The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue Supplement 1 Part 1

Surgical Techniques | March 01, 2010

Realignment and Extended Fusion with Use of a Medial Column Screw for Midfoot Deformities Secondary to Diabetic Neuropathy: Surgical Technique

Mathieu Assal, MD¹; Adrien Ray, MD¹; Richard Stern, MD¹

¹ Service de Chirurgie Orthopédique et Traumatologie de l'Appareil Moteur, Hôpitaux Universitaires de Genève, 24 rue Micheli-du-Crest, 1211 Genève 14, Switzerland. E-mail address for R. Stern: richard. stern@hcuge.ch

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DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 91 -A, pp. 812—20, April 2009

J Bone Joint Surg Am, 2010 Mar 01;92(Supplement 1 Part 1):20-31. doi: 10.2106/JBJS.I.01288

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Abstract

BACKGROUND:

The failure of nonsurgical treatment of patients with midfoot and hindfoot deformity secondary to diabetic Charcot arthropathy may lead to a rocker-bottom foot deformity with recurrent or persistent plantar ulceration. We report our experience with realignment and extended fusion with primary use of a medial column screw for this midfoot deformity.

METHODS:

From July 2001 through July 2005, we performed reconstructive surgery on fifteen adults with diabetes mellitus who had a severe neuropathic midfoot deformity consisting of a collapsed plantar arch with a rocker-bottom foot deformity. Thirteen had a nonhealing midfoot plantar ulcer. All underwent realignment and arthrodesis with a medial column screw; some required additional fixation techniques depending on the extent of the deformity. Outcome measures included ulcer and surgical wound-healing, radiographic results, complications, and the need for amputation.

RESULTS:

The mean duration of clinical follow-up was forty-two months. Fourteen patients were able to walk, and there were no recurrent plantar ulcers. Thirteen patients were able to wear custom-made extra-depth, wide-toed shoes with molded inserts. One patient without prior ulceration had development of a deep infection that necessitated an amputation. Four feet had a nonunion, one of which was symptomatic requiring a revision to obtain union.

CONCLUSIONS:

Surgical reconstruction of a collapsed neuropathic foot deformity is technically demanding, but a successful outcome can result in a plantigrade foot that is free of ulceration and abnormal pressure points and a patient who is able to walk. The procedure described has an acceptable degree of complications although it has a high rate of nonunion.

LEVEL OF EVIDENCE:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

ORIGINAL ABSTRACT CITATION:

"Realignment and Extended Fusion with Use of a Medial Column Screw for Midfoot Deformities Secondary to Diabetic Neuropathy" (2009;91:812-20).

Figures in this Article

INTRODUCTION

Progressive midfoot and hind-foot deformities secondary to diabetic neuropathy often lead to a severe, unstable rocker-bottom foot with plantar ulceration. A sound treatment option is surgical realignment and stabilization by means of a midfoot, and at times an additional hindfoot, arthrodesis with the aim of restoring a plantigrade foot^1,2. It is critical that the first step in the surgical technique achieve reduction and realignment of the medial column (talonavicular, navicular-medial cuneiform, and medial cuneiform-first metatarsal joints), and a medial column fusion is performed with use of a long intramedullary screw. After stabilizing the medial column, we proceed from medial to lateral and assess clinically and radiographically if there is a need to reduce and stabilize other joints (the navicular-second cuneiform joint and the tarsometatarsal joints), and then assess the need for stabilization of the lateral column (calcaneocuboid joint) and the subtalar joint.

SURGICAL TECHNIQUE

Incision and Exposure

In an illustrative case of a patient, the preoperative deformity is shown in a drawing (Fig. 1), anteroposterior (Fig. 2-A) and lateral radiographs (Fig. 2-B), and a photograph (Fig. 3). A preoperative photograph of the plantar ulcer is seen in Figure 4. At the time of induction of anesthesia, all patients receive a second-generation cephalosporin as antibiotic prophylaxis. The patient is placed on the operating table in the supine position. A thigh tourniquet is used for all procedures, and an occlusive dressing is placed over any open ulcers prior to the start of the operation. After exsanguination of the limb and inflation of the tourniquet, an incision is made along the medial aspect of the midfoot in line with the talar-first metatarsal axis (Figs. 5-A and 5-B). Blunt dissection is carried down to the medial column bones (talus, navicular, cuneiform, and first metatarsal), with careful attention paid to the tibialis anterior and tibialis posterior tendons as they insert on the medial cuneiform and navicular, respectively (Fig. 5-A). Since the anatomy is frequently markedly disrupted, it is important to avoid injuring these tendons. They are not detached from their insertions, but mobilized as needed to gain access to the medial column joints (talonavicular, navicular-medial cuneiform, and medial cuneiform-first metatarsal). At times, they insert onto a fragment of bone that has become detached from its normal position, in which case the tendon is later reattached to the reconstructed medial column.

