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26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
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365
Fig. 26.2 Radiographic imaging AP foot views (a–d)—
rst metatarsophalangeal total joint arthroplasty with
implantation of a long-term polymethylmethacrylate
(PMMA) antibiotic spacer may be a useful means of longterm functional preservation
366
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J. S. Steinberg et al.
proximal migration. The incision is then closed
and standard postoperative dressing applied
with postoperative shoe. Incisions are then
removed in the clinic in 2–3weeks, and K-wire
removed at 4weeks.
Lesser Metatarsal Head Osteotomies
Ulcerations are also commonly encountered
beneath the lesser metatarsal heads. In the event
adequate ofoading or soft tissue rebalancing is
unable to resolve these high pressure areas surgical ofoading of the metatarsal head whether
through osteotomy or metatarsal head resection
may be efcacious [15]. Isolated metatarsal head
resections while effective at resolving plantar
metatarsal ulcerations have been shown to have
high rates of transfer lesion development to an
adjacent metatarsal head and other complications
such as oating toe [16]. Newer techniques
adapted from elective surgery such as the Weil
type osteotomy or oating type osteotomy allow
for reduction in plantar pressures while retaining
predictability and limiting dissection in the
comorbid patient.
Distal metatarsal metaphyseal osteotomy
(DMMO) is a percutaneous extra-articular
lesser metatarsal neck osteotomy [17], which
can be applied in a minimally invasive fashion
to reduce the plantar pressure of the metatarsal
head responsible for skin ulcerations in diabetic feet. Early studies demonstrate notable
improvement in plantar pressures with reduction in the rate of transfer lesions as compared
to historical rates with metatarsal head resections [18]. However, in these cases, the need to
shorten the metatarsal bone must be weighed
against the need to maintain a functional metatarsal parabola to prevent recurrent or transfer
skin lesions.
Procedure
Patient remains in the supine position on the
operative table and the local block is completed
with the anesthetic agent of choice. The extrem-
ity is scrubbed and draped in routine aseptic
fashion. A 3mm incision is made dorsally at
the planned osteotomy site after uoroscopic
identication of the surgical neck of the metatarsal. A perpendicular or short oblique osteotomy will be made at the neck or diaphysis of
the affected lesser metatarsus [2–5]. The
authors prefer to complete this with a 12mm
Shannon burr at a speed of 1600 rounds per
minute and a torque of 80 N-m. Fluoroscopy
and manual manipulation of the metatarsal
head can be used again to conrm completion
of the osteotomy. Following the osteotomy, the
metatarsal head will freely displace dorsally.
Fixation is not commonly utilized, however,
can be used in the form of a K-wire to maintain
corrected position. Skin closure will be
achieved with a single suture. Full weightbearing in a “postoperative” shoe will be permitted immediately and used until bone healing
noted on radiographs.
Use ofFunctional Antibiotic Spacers
Elution of local antibiotics can yield high concentrations into target tissues and can be particularly effective in the setting of chronic
osteomyelitis and poorly perfused tissues.
Additionally, these antibiotics can be conjoined
with structural ller or spacers such as nonabsorbable polymethylmethacrylate impregnated cement, which can be particularly useful
when needing to replace osseous structure lost
during excision of infected tissue. Early randomized controlled trials demonstrate improved clinical cure rates when utilizing antibiotic
impregnated bone cement as bone ller in the
setting of diabetes related osteomyelitis [19].
Additionally, placement of antibiotic eluting
cement spacers has been shown to have longterm stability, even in weight-bearing zones [20].
While these techniques are still in their infancy,
newer devices and compositions will continue to
expand their utilization and efcacy in this eld
(Fig.26.3).
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
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cd
Fig. 26.3 Clinical images (a, c) and radiographic images (b, d) AP foot view—preoperative (a, b) and postoperative
(c, d) of right third toe proximal interphalangeal joint arthroplasty for rigid hammertoe correction
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J. S. Steinberg et al.
Osseous Midfoot Deformity
Ulcerations of the midfoot can lead to devastating outcomes. Literature shows that 9% of diabetic neuropathic patients with midfoot
ulcerations will go onto proximal amputation
[21]. As with forefoot ulcers, midfoot ulcers are
generally caused by increased plantar from a
Charcot, subluxed midfoot joint(s), exostosis,
poorly performed partial foot amputations [22–
24]. First line treatment for midfoot ulcerations is
external ofoading with surgical shoes, custom
shoes, total contact casting, or Charcot restraint
orthotic walker (CROW) boot. When conservative treatment fails, surgical intervention is generally recommended.
