residence fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from Arthrex Inc. and Stryker. I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, we suggest starting with the Help tab to troubleshoot your problem. If you continue to have issues, try closing all your browsers and logging back in the way you did the first time. Registered physician attendees may earn one hour of AMA, PRA, Category 1, CME credit by completing an evaluation and CME claim form at the end of the webinar. You will be able to find the link to Claim CME in the chat tab, and we will also follow up with an email at the conclusion of this broadcast. This webinar is being recorded and will be available for on-demand viewing on the Physician's Resource Center at www.aofas.org slash PRC in approximately one week. We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab on your navigation column. I will now turn the program over to the moderator, Dr. Punjabi, to begin. Thank you. Thank you, Jennifer. I want to start off by thanking the Education Committee and the AOFAS for this opportunity. I want to thank the panelists for taking time for this evening to deliberate in this webinar. I want to also thank the attendees who have logged in now and will log in later in advance for their participation. I want to encourage them to ask questions, interact, use this Q&A box. We would really like to have their feedback, their comments. Let us know what we did right, what we could do to improve. Your feedback is always going to be helpful for us. I'm going to introduce my co-panelists here, Jesse Daugherty, he's Associate Professor at the University of Tennessee College of Medicine. And we also have Dr. Philip Kaiser, Foot and Ankle Orthopedic Surgeon, Instructor of Orthopedic Surgery, Harvard Medical School. We have Richard Laughlin, Professor, Department of Orthopedic Surgery, University of Cincinnati. Salim Parekh sent his apologies, he got stuck because of a delay in his flight. So he may or may not join us, I hope he can. So this webinar is on Charcot Neuroarthropathy and we are mainly focusing on the complications. This will be a case-based interactive session. So again, I want to encourage the attendees to ask questions throughout the session and we'll monitor the Q&A box here and then hopefully address those questions. The objectives of this webinar is to, like I said, focus on complications of surgical management. So we'll describe, we'll attempt to describe how complications are defined and try to deliberate on why complications occur and how can we avoid and if they occur, how can we manage these complications and hopefully go through some current trends in management. Like I said, it will be a case-based approach and the faculty who we have here have kindly gave their cases and we put them into presentation. So what I'm going to be doing is start the case and then as I present the cases, I will ask our esteemed faculty to chip in, give their thoughts and folks who are listening in can also provide their comments in the Q&A section. So here is the first case. As you can see, it's a patient with ulcer on the medial laminates with the A1C 8.2. And I know who submitted this case, but I'm going to ask the panelists to weigh in. It's obviously a diabetic patient with severe deformity in the forefoot and in the midfoot on AP weight-bearing radiograph and also lateral radiograph. So why don't we start off with Richard. Rick, what are your initial thoughts? This patient is diabetic, has ulcer on the medial laminates over the bunion deformity. And this presented to your practice and then I'll ask Phil later. So why don't we start off with you, Rick? I think just based on the subject of the webinar tonight, I think we'll skip all the non-operative things. But obviously you're going to treat the wound, try and get it to heal first. I think for me, internal fixation when you have an open wound, I try and avoid that. So on this, I might excise the wound, debride it and then straighten the first toe out and then just pin it with K-wires or Steinman pins until you get the wound to heal. And then go back in and do internal fixation after the wound's healed. You wouldn't do any osteotomy at this stage or fusion at this stage? Well, I think if the ulcer communicates with the joint, I would take down all the cartilage and then just pin it. Yeah. Okay. That's a good option. What about Phil? Do you agree with this or do you want to try something different? I think that's totally reasonable for a medial eminence ulcer, bony debridement, cleaning of the ulcer. And then it's a question of whether the medial eminence is part of the larger deformity. It looks in this case, she just has a severe bunion deformity on top of metatarsus adductus. And if the medial eminence is the only problem and her plantar foot's okay, I think you could just address the first ray issues because it's a pretty complex deformity through the midfoot and might deal with that problem first before making more surgery and further correcting the midfoot. Would you address the midfoot and forefoot together? I think if the problem right now is her medial eminence and the severe bunion deformity, I would address that alone and try for, you know, cure of infection and bony resection. And then I think you could jump to more internal fixation down the road if you had her ulcer healed and non-infected and then address the midfoot if you needed to. Okay. I mean, there are obviously a variety of ways to address this. I'm not going to ask Jesse because this is his case and, you know, obviously he put these variety of options, you know, and well, this is what was done. Jesse, why don't you comment on this and what you're thinking? No, I think, you know, I agree with both guys. I agree with Rich and Phillip. I think it's hard without the full story. So this is someone that originally I did non-op and then the ulcer was something that I kind of anticipated and was superficial, probably a grade one ulcer from his footwear. And so 100%, I think pinning the toes straight and decompressing the skin is probably the safest and most conservative thing followed by internal fixation. In this scenario, just based on the superficial outside in nature of the ulcer, I was able to perform an acute correction and get away with it. And to Phillip's point, at the time there was really no instability that I could appreciate that was overly exaggerated that would necessitate a midfoot reconstruction. At that point, I felt like the forefoot was a salvage procedure