Fig. 1

Figs. 1 through 4 An illustrative case of a patient with progressive midfoot and hindfoot deformities secondary to diabetic neuropathy that led to a severe, unstable rocker-bottom foot with plantar ulceration. Fig. 1 Drawing of the deformity.

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Fig. 2-A Fig. 2-B

Fig. 2-A Preoperative anteroposterior radiograph demonstrating the midfoot deformity. Fig. 2-B Preoperative lateral radiograph.

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Fig. 3

Clinical photograph of the deformity.

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Fig. 4

Preoperative photograph of the ulcer.

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Fig. 5-A Fig. 5-B

Fig. 5-A Drawing of the surgical incision (dashed red line). The course of the tibialis anterior (TA) and tibialis posterior (TP) tendons is seen. Fig. 5-B Photograph of the surgical incision.

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Preparation of Joint Surfaces

All scar and inflammatory tissue around the displaced bones and dislocated joints is removed, particularly around the navicular and/or the medial cuneiform. This maneuver mobilizes the bones and facilitates later realignment. With the goal of the procedure being a medial column fusion, all joints to be fused are débrided of cartilage and sclerotic bone (Figs. 6-A and 6-B). Distraction of the medial column generally facilitates access to the joint surfaces, and this is achieved by placing a temporary external fixator or suitable clamp between the talar neck and the first metatarsal shaft (Fig. 7). Usually the first joint surface that is prepared for fusion is that of the talar head, followed by the proximal and distal navicular and medial cuneiform joint surfaces, and finally the base of the first metatarsal. At times, it is not possible to bring the navicular and/or medial cuneiform back to their original anatomic position in the medial column despite appropriate distraction. This situation may occur in patients with long-standing plantar dislocation of these bones, resulting in a chronic shortening of the medial column. In such cases, no further attempt is made to reposition the bones and they are removed, morselized, and later used for bone graft. In other cases, a decompression wedge osteotomy of the bones may permit their reduction.

Fig. 6-A Fig. 6-B

Débridement of cartilage and sclerotic bone with an osteotome (Fig. 6-A) and rongeur (Fig. 6-B). T = talar head, N = navicular, and C = medial cuneiform.

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Fig. 7

Drawing showing the use of a temporary external fixator or suitable clamp for distraction of the joints between the talar neck and the first metatarsal shaft.

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Medial Column Screw Insertion and Medial Column Fixation

To stabilize the medial column, fixation begins with a cannulated intramedullary screw, 8 mm in diameter and 150 mm in length, placed from the posterior part of the talus into the first metatarsal. This is accomplished by first drilling a guidewire from a cannulated screw set in a retrograde fashion parallel to the subtalar joint through the head of the talus, exiting posterolateral to the Achilles tendon (Fig. 8, A). The entry point in the talar head for the guidewire is critical as this affects the final position of the foot, specifically regarding arch height and midfoot abduction or adduction. Visualizing the talar head in quadrants, the entry point should be inferomedial, as seen in Figure 8, B. Introduction of the guidewire in the two upper quadrants lowers the final foot arch and should be avoided. Conversely, placing the guidewire too inferior in the lower quadrant increases the height of the foot arch. Placing the wire laterally results in insufficient forefoot adduction, and placement too medially results in overcorrection. Once the guidewire has been correctly introduced into the talar head, the angulation of the wire in the sagittal plane should be such that it is parallel and close to the posterior facet of the talus. This affects the final position of the head of the screw and, if not done correctly, can result in impingement between the head of the screw and the tip of the posterior aspect of the malleolus. In order to control the position of the talus to ensure that the guidewire is correctly inserted, a 5.0-mm threaded wire can be inserted into the upper talar neck from medial to lateral and used as a joystick. In some cases, it is not possible to bring the long-standing plantar-flexed talus into appropriate position because of contracture of the posterior capsule, and at this point a posterior capsular release is performed. The position of the guidewire is assessed with the image intensifier (Fig. 9). When the tip of the guidewire is palpable in the soft tissues posteriorly, just lateral to the Achilles tendon, a small incision is made to access the tip and advance the guidewire until its distal end is flush with the talar head. At this time, attention is directed to reducing and aligning the midfoot. The midfoot bones should be in line with the talar neck axis. The navicular, medial cuneiform, and first metatarsal can be temporarily fixed with 1.6-mm Kirschner wires. Once the alignment is thought to be satisfactory, the guidewire is drilled antegrade successively through the navicular and medial cuneiform into the medullary canal of the first metatarsal (Fig. 10-A). It is best to place the guidewire as far as possible into the first metatarsal. After drilling over the guidewire (Fig. 10-B), an 8.0-mm fully threaded cannulated screw is inserted (Fig. 11). The screw is fully threaded and is not used as a lag screw, but rather functions as a position screw. No attempt should be made to apply axial compression as the midfoot bones are usually osteopenic and fragmented. Currently, the longest screw length available is 150 mm, but even longer screws could be used. The screw remains in an intramedullary position and does not broach the cortex of the first metatarsal head.

