15

Reconstruction of Lisfranc’s Joint Dislocations

Secondary To Charcot Neuroarthropathy Using A Plantar Plate

Abstract

The purpose was to determine whether a plate applied to the plantar (tension) side of the medial midfoot provides a strong, sturdy construct for arthrodesis and ambulation after Lisfranc’s dislocation secondary to Charcot neuroarthropathy resulting in good clinical outcomes. Twenty-four consecutive patients (25 feet) from 1999 through 2004 underwent Charcot reconstruction for Lisfranc’s dislocation. Clinical and radiographic follow-up was performed every three weeks during the postoperative course. Union was achieved in 24 of 25 feet. The average time to ambulation was 11.68 weeks (range 7-20) for twenty-four patients. The average follow-up was 38.0 months (range 17-64). The union and time to ambulation rates show that a plate applied to the plantar aspect of the medial midfoot provides a strong, sturdy construct for arthrodesis and ambulation in LisFranc’s dislocations in Charcot neuroarthopathy. Marks, Parks and Schon (32) demonstrated the tension side is able to maintain correction over high and repetitive loading, which is ideal for arthrodesis of neuropathic Charcot joints.

Introduction

Neuropathic arthropathy was first described in association with tabes dorsalis in 1868 by Jean Martin Charcot, with bone and joint changes secondary to a “trophic effect”(1). Thereafter, similar bone and joint changes have been described in patients with diabetes mellitus, syringomyelia, leprosy, scleroderma, hereditary sensory neuropathy, lyme disease and alcoholic neuropathy (2,3,4,5). Today, Charcot neuroarthropathy is characterized by episodes of “active” and “inactive” periods. An edematous, erythematous, warm foot that shows progressive destruction and dislocation of bone and joints characterizes the active period.. It is estimated that 0.1% to 2.5% of diabetics will develop neuropathic fractures (6,7,8). Since diabetes mellitus is becoming an epidemic particularly in the United States, this is becoming a prevalent problem

The exact etiology of neuropathic arthropathy still remains undefined. Two theories exist today that help to explain the possible cause. First, the neurotramatic theory, experimentally confirmed by Eloesser in 1917 and later developed by Johnson in 1967, proposes a decreased protective sensation permits cumulative “ microtrauma” resulting in fracture and joint destruction (2,9). In 1981, Brower and Allman suggested a neurovascular theory that proposed that a loss of vasomotor tone or “autosympathectomy” leads to increased blood flow and active bone resorption (10). Both theories are believed to play a role in the development of Charcot neuroarthropathy (11).

The staging of neuropathy, as described by Eichenholtz, uses both clinical and radiographic criteria (12). In Stage I, the foot exhibits progressive edema, hyperemia and increased temperature. Radiographically, debris, joint dislocation, and bone fragmentation are noted. In Stage II, the swelling, warmth, and redness decrease. Radiographically, there is sclerosis, absorption of fine debris, and fusion of large bone fragments. In the final stage, Stage III, there is resolution of clinical inflammation with radiographic bony consolidation. An additional stage, Stage O, was later added by Shibata, Tada, and Hashizume (13). This stage has the same clinical signs as Stage I, erythema, edema, and warmth; however radiographic changes are absent or minimal. Although clinical and radiographic criteria are important, anatomical location and incidence are essential to determine treatment and outcomes. Brodsky’s classification determines anatomic location as well as treatment prognosis (14). According to Brodsky, 60-70% of neuropathic arthropathy occurs at the tarsometatarsal articulation, which is the most common location (14). In addition, Schon also has a classification, which determines anatomic location (15).

The exact treatment regimen for neuropathic arthropathy is also undefined. Both conservative and surgical options are available (16). Conservatively, treatment usually consists of a lengthy course of immobilization, achieved with the use of contact casting, removable casts, ankle-foot orthosis, or molded shoes (17). Associated ulcers are treated with local wound care and antibiotic therapy as needed. If conservative treatment is ineffective, patients become at risk for skin/bone breakdown, which may become limb or life threatening. Therefore, surgical treatment aimed at correcting the deformity may be indicated. The primary goal of surgical treatment is to create a functional plantigrade foot allowing the patients to be return to functional activity, prevent further breakdown and to decrease medical cost.

Indications

Indications for surgical treatment include chronic ulcers associated with bony deformities or contractures, unstable joints of the foot and ankle that are not able to be treated with a shoe or brace, recurrent infected ulcers with bony prominences, and acute displaced fractures in neuropathic patients with adequate circulation (Figure 1) (3,18). Traditionally surgical treatment has been limited to the “inactive” phase of the disease.