that may or may not end up with a partial forefoot amputation. And I felt like the midfoot was more of a quality of life procedure and so I chose to ignore it. Okay. Now, you know, having made the forefoot slightly rigid, do we anticipate any problems, Phil, in the midfoot or up the chain? I don't think specifically just from the first MTP fusion, I think that's a great way to solve the medial ulcer. You know, it looks, the comparison radiographed before with the MTP fusion, the midfoot looks about the same. She's got a prominence breakdown of the midfoot and the long standing deformity there. So not unexpected that without, you know, sufficient offloading that she could develop an ulcer in that area over time. Okay. You know, I mean, if this patient was not diabetic, you know, one would be hesitant to put in that much of a hardware in the great toe with an ulcer in vicinity, right? But you know, time and again, this hardware, you see, I mean, you know, patients with diabetes and Charcot neuroarthropathy tend to behave slightly differently. I think, you know, I've seen, we can certainly get away with hardware time and again, but you will see what has happened next to this particular patient, you know. So what happened, Jesse? So why did you have to do this? Yeah. So go, if you want to go back one slide. So I got away, you know, I got away with the first surgery, right or wrong. We got a couple of years and came back and again, start at this point, the forefoot was doing okay. And he started to develop thick callus formation under the plantar aspect of the foot. And at that point, it was non-infected. And so I ended up, this is probably not what I would choose to do now, but going through the library, trying to find good cases where I can show you what not to do. So I felt like I could surpass the zone of dissolution with a plate. I think maybe one of the advantages of a plate is you're able to capture a particulated bone a little bit better. Of course, you've got that metal burden that's more superficial, which I think is probably more problematic than an intercalary or intramedullary beaming screw. You know, at the time, I think I was probably thinking less surface area at the fusion site. It's going to be sacrificed if I use a plate. And honestly, I think this was probably done in 2014 or 15 and beaming became popular in probably 2013 to 16. So I didn't have a lot of experience. And so I thought I was being smart and putting a plate on the tension band side of the osteotomy and reconstruction. Rick, would you do anything different? No, I like the concept of a tension band plate on the plantar surface. You can usually get it covered fairly well. I think the other point that is important to think of is when you think of the timing of the surgery, this patient's probably pretty far along in the Charcot process. So I think you have to be really careful if you do this early on when they're in more of the inflammatory or fragmentation stage, because that's when you really need the long fixation. But at this point, it looks like, you know, they're probably past all that and in the remodeling phase. And so you're kind of essentially doing an osteotomy through the through the midfoot. Phil, would you go for a beaming for this case or would you go for plantar plating? What is your current strategy? Just, you know, my training has been a little more recent. And, you know, what we learned was the beaming techniques in these super construct and, you know, some of the people I worked with in North Carolina and Carol Jones have kind of written up about this recently. And, you know, adequate midfoot resection, you know, medial column, either beam or nail of your choice, and then something up the lateral column. And then there's the, you know, the concept of even though the subtalar joint's not involved, just to kind of make a super construct, whether we involve that or not. That's an area of ongoing study and research, but kind of making this super type tripod construct for these midfoot deformity correction cases. I have a question for you guys. Now, you know, if the problem is in the metatarsal cuneiform articulation, are you guys preparing the navicular cuneiform joint, talonavicular joint, in the sense that you're removing all the cartilage or is just extending the fixation? Rick, what is your practice? I think if I'm going to cross the joint, I would try and prepare the joint to try and get it to fuse. I have done that before where you don't prepare the joint and the hardware eventually fails. Now, most times you've corrected their deformity enough to where you can get them in a brace, but I think if you don't take down the joint, the hardware will eventually fail. Okay. What about Jesse? Are you preparing those joints? Yeah. I mean, I think Rich is right. I agree. I think that's the, if you can safely, I think you have to look at it on a case by case basis, which we all do because none of these cases are the same, and if you can safely debride the joint, then that'd probably be the preference, particularly at the talonavicular joint. If it's going to require a larger incision or it's going to alter your osteotomy in some way to cross the TMT or the naviculokineiform without formally preparing that joint, then I think you can justify doing that based on other factors that contribute to the case. Phil, any other thoughts? Do you prepare those joints or do you not prepare or have had them? No, medial column, I'll prepare all three joints if I'm putting up a beam or a nail, including the TN joint, which may be normal, but adds to the fixation, I think adds to the construct. So in most cases, I'm preparing that kind of through a direct medial incision, I take down tibialis anterior, I'll repair it at the end, but that's usually my choice for these. Okay. All right, so let's see what you've done later on. So that failed, now what? Yeah, so he made it a year and I made it another year and a half and, you know, he's, you can call it a failure, Binod, because you're the moderator, but he doesn't have an ulcer. Yeah, this is where we can talk about complication, you know, how do you define a complication? I know this was not a diabetic guy, you know, obviously he will have a mid foot pain and, you know, a bent screw, you know, and he still has arthritis and all that, but a diabetic person doesn't have any pain, blessing or not, but, you know, why would you call this a failure? Now, if there's no ulceration, he's got a plantigrade foot, would you call this a