Fig. 8

A: Drawing of a guidewire drilled in a retrograde fashion parallel to the subtalar joint through the head of the talus, exiting posterolateral to the Achilles tendon. B: The talar head is depicted in quadrants; the entry point should be inferomedial. S = superior, I = inferior, M = medial, and L = lateral.

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Fig. 9

The position of the guidewire is assessed with the image intensifier as it exits the posterior aspect of the talus.

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Fig. 10-A FIG. 10-B

Fig. 10-A Following alignment of the midfoot, the guidewire is drilled antegrade sequentially through the navicular and medial cuneiform into the medullary canal of the first metatarsal. Fig. 10-B Drilling over the guidewire with a cannulated drill-bit.

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Fig. 11

Insertion of the 8.0-mm cannulated, fully threaded screw.

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In addition to the medial column intramedullary screw, we use two 3.5-mm screws placed on the medial side in order to fix the frequently fragmented navicular and medial cuneiform bones. These screws pass oblique to the intramedullary screw from the medial cuneiform, navicular, or talus into the first metatarsal (Fig. 12). Figures 13-A and 13-B show the postoperative anteroposterior and lateral radiographs.

Fig. 12

Two additional 3.5-mm screws are placed on the medial side in order to fix the frequently fragmented navicular and medial cuneiform bones.

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Fig. 13-A Fig. 13-B

Fig. 13-A Postoperative anteroposterior radiograph. Fig. 13-B Postoperative lateral radiograph.

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Additional Foot Fixation and Soft-Tissue Procedures

After stabilizing the medial column as described, we proceed from medial to lateral and clinically and radiographically assess whether there is a need to reduce and stabilize additional joints. In every patient, we proceed as previously described and all joints to be fused are débrided of cartilage and sclerotic bone. If the navicular-second cuneiform joint and the tarsometatarsal joints show obvious signs of instability, we use a contoured dorsal 3.5-mm straight plate that extends from the talus to the second meta-tarsal. Then the lateral column is addressed, and the subtalar and calcaneocuboid joints are approached either through a lateral longitudinal incision or an Ollier-type incision centered over the sinus tarsi. If there is lateral column collapse, we fuse the calcaneocuboid joint and the cuboid-fourth and fifth metatarsal joints with a can-nulated 6.5-mm intramedullary lateral column screw, which passes from the calcaneus to the fourth or fifth metatarsal. This is combined with a subtalar fusion with use of a single, cannulated 6.5-mm screw.

Figures 14-A and 14-B show the preoperative anteroposterior and lateral radiographs of a patient with a severe deformity through the Lisfranc joint, and Figure 15 shows the large plantar ulcer. The postoperative radiographs are seen in Figures 16-A and 16-B.

Fig. 14-A Fig. 14-B

Figs. 14-A though 16-B A patient with disruption of the Lisfranc joint with a severe deformity. Figs. 14-A and 14-B Preoperative anteroposterior (Fig. 14-A) and lateral (Fig. 14-B) radiographs.

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Fig. 15

Preoperative photograph of the plantar ulcer.

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Fig. 16-A Fig. 16-B

Fig. 16-A Postoperative anteroposterior radiograph. Fig. 16-B Postoperative lateral radiograph.

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Bone graft is used in all patients and consists of either local graft, morselized pieces from the foot, or cancellous bone from the proximal part of the tibia. No allograft or other bone graft substitute is used. If an equinus deformity (<5° of dorsifiexion) is present after fixation is in place, either an Achilles tendon lengthening or a gastrocnemius recession is performed, depending on the origin of the deformity. If the equinus deformity can be reduced with the knee in flexion, then a gastrocnemius recession is performed. Otherwise, an Achilles tendon lengthening is performed as an open procedure through a medial longitudinal incision parallel to the tendon. If this does not fully correct the equinus deformity, and a previous posterior cap-sular release was not done, we perform an additional soft-tissue release of the posterior subtalar and ankle joints. In terms of wound closure, any periosteal flap that has been elevated and preserved is carefully repaired with resorbable 2—0 sutures. While we usually do not use subcutaneous sutures in foot surgery in an effort to avoid local nerve entrapment, in these neuropathic patients, we routinely use subcutaneous sutures in order to eliminate dead space and decrease the risk of postoperative wound dehiscence. The skin is carefully closed with interrupted 3—0 nylon sutures. As a final step, the occlusive ulcer dressings are removed, the tourniquet is released, and the ulcer is débrided. Necrotic tissue and callus are removed as an ellipse of full-thickness skin around the ulcer to expose bleeding tissue.