Gross instability at the tarsometatarsal articulation leads to characteristic symptomatic medial and plantar bony prominences, which may lead to ulceration and infection, often resulting in amputation of a limb (19). Ostectomy alone does not address the biomechanical instability and thus does not provide long-term benefit (20). Meanwhile, amputation in addition to the effect of the loss of limb puts the patient at further risk for an additional amputation of the contralateral limb (21). Pinzur et al demonstrated that energy consumption with a unilateral amputation is directly proportional to the number of functional joints remaining and inversely proportional to the length of the remaining limb (22). Additionally, due to the energy costs, patients often adapt their lifestyle by becoming less active, resulting in reduced physical conditions of the muscles of the remaining lower extremity (21,23,24). Furthermore, Waters et al demonstrated that energy consumption increases 10-40% with a unilateral BKA and 50-70% with a unilateral AKA(24).

There is limited information in the literature concerning midfoot arthrodesis using the planter plate for neuropathic joints. However, we believe that there are benefits for those who fit the appropriate clinical history and surgical criteria.

Procedure

Patients were taken to the operating room and placed in a supine position. Following admission of general anesthesia, cotton padding was placed over the upper thigh of the foot being operated on and a pneumatic thigh tourniquet was applied. The foot was then prepped and draped in the usual sterile manner. The tourniquet was applied and elevated. Attention was then directed to the Achilles tendon where a linear incision was made over the distal 1/3 of the lower leg. The tendoachilles lengthening was performed with an open Z -plasty. Approximately 2cm of lengthening is achieved. The paratenon was re-approximated using 3.0 vicryl. The subcutaneous tissue was closed using 3.0 vicryl, skin was closed in a horizontal mattress type stitch using 4.0 nylon. Attention was then directed to the planter medial aspect of the foot. A straight incision was made beginning at the talonavicular joint and extending to the distal one-third of the 1st metatarsal shaft. The incision was deepened via sharp and blunt dissection down to the 1st metatarsal, medial cuneiform, and navicular. A full thickness tissue flap was then retracted off of the tarsometatarsal joints. Attention was directed to the base of Lisfranc’s articulation. An osteotome was used to remove approximately 1cm block of necrotic bone across Lisfranc’s joint, down to good healthy bleeding bone. If all the charcot bone could not be resected through the medial incision, a second incision was made on the lateral aspect of the foot between the 4th and 5th metatarsals. This incision was deepened down to the base of the metatarsals and cuboid. All necrotic bone from the lateral to medial aspect was removed, completing the resection of Charcot bone across the Lisfranc’s joint. Depending on the extension of charcot destruction, the same procedure was performed through the innominate i.e. naviculo-cuneiform joints, depending on the extension of charcot destruction, in order to restore the medial arch of the foot. The Lisfranc’s joint was adducted and held into a plantarflexed position using two .062K-wires for temporary fixation. Next, a 3.5mm reconstruction plate was eccentrically loaded and applied to the plantar aspect of the first metatarsal, medial cuneiform and navicular (Figure 2). One 3.5cm cortical screw was placed outside of the plate in an oblique fashion seating on the medial wall of the first metatarsal aiming at the lateral edge of the navicular. Its length depends on the extension of the debrided region. A second cortical screw was inserted outside of the plate from the medial cuneiform or navicular into the 2nd or 3rd metatarsal base. No fixation was used on the 4th and 5th rays. Autogenous or allogenic cancellous bone can be used to fill any void or space at the arthrodesis site.. The incisions were then dressed using betadine soaked adaptic, 4x 4’s, and kling. A dry sterile dressing was applied, followed by a posterior splint or Jones compression dressing. The post-operative course included serial radiographs every three weeks, while patients were kept non-weight bearing depending on radiographic and clinical appearance (Figures 3 and 4). The patients were placed in a walking cast or CAM Walker for an additional 2-3 months, after initiation of weight bearing with physical therapy.
Results