failure? Yeah, I mean, it's certainly not what I set out to accomplish and again, you know, you're looking to get the patient and, you know, if you can get them in commercially available therapeutic footwear, then I think that's a, you could probably argue that that's a level of success, but I do agree and I'll let the other panel discuss, certainly I did not accomplish what I originally had set out to do. We'll talk a little bit more about, you know, how we define complications in different settings. So this is another case of yours, Jesse, why don't you take it further from here? This is a 56 year old, surprisingly his A1C is 6.2 and they're usually above 10 in my practice. He has no ulceration and I'll open it up to you guys of how you would manage this. Rick, I mean, if there's no ulceration, could this be managed conservatively or do you, you know, how do you decide when to operate? I'm going to see if there's any AP x-ray. Okay. Those are AP x-rays and lateral x-rays. And how do you decide when to, you know, surgically intervene or not or continue with conservative management? I guess for me, my two indications for a Charcot foot is either an impending ulceration or an ulcerations that you've gotten healed and then you want to take care of the deformity. So you don't get a recurrent ulceration or some of the people will actually have pain. So pain can be an indication as well. If you have neither of those, then I usually try and brace them. Let me see. There is a question in the chat box by Dr. Rajeev Shah, he's a past president of the Indian Foot and Ankle Society, a great surgeon from India. He's wondering whether you guys add plate to a beaming screw to provide rotational stability. I've done about everything and, you know, I've had some things work and some things, you know, fail. I think it's not very predictable and you can see in this scenario, I added a frame to a beaming screw. And typically, you know, we've had some success with that with intramedullary nailing the ankle and hind foot for unstable Charcot when you get mechanical axis deviation. My thought in this case at the time, there was an ulcer. So I originally tried to treat that patient non-operative with bracing. At six months, he started to develop an ulcer under the lateral column, under the cuboid. And, you know, I think Charlie Saltzman published nearly a 30% amputation rate once there's an ulcer present, particularly the lateral column ulcers are predictive of secondary operations. And so trying to be slick here and be a hero, I thought, well, I'll be really smart. I'll do what all the smart guys are doing now. I'll beam the medial column. I can stay remote to the ulcer and really push the limitations of internal fixation if I'm not near the infection. And then just like we do with frames and the hind foot and the ankle, maybe try to keep my wires away from my internal fixation to the best of my ability and stabilize the lateral column and protect the patient from non-compliance by putting a frame on. So you're stabilizing the lateral column with the frame rather than. Yeah, yeah. I mean, I really was. I guess that's what I was thinking. I don't know, man. That was four years ago, you know. I could have done a better job because you can look at my next x-ray. No, with Charco, every case is a teacher for me. You know, every case is, you know, gives me a different experience. Honestly, you know, there is so much to learn. I say, you know, this is why it's so exciting about this. So yeah, I mean, you know, looking at it, it just looks like the midfoot looks great. But, you know, do you think there is a forefoot supination down there or is it just where the patient is? I don't think he has his foot all the way down here. And I mean, I released the Achilles completely on all these. It's either that or he's still got some residual Aquinas. But honestly, at this point, I was probably patting myself on the back feeling pretty good. Yeah, why not? What's happened now, Jesse? I don't know. I always think about that disappearing shoulder thing we used to study in residency when I see these x-rays and it's just, you know, there's no open wound at this point, complete dissolution of the bone. I love to hear, Phillip and Richard, what do you guys do now? You know? Yeah, you know, tough case, Jesse. Any signs of infection either like clinically or, you know, on inflammatory markers or anything? Yeah, I didn't. Clinically, he didn't look infected and I didn't go searching, honestly. You know, at this point, if he's getting kind of, you know, breakdown or instability, which he looks he's kind of falling apart there, probably take out the beam or bolt or whatever you got in there and, you know, try to do it again in a frame. But that's a long, long process. And at this point, if he's kind of losing his tail, it looks like he's lost at least the tail or head or neck. I think you kind of opt to go for a TTC at this point. Yeah, you know, the thing is, this happens. It's like just tumors. Sometimes the tumors are so aggressive and sometimes they're not aggressive. Same thing, I think, happens with Charcot. Some of the Charcot patients have a very aggressive course. And then within your eye, in front of your eyes, the bones disappear. And then this looks like as if there's an amputation happening between the midfoot and the hind foot. There's no bone there. I've come across those things, you know, but yeah, it looks like a very active, aggressive inflammatory process going down there. And do you think it is because you have a rigid midfoot? Yeah, I don't know what I mean. I've had the super, you know, to Phillip's point about fusing the subtalar joint, which I'm not sure. I know a lot of people like to say that's a good idea. I haven't been convinced 100 percent, but back to Phillip's point, you know, you make the whole foot rigid, the subtalar joint, talonavicular joint, and a midfoot and forefoot. And still yet, you see some of these people where you have success at three or four years. So I don't know if it's the rigidity that's the problem or if it's just the ongoing lack of biology and the Charcot neuroarthropathy process with the resorption and vascular changes. All right. And it looks like there is some consolidation. We just waited on this? Yeah, yeah. So I probably should have gone with Phillip's advice. You know, if I operate on these people, you know, more than once every three or four months, I start to become more depressed than I already am. And so I chose just to ignore the last