POSTOPERATIVE MANAGEMENT

Prior to leaving the operating room, all patients are placed in a non-weight-bearing below-the-knee splint, which is changed at two and six weeks postoperatively, and monthly thereafter, for a total of four months. The ulcers are managed with wet-to-dry dressing changes twice weekly. After four months, patients are allowed progressive weight-bearing in a removable cast. The radiographic appearance of osseous healing is not an important assessment tool for advancement of weight-bearing. Weight-bearing status is advanced empirically at four months postoperatively. When the patients are bearing full weight without difficulty in the removable cast, they are managed with an extra-depth, wide-toed shoe.

CRITICAL CONCEPTS

INDICATIONS:

A midfoot collapse with an associated nonhealing plantar ulceration in patients who fail management with a Charcot restraint orthotic walker (CROW; Leserre et Lenoir, Geneva, Switzerland) (Fig. 17).
A patient without a plantar ulcer but with deformity and midfoot instability not amenable to brace treatment. If the instability cannot be controlled with an orthosis, most patients have progressive collapse of the midfoot and eventualulcer formation.

Fig. 17

Charcot restraint orthotic walker (CROW).

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CONTRAINDICATIONS:

A patient with an active infection. The presence of an open plantar ulcer that has failed nonoperative treatment (wound care, total contact casting, and antibiotics) is not considered a contraindication to surgery. However, a patient with active soft-tissue or bone infection, defined by fever, uncontrollable serum glucose levels, purulent drainage, or lymphangitis, does not undergo reconstructive surgery until there is resolution of the soft-tissue infection.
A patient with a fixed rocker-bottom deformity. In such patients, an alternative technique such as exostectomy may be successful. This is only possible in a patient with a stable Charcot foot deformity.

PITFALLS:

Failure to appreciate the position of the tibialis anterior and posterior tendons (because of markedly disturbed anatomy), as they thus may be cut or detached from their insertions
Failure to adequately débride joint cartilage and sclerotic bone
Failure to accurately reduce the medial column by decompression, appropriate wedge osteotomy, or actual bone removal
Failure to use a small external fixator to help with reduction when necessary
During insertion of the guidewire in a retrograde fashion, failure to control the position of the talus and ensure that the guidewire is centered in the medial column
Failure to perform a posterior capsular release to correct a plantar-flexed talus
Failure to use the longest, 8-mm, intramedullary screw to place the maximum amount of screw thread into the first metatarsal
Failure to place the frequently fragmented navicular and medial cuneiform bones into the fixation construct medially
Failure to address instability at the navicular-second cuneiform joint and the tarsometatarsal joints
Failure to appreciate the additional need to stabilize the lateral column
Failure to add bone graft
Failure to perform either an Achilles tendon lengthening or gastrocnemius recession in the presence of an equinus deformity (<5° of dorsiflexion)
Failure to perform an additional soft-tissue release of the posterior subtalar and ankle joints to correct an equinus deformity

AUTHOR UPDATE:

There have been no substantive changes in the procedure since the publication of our original report.

Acknowledgements

Note: The illustrations in this article were the work of Adrien Ray, MD.

REFERENCES

Rooney J; Hutabarat S; Grujic L; Hansen S. Surgical reconstruction of the neuropathic foot. The Foot . 2002;12:213-23.[CrossRef]

Sammarco VJ; Sammarco GJ; Walker EW Jr; Guiao RP. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. J Bone Joint Surg Am. 2009;91: 80-91.[PubMed] [CrossRef]

Topics

diabetic neuropathy ; bone screws ; foot ; plantar ulcer ; midfoot ; navicular bone of foot

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Mathieu Assal, Adrien Ray, Richard Stern; Realignment and Extended Fusion with Use of a Medial Column Screw for Midfoot Deformities Secondary to Diabetic NeuropathySurgical Technique. The Journal of Bone & Joint Surgery. 2010 Mar;92(Supplement_1_Part_1):20-31.

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