There were twenty-four patients and twenty-five feet (one bilateral) who underwent the procedure. The average age of the fourteen men and ten women in our study was 58.8 years (range 42-74). All of the patients were neuropathic, twenty-two (22) of the patients were diabetic, with twelve being insulin dependent. One patient had alcoholic neuropathy, while another patient had idiopathic neuropathy. Union was achieved in twenty-four of twenty-five feet. This was determined by a clinical stable foot, no evidence of sclerosis or gapping at the fusion site, maintenance of solid hardware and trabeculation identified on radiographs. The average time to ambulation in a walking boot was 11.68 weeks (range 7-20) for the twenty-four patients. Average length of follow-up was 38.0 months (range 17-64). Complications were noted in eleven patients including infection, ulcer, charcot developing into other joints, and wound dehiscence. . Another patient developed heel decubiti, secondary to a poorly fitted cast unrelated to the procedure, which also healed with antibiotics and local wound care (Table 1). One patient passed away 18 months after surgery, unrelated to the procedure. This patient had consolidated and was ambulating after twelve weeks. There was no correlation between the surgical approach or method of arthrodesis and incidence of complications. Our patient survey included sixteen of twenty-four patients. The results revealed that 14 of 16 patients were satisfied with the procedure overall and 14 of 16 would undergo the same procedure again.

Discussion

The accepted treatment for neuropathic arthropathy has historically been immobilization in a cast or brace until consolidation has occurred. However, there are patients who have a disabling fixed deformity or severe instability that will not respond to bracing or casting alone (25). Likewise, there are patients who are conservatively treated for years and treatment fails (26). All twenty-four of our patients failed conservative therapy, including immobilization, casting and bracing. Previously, surgical reconstruction did not show favorable results (27-30). Recent literature has shown that arthrodesis can provide a successful outcome for these patients. Myerson et al reported good results in 27 of 29 patients with neuropathic arthropathy who underwent surgical arthrodesis (31). Historically, Charcot reconstruction has been performed in the late second or third stages as classified by Eichenholtz. Each of our procedures was performed on patients with late stage II or stage III Charcot deformity. Research has shown that a plate applied to the plantar (tension) aspect of the medial midfoot provides a stronger, sturdier construct than midfoot fusion with screw fixation (32). Studies have also revealed that a plantar plate allows significantly less initial displacement and maintains stabilization at a much higher load (32). By maintaining correction over high and repetitive loading, the patient should be able to ambulate earlier while maintaining arthrodesis. To date, data has not been published concerning the outcome of using a plantar plate for Charcot reconstruction and return to earlier ambulation. By utilizing the plantar plate on the tension site and employing AO principles, we have found that a sturdy construct on which to ambulate markedly increases the stability of the reduction and helps to facilitate arthrodesis and early ambulation.

It is equally important to address the muscular ankle equinus that is often associated with neuroarthropathic patients when performing arthrodesis of Lisfranc’s joint secondary to Charcot neuroarthropathy. The chronic stress created by the ankle equinus is often the deforming force which causes the development of eccentric loading of the bones and joints of the midfoot, leading to the formation of a rocker bottom deformity (6,15,16,18,33,34). Recently, Armstrong et al demonstrated that peak plantar force foot pressures are reduced 27% following lengthening of the Achilles tendon in diabetic patients (35). Breakdown most commonly affects the tarsometatarsal articulation, which is usually the point of greatest structural weakness where eccentric loading will occur (14,34,36,37). By performing a tendoachilles lengthening or gastroc recession, the pathological stress is decreased, thus helping to prevent re-occurrence or breakdown elsewhere (38).

The importance of arthrodesis as a means of limb salvage in the diabetic population is a perfect example of why surgical reconstruction and early ambulation are needed. One study reported that 40-45% of all nontraumatic amputations in the United States are a result of diabetes (33). Once a diabetic patient loses a limb, the contralateral limb is placed at high risk. A second amputation occurred in 55% of these patients within 5 years (33). Other studies show that 30% of the patients will die in the first three post-amputaiton years, and 60% will die within the first five years (39). These findings prove that amputation is not only debilitating to the patient's quality of life, but life threatening.

Amputation is also more costly than a salvage procedure. Simon et al recently found that the average cost of early arthrodesis in patients with midfoot Charcot neuropathy was between $9,527 and $16,417. The patients who underwent below the knee amputations costs ranged from $17,261 to $39,045 for the same time frame (40). Another study reported the total costs of surgical reconstruction versus below knee amputation for severe neuropathic foot and ankle deformities to be 14% less in the reconstructive group over a five year period (41).

Conclusion

Various methods of fixation can be used for arthrodesis of a midfoot dislocation. The modification of applying a plate to the plantar medial foot for midfoot fusion provides a more stable construct than simple screw fixation, enhancing the arthrodesis (31). Our results indicate that arthrodesis with return to early ambulation can be achieved using this technique. In patients with an unstable deformity or those experiencing recurrent ulcerations, this is a viable alternative to amputation. Further study and longer follow-up will allow long-term assessment of these outcomes.

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Table 1 Radiographic Patient Data