x-ray and put him in a boot and brace. And here he is probably four months later. All right. So, you know, I'm going to show some couple of my cases, you know, where, you know, I don't know whether it's because of the beam, because it's a long lever arm we're having a problem or not, you see. So this is a case I'd done some years ago. You know, obviously, you can see there is a Charcot process between the base of the metatarsals and the cuneiforms. And I thought I did very well after, you know, seeing a nice little fusion down there. So at this stage, I have a question for you guys. Should we proactively remove these screws, these long screws? Do you foresee a problem of this long metal screws, you know? Obviously, there's still some motion at the talonavicular junction and the calcunicuboid junction and the subtalar joint. Is this metal causing any further distraction? Or is it providing a stimulus for the Charcot process? We don't know. But do you think there is a, we can provide, we can prevent problems by removing the hardware once we achieved our aim of getting union and correction of deformity or stabilization of the deformity in the midfoot? I don't ever take out the hardware. You don't take out the hardware? Not unless there's some problem with it or if it becomes prominent, but I tend to leave it in. Have you seen patients go with disruption? Is it with the, you know, look at the proximal end of the screw. Will it have a windshield wiper effect? Or will it? What did I say? Did you take down the talonavicular joint? I did not. I mean, you know, should we routinely, I mean, do you want to have an entire medial ray fused? Is that our aim? Should we do that? I don't know. I mean, you know, honestly, these are the questions which I would love to know the answers. You know, I myself don't know. I mean, I started removing some of the hardware when I see initial resorption in the bone. You see, I will show you why. You know, I waited and waited and this guy has lost his neck of the talus now. I don't know whether it's because it's the long screw, which is doing a windshield wiper effect. I don't know because we are increasing the rigidity by having a long stainless steel screw there. You know, I don't know. I mean, you know, this and who obviously. You know, I think Vinod, he, but you could, the other flip side of that argument would be he could have already progressed and collapsed more through the TN joint if you had not have had that screw there. I have had some success with, for instance, just doing shorter bridge plating on a good candidate, meaning a decently controlled, well-educated diabetic where you can bridge just the zone of dissolution, maybe the naviculo cuneiform metatarsal joints, and then go back and remove the hardware to your point. But I think there's a lot of validity to what Richard said in a salvage case like this. You know, you're trying to go back and violate the integrity of the skin envelope as few times as possible. And so leaving the metal for me is always my preference. Yeah, I mean, you know, this is something new for us. This is another place where I see a bent screw. It's another case, by the way, you know, and then he came back with a whole ankle, you know, showing the sarco process. It's like, you know, the disease spreads from one joint to the other joint. You know, so I don't know whether making a section of the foot very rigid increases the stresses more proximally and causes to more destruction. We have seen this happen. I've seen this. You guys have seen this. I think because these people are surviving longer. I think I've been in this now for almost 30 years, and I can remember writing a case report, you know, more than 20 years ago. And one of the reviewers said, you know, once you get a sarco process in one joint level, for instance, the midfoot and that heals, you don't ever see it again. It doesn't go to any of the other joints. But I think patients are surviving a lot longer. And you do see it just like this. And these feet, I think one of the problems when you fuse the midfoot, somehow the foot wants to collapse. I mean, that subtalar joint wants to go into valgus. And that brings up the question on whether you should be doing something with the subtalar joint when you fuse your midfoot just to stabilize it. Yeah, those are, you know, questions to be answered. So he went to, I'm going to show you another case here. You know, obviously, this patient is in a wheelchair. And you can see this is the metatarsal head. She has been around in wound care centers. She has expensive grafts put on, regranics, and all sorts of things. But that's the metatarsal head, and the joint is exposed. And then this is what she has in the midfoot with a dorsal bunion kind of thing. So we saw Jesse's case, which was a medial exposed bone with a Alex valgus deformity or a bunion deformity. This is a dorsal bunion with the head exposed. Now, Phil, what are your initial thoughts about this case? I think, obviously, with the exposed ulcer and exposed bone, presumed osteomyelitis, you know, aggressive debriement, bony debriement, you know, you can think of doing something like a Keller arthroplasty for the great toe. And it's a discussion, you know, how much of that midfoot deformity is contributing to this dorsal bunion. And if you want to tackle that at the same time, you know, with that amount of ulceration and presumed infection, I'd definitely shy away from internal fixation if you're going to reconstruct the midfoot at the same time. So that kind of obligates her to the frame course and bony resection of the midfoot correction to deforming and application of frame. Or you can just do an aggressive bony debridement and probably get that wound to heal. The problem is you haven't really corrected the underlying deformity that's led to that in the first place. Rick, what are your thoughts? Similar, I just debrided the bone back to where you can get a healthy wound bed and then again, maybe stabilize the toe with K wires or Steinman pins and then get the wound to heal and worry about the rest after you get the wound to heal. Jesse, your thoughts? Yeah, same as Rich. I just shorten it and primarily close it and put some vancomycin powder and wash it out really well with some Iricept or try to eradicate the infection. I think I did something of each of those three different views which you guys mentioned. So Jesse, you mentioned you could use shorter screws or shorter internal fixation. I got that. I debrided the bone. So I know, like I said, in the first case when we had a plate on the big toe, I don't mind putting hardware though in presence of a ulcer which is not like a cellulitic. So there's no active infection going on in there. So in my experience, the Charcot patients do behave slightly differently. So what I did, I went into the midfoot. I wanted to correct the midfoot to get the correction of the dorsal bunion because as long as the first ray is elevated, there's no way the ulcer is gonna get decompressed. That there's gonna be a bony pressure all the time. So I needed to plantar flex the first ray. So I went ahead and got that done. And like, I didn't want to use long screws here. See, obviously the first metatarsal head was exposed. I couldn't put a beaming screw even if I wanted to. So I went for the short fat screws and what I like to call is rafting instead of beaming. So I'm kind of supporting and fixing that short segment of instability. So I'm kind of shying away a little bit from using a very long super construct, to be honest, just because of these kinds of things, because you see they can probably provide too much rigidity. So I got that, this is intraoperative. See, I'm short and it got ulcer degraded. And I put this K wire. I didn't want to lose the great toe because great toe, as you know, guys, it provides some stability to the foot. And I threw a frame on top of that to stabilize the whole thing. Fix both lateral and middle columns. And the wound, you know, this is the wound here. And then those are the wounds for the midfoot approach. And this is something I want to spend a couple of seconds here. And what I tend to do is I pass these threaded rods all the way from the bottom most ring to the leg rings. You see, so this foot is kind of a cradle, what I call as a foot cradle. So, you know, the forces from the bottom most ring are transmitted to the tibial rings. The foot is as if it is floating in a cradle. And this works actually. So the foot, the construct which you have in the foot is completely protected and it went on to heal. But, you know, obviously every, you know, this is what I was trying to say. The complication here is for me, the half-pin, breaking of the half-pin. You guys use half-pins or smooth wires in the tibia? I try to stay away from the half-pins because I've not only had the pins break, but I've had the tibia break a couple of times through holes. So I usually will span the entire tibia. Like you have a ring about where that first half-pin is. And then I'd put a ring up closer to the knee and then put, you know, a couple of wires up on that ring too. Phil, what is your practice? Do you use the- I usually do three rings on the tibia, all with thin wires, tensioned. Anything different, Jesse? Yeah, I'll use two rings. And if I use half-pins, I'd just say, make sure they're in the confinements of the frame. You don't want to put a half-pin above your highest ring. Yeah, so I see, I mean, I have moved on from half-pins to smooth wires. I, you know, I think maybe here the complication was because the forces were entirely transmitted to the tibial rings, but certainly protected the foot, you see? So I got the objective. So do you want to call it? It is probably a complication in a purest sense, but, you know, those half-pins don't bother her. But I certainly want to avoid that and I started using half-pins, I mean, smooth wires. So this was some time ago, you know, and she did well. You know, again, you know, in my mind, I don't know whether we should, we could leave these screws or these tips of the screws would cause any problems, you know, but luckily this particular patient, she was okay. You know, she was not able to walk and she's able to walk very well with the cane. So, but you can see some erosion occurring at the tips of these screws, you see? So that bothers me, honestly, you know, should we really, you know, after we achieve our stability in the midfoot, I don't know, to be honest, the question, in my mind, you know, at this stage, I'm thinking, you know, what good am I doing leaving these screws? I got the union there where I wanted to. It's not going to collapse, but leaving these screws, am I, you know, putting the tail or head into some kind of danger? I don't know. I really don't know. Anyway. So- So do you brace those people long-term? After I achieve, yeah. I mean, this was like a nine-month course and after I removed the frame, I put them in a cast, yes, at least for three months until they are sick of the cast, you know, and then, you know, sometimes I put them in a crow walker too, if they are agreeable. But these part of, some of these patients don't listen to you at all. They want to get into your regular shoes. If we have time, we'll get into one of the cases too, but this is a Celine Parekh's case. I'm going, he's not there, but we can, you know, see what he has in here. Looks like they did a, started off with a spider bite, I believe, you know, so it's a bit of infection. They got this thing put on, but it looks like there was a wound break down medially. And, you know, when they have a plate on the medial side, I don't know. Obviously, Jesse, you showed a plate which was plantar rather than medial. If Celine's not there, I was going to ask him, you know, why this was done medially, but I don't know whether he did it or he just inherited this case, but you can see the plate was taken out and, you know, and the other, and then the side, the tibia had a problem. So he went in to fix this. I'm going to be going through pretty fast here because he's not there. I just want to go through his slides. And then they did a tibial nail. It's gone into non-union. I think it's an infected non-union at this stage. Any thoughts as to how to deal with this infected non-union here? Jesse, if this was your case, this is an intramedullary nail. Yeah, I mean, just being honest, my first thoughts of BKA, but I don't know this patient. I mean, if this patient has an A1C of 14, they're getting a BKA. If they've got an infected non-union of the tibia after this many surgeries. Phil, do you want to add anything heroic here? I agree with Jesse. You know, first discussion is BKA versus limb cell, which I think, you know, five or six operations, and this is the stage we're at. Infected non-union, in my mind, all this stuff's got to come out. Good bone cultures, antibiotics, and then you could discuss, you know, a frame or something like that, but you'd have to shorten him acutely and compress him down, I think, with a frame, if you were to attempt limb salvage. Rick, anything different? No, I agree. I think sometimes you can, you know, resect the non-union, get your good cultures, and then you can put an antibiotic rod down, just a very thin rod, and then put a frame on top of it and compress it. Phil, anything exciting they do in North Carolina? You know, we've done a few rods and frames in the couple cases of bone transport. You know, that's as probably fancy as I would get. You could do that over a rod, but we did one case down there, bone transport. It was for a case of infection, if it was tibia fracture, just osteomyelitis, but a pretty big defect. So you couldn't bring it back, and then, you know, over time, kind of move a segment down. But that's a lot to go through for this. Would you put a cage in him? I would not put a cage in him. No, I think less permanent hardwood, the better. I think an antibiotic coated nail, if you're going to move a frame over a nail is fine, but I wouldn't do anything more than that. Okay, this is what was done. Obviously, the infected non-union was resected. Antibiotic spacer was put in. Three months down the line, by the time, you know, they cleared for surgery, I presume they followed the markers and chose to put a cage. And what do you think might have happened, might happen in the long-term? I tried this, and I mean, it looked really good, just like this does for about three or four months. I mean, I think it depends on the patient. Again, if this is a patient with hemoglobin A1C of six, this may work. I think if it's higher than that, I don't know if this is going to be a long-term solution. And you may not know for a year, I mean. That's true, though. I mean, a year, two years, sometimes they come back. This is the other side. This is the other side got, you know, infected. And the other side, they put a rod in there, but ultimately lost it. But the good side is this side now, this particular patient, you know, which has the right side so far, seems to be happy. That's a saline's case. So I'm going to put up another case here. This is, this side is the left side, and the right side is beginning to have problems. The left side already had problems, it's stable, but the right side, if you look at the right side, he has this disappearing talus and the navicular, as you can see. You know, some of these processes, like we talked about earlier, can be very aggressive. And before your own eyes, you see, they can, you know, feel like a bag of bones. So he had this severe dislocation of the ankle joint and also subtalar joint, you see, as you can see here. Oh, sorry, before that, what would you do? I mean, would you be able to correct this acutely? And what are your thoughts? Let's start with Phil. Yeah, you know, for this case and kind of the midfoot, even like the stage ones, I think there's, you know, some push to maybe tackle some of these earlier rather than later. You know, the original teaching was total contact casting or bracing for early Charcot, but I think if people get into fragmentation and deformity where the foot's shifting on you, clearly in this case with this ankle dislocated, here's a example of that, but more than midfoot cases, I think there might be an evolving role to treat early midfoot Charcot with deformity, especially in the setting of impending ulceration. So yeah, so obviously there's a midfoot problem and a hind foot problem. Jesse, what would you do? Yeah, so for this one, I would ignore the midfoot and I would do a hind foot fusion nail and just try to restore the mechanical axis of the ankle. And, you know, if you look at the union rates, even in the midfoot reconstructions, the Carolina study, they had less than 50% union. And so maybe there's some thought that a fibrous union dissipates the forces more because you're, you know, Bernard, you're talking about your concern with the rigidity of the midfoot. And I think you're probably onto something. So I just ignore the midfoot and address the hind foot and ankle here. You know, and in that study, their only amputations were those that had an ulcer and developed deep infection. And so they had about 15% amputations and they had about 25% deep infection. And so, but you didn't see that the ones that had failures of their midfoot construct went on to amputation. So a lot of these I've seen in my practice, you fix the midfoot, you think it looks really good and then it collapses again, but they don't end up with an ulcer. And so the foot's still a big save. And so I'm less concerned now with instability of the midfoot than I thought, think I was probably five or six years ago. What about you, Richard? Yeah, I agree. And sometimes in cases like this, you may end up just taking the talus out and trying to do a tibial calcaneal fusion. That way you only have one joint. Then I kind of leave the transverse parcel joint alone and let it get a fibrous union. I've done a case like this before where the talus just started crumbling once you tried to reduce it back into the mortise. And so sometimes you just better off just take it out. It's almost like you have a crystal ball there, Rick. I will show you how this evolved. So basically, I just thought I will provide some stability with these screws in the midfoot. And I wanted to reduce the hind foot. Now, I was not able to reduce the hind foot. So I did do a medial and lateral medullar osteotomy. And I put through as many screws as I could, as you can see. Now, at this stage, would you add a frame or would you be happy with this much construct? That's a pretty long day. I'd probably leave it like that. If I got all the skin closed, I'd probably just put them in a cast. Yes, and that's what I did. And he did initially pretty good, but unfortunately, in fact, he was beginning to heal his osteotomies and beginning to see some union in the midfoot. I was very happy. But when I was not there and he presented with all pretty severe infection, according to the attending at that time, he had gas, as you can see in the soft tissues, you see. He probably would have done very well had he not an infection, but look at that, all that gas everywhere, around in soft tissue. So at that time, they were contemplating amputation, but I asked if we can just remove the hardware and keep the case there until I come. So they removed the hardware and then the patient recovered pretty fast. And then I followed the patient up and treated him in a cast and then put a frame to see if we get some stability to heal this. He was sick of the frame. And then I saw that he was starting to result in the hind foot. Rick, probably I should have taken the thalassof but you can see, he continued to have sinuses and that probably was because of this hardware. So I removed that, but you can see this bone has completely united. And then he kind of developed a pseudo arthrosis and kept getting infection. So we put some antibiotics in the antibody beads and I thought I will really compress it to get some stability down there. He spent a lot of time in the frame. I think I did get some union in the hind foot but still was draining. So I went in to remove that and put some more antibiotics. Finally, he is left with this kind of scenario with a pseudo arthrosis in the... So he has one unit, which is the tibia and the calcaneus without the thalas. And then in the forefoot and midfoot, which is one long bone. And this is where we are right now. So he's in a crow walker. He's happy to keep his foot. But why? A long journey for this particular patient, few years actually. This is a complication. We did go through several complications. I did get through several complications, but you know, but- I wouldn't call it a complication though. I mean, I think in these people, you have to be prepared to do more than one operation. And especially we haven't really addressed the issue of obesity, but when these people are really large, they don't do well with a bologna amputation. So if you're able to preserve their foot and get them to a point where they can wear brace and they're not on antibiotics, I'd say it's a win. Got it. So Phil, this is your case. You want to start telling us about this case, please? Yeah, this is a lady that I saw last winter and actually her case not finished yet. So it'd be interesting to get people's input, but a 40 year old female. She was a type one diabetic with neuropathy. She's had a renal and pancreas transplant. She's on multiple immunosuppressive medications. Pretty hard charging lady, active for 40s, despite this past medical history. She had an attempt at non-op management. She was kind of intermittently compliant with a Charcot-Walker and brace, and she enjoys pretty competitive, high intensity impact exercise. Advance to the next slide. And so she came into ED later this past winter, increased pain, left ankle swelling, no open wounds, but noticeable change in kind of her clinical status. She had some erythema around the ankle. So they aspirated her ankle in the ED, which I think grew out a staph species. And clearly infected Charcot at this point, fragmentation, breakdown of the talus, and kind of, I remember her asking briefly as I was talking to her about limb salvage versus amputation, she had brought up if she was a candidate for a total ankle, and I kind of quickly glanced over that and got her back on track to the limb salvage versus amputation talk. So Jesse, any initial thoughts? Yeah, I mean, I mean, this is a tough case and so a tough patient. And so I think the biggest probably factor in dealing with Charcot is management of patient expectations. And it sounds like you've already had that discussion, Phillip, and I mean, anything short of an amputation in this case, if it's truly infected with staph is gonna be a huge win. And so you just have to discuss with her if she's ready to endure multiple operations, just with the understanding that this could still end up with a blow in the amputation. And I can tell you if she indeed, she's committed to that or rather twist your arm to convince you to try salvage, then I would take out all her infection and take out her entire talus, thoroughly debris that area and probably put in cement, antibiotic cement, try to keep her off of it and see if I can eradicate the infection in this case before I put internal fixation. And so you could stabilize her in a small wire frame simultaneously. I think at the same time, depending on her, she sounds like a smart lady. You could probably stabilize her in a cast, non-weight bearing with a big cement ball in there. And it may declare itself before you get to stage two. But I think management of expectations in this case is gonna be the biggest, probably predictor of patient's level of satisfaction with your care in six months. Rick, do you use antibiotics? Do you use cement? If so, what is your cocktail there? What I've done with this is again, to breed everything. And then I prepare the calcaneus as if you're gonna do a TTC nail. So I make the entry point and go up into the tibia to breed all that. And then I make a antibiotic nail just by hand rolling the antibiotic cement over the ball tip guide wire and put it up in the canal. Then put a small wire frame on and compress it, wait for all the wounds to heal and our inflammatory markers to come down. And then you go back in a couple of months and switch it out for a regular rod. What antibiotics do you use and how much? Well, I just do cultures and get the infectious disease guy to tell me what to give them. Okay. For antibiotics in the rod, I do vancomycin and tobramycin. Okay. Phil, what have you done in this case? Yeah, so I took her to the OR, pretty aggressive debridement and then plan for basically, and this was pincer study of single stage reconstruction with a thin wire frame. So if you go to the next slide, Vinod. So aggressively debrided, I'll take out the distal fibula for a lot of these. The tails was basically dead, but whatever was healthy fragmented bone, I put that in the bone nail with the distal fibula and then went for basically what became a TC fusion with a thin wire frame. Okay. Did you put any antibiotics in there or just a- I think there was, I might've put powder in or some stimulant, but I didn't put a spacer in anything formal like that. She did well after surgery, one month post-op. She has good alignment, foot looks good. She healed all her wounds. She's active as she can be, just wheeling around on her scooter. And the next slide, I think, Vinod, she was admitted, the transplant patients, they follow pretty closely here, especially the double transplant patients. She had a little bit of cellulitis around one of her pins, cleared up with a few days of antibiotics. This is her two months now and she's still, this is an ongoing case. She's still in the frame and put on the footplate for her to let her start weight bearing. You can get, kind of tell from her healthy leg, she's a fit young woman who wants to exercise and do things. And that's the lifestyle she wants to get back to. And I think, some parts been in denial and I've tried multiple conversations. We have a good relationship, but had her stand up in the frame and she's a good, I'd say three centimeters short on that side. I know it's gonna be a big issue for her, unfortunately, going forward. So, we talked about all the options and Vinod, if you go to the next slide, we talked about, do we make a lift for your shoe eventually? Do we do a lengthening and even below knee amputation? So, I'm lucky I work with a team of other doctors, plastic surgeons, vascular, and we do a lot of limb salvage, but we also do a lot of amputation. So, I invited her to come to our, kind of our multidisciplinary clinic to talk just about that as an option, so she can have all the information. She's a little bit different. She's 41 and would probably do very well with a below knee amputation and kind of our modern techniques for TMR and RPNI. So, I think she'd be a great candidate for her. And again, we have a good relationship, but so I was kind of looking up this case and grabbing some of her photos. And I saw another note from within our healthcare system, but not our hospital, another foot and ankle provider. She was at his office, you know, a couple of weeks ago, asking about a total talus or total ankle replacement. So, challenging, challenging. They live in a different world. I reached back out to her. So, she's coming back to see me and hopefully we can kind of move forward with more realistic expectations. All right. So, I think we're going to rapidly go through one case, you know, because we are running out of time here. I hope we can address a couple of questions as well. I'm going to show Rick's case here because this particular case has a slightly different dimensions to it. You know, here we're dealing with somebody who had a severe peripheral vascular disease. You know, let me see, I'm just going to close this over here. So, you can see there's a big ulceration down there and a very disvascular limb. Obviously, anybody wants to do any open reduction? I suppose not, right? Given the vascularity status. Rick, why don't you tell us anything more you want to add to this case? Yeah, this guy had the provider that saw him initially got a vascular consult. Vascular told him not to make any incisions on him. So, they tried to treat the trimalleolar ankle fracture in a cast and it slowly just went into more and more valgus and then he developed an ulceration over his medial malleolus fracture. And so, we basically, we did send him for, the vascular surgeon saw him and did an angioplasty on him which helped the wound and then we put him in a frame and just corrected his deformity and his medial malleolus ulcer healed. And so, we put a single screw in that. The screw probably wasn't enough. All the screw basically got loose and he slowly, you can advance the slides and see what happens to his ankle. We did get it, we kept his ulcer healed and got him to the point where he's in a brace and last I checked, his other leg was dead and he was getting above knee amputation. So, this was a tough case. But I got a lot more cases to go but I got a message from our organization that we cannot go more than five more minutes because of the CME restrictions. So, I want to take a chance to thank the panelists. I want to thank the attendees for their Q&As. Hopefully, we can answer them as we go along but I can take a couple of questions here. One question is about the infection. Let's see, what imaging modality do the panelists use to assess osteomyelitis in these patients? MRI with gadolinium, indium-labeled bone scan, PET scan? You know, my philosophy is just look at the patient. You know, the patient is very ill. We know, you know, there's infection, smelling. I have a great case, we're running out of time but, you know, you can smell the infection. Sometimes, you don't need all these fancy modalities but any thoughts from the panelists about investigation to assess osteomyelitis when there is no wound, you know, this closed case, for example, or how do you differentiate between SHARP and osteomyelitis? Clinical, you know, like you said, is probably the most important. If they don't have a history of an ulcer or an open wound, then it's generally, usually not osteo. It's important to remember your lab parameters, ESR and CRP are gonna be elevated, your white blood cell count, those can all be elevated in the face of SHARCO without infection. For me, the advanced imaging modality when there's not a bunch of metal in place is an MRI. And you can, there are subtle things you can look at on MRI that can help you distinguish between infection and SHARCO just based on the nature of the disease and really the pattern of the disease geographically in the foot. And then if there's ever a question, which is every three or four months, I'll get a tagged white blood cell scan. It's pretty rare, but for probably every 10 MRIs, there's maybe one where it's, there's a clinical and an MRI question that needs to be answered with a white blood cell scan. Anything different from the rest of the panelists? No, I'd say I usually just get an MRI. Phil? Yeah, same. Mostly been using MRIs and, you know, areas of ulceration or wounds. I'm assuming some degree of infection, especially if there's open bony involvement. Got it, folks. I think it has been exciting one hour and plus few minutes. I totally enjoyed interacting with you folks. I learned a lot. I hope we covered our objectives. We described our complications or tried to describe complications. We explained some of the reasons why these complications occur. And hopefully we learned to very, we can avoid some of the complications and manage complications. And, you know, there's a lot more we can discuss. Hopefully we will probably have a part two because I honestly have much more, many more exciting cases, which you guys submitted. Hopefully we can talk a lot more. Hopefully there'll be more interaction, more questions asked, you know, either from the audience who is currently logged in or who will log in at a later time. And hopefully we'll be able to address those. Again, I want to thank each one of you for taking the time off from your busy evenings and sharing your valuable input in this complicated topic. Thank you again. Thank you. Thanks everyone. Thanks guys. Thanks for posting good cases. Thank you. Jennifer.

Charcot neuroarthropathy

surgical management

complications

deformities

ulcerations

patient expectations

diabetes control

infection risk

multidisciplinary approach

disease progression