Midfoot Exostectomy
Plantar foot exostoses can lead to increased plantar pressure resulting in ulcerations. In patients
with stable midfoot joints, consolidated midfoot
Charcot, or who are not in immediate risk of midfoot collapse, an exostectomy may be an acceptable surgical option.
achieved. Layer closure is performed, dry sterile
dressing is applied.
Osseous Midfoot Reconstruction
When an exostectomy is not sufcient enough to
surgically treat the deformity, a reconstruction
may be necessary to stabilize the midfoot to prevent further joint collapse. If a reconstruction of
the midfoot is required, generally a combination
of osteotomies and fusions is needed as these are
multiple planar deformities (Fig.26.4). Extensive
preoperative planning is of paramount importance when treating Charcot deformities as the
goal of the reconstruction is to [25]:
• Maintain anatomic realignment
• Limit soft tissue dissection/use minimally
invasive internal xation
• Obtain joint fusion
• Fuse/xate joint one level beyond Charcot
affected midfoot
• Use rigid xation
• Shorten foot to reduce soft tissue tension
• Use of external xation if indicated
Procedure
The patient is positioned on the operating table in
the supine position with an ipsilateral hip bump.
The author discourages the use of tourniquet to
avoid incision healing complications. Incision
placement is generally along either the medial or
lateral glabrous function, depending on the laterality of the exostosis. This is recommended to allow
for weight-bearing and prevent wound dehiscence.
A 3cm incision is made along the glabrous junction care taken to avoid unnecessary undermining.
The muscle belly is retracted inferiorly and dissection is carried plantarly along the bones until the
exostosis is encountered. After adequate dissection of the exostosis a sagittal saw is used to resect
the prominence ush with the plantar border of the
midfoot bones. The author recommends resection
of an additional 3mm of bone to ensure the exostosis is resected. Fluoroscopy is used to conrm
resection of the exostosis. The incision is irrigated
with copious amounts of saline. Hemostasis is
Procedure
The patient is positioned on the operating table in
the supine position. Ipsilateral hip bump is recommended to prevent external rotation of the hip.
A thigh tourniquet is recommended for patients
without peripheral vascular disease. The equinus
deformity is generally addressed rst either by a
percutaneous tendo-achilles lengthening or gastrocnemius recession. The authors also recommend fusing the subtalar joint to stress shield the
midfoot correction. Incision placement is along
the medial glabrous junction of the midfoot, over
the base of the deformity. Dissection is carried
down to bone. A subperiosteal dissection is performed superiorly and inferiorly across the midfoot laterally. A second incision is placed along
the lateral glabrous and the subperiosteal dissection is then completed. After the dissection is
completed, the placement of the midfoot osteotomy is based on the deformity. A section of bone
in the midfoot is resected, to realign the foot in all
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
ab cd
ef hg
369
Fig. 26.4 Clinical images (a, b, e, f) and radiographic
imaging (c, d, g, h) multiple views—preoperative (a–d)
and postoperative (e–h) status post-single-stage multilevel, multi-plane, multi-tissue deformity Charcot recon-
three cardinal planes. It is also recommended to
prepare and fuse adjacent midfoot joints to
increase stability of the construct. After the midfoot is realigned and temporarily or provisionally
neutralized, rigid xation is placed. Options for
xation included plates and screws, intramedullary xation or external xation can be used.
Intramedullary beaming is recommended when
appropriate as it decreases soft tissue dissection
compared to the use of plating. Beaming from the
rst metatarsal across the midfoot to the talus is
performed to stabilize the medial column.
Followed by additional medial column beaming
from the second metatarsal into the talus and
lastly lateral column beaming from either the
fourth or fth metatarsal into the calcaneus. In
xating the lateral column, it is important to
address the calcaneal cuboid joint sag to prevent
increased pressure plantar to the cuboid.
Following internal xation and external xator
may be placed to further protect and ofoad the
reconstruction. Following the reconstruction
patients are non-weight-bearing for several
weeks with regular monitoring of plain lm
struction with TAL, corrective arthrodesis of the STJ,
TNJ, and CCJ, and corrective midfoot osteotomy with
internal xation
radiographs to observe bony consolidation at the
surgical sites.
Osseous Rearfoot andAnkle
Deformity
As is true with deformities within the remainder
of the extremity, instances where accommodative
treatment modalities are either insufcient or
inappropriate to address the rearfoot and/or ankle
deformity, corrective surgical treatments should
then be considered. Numerous scenarios may
contribute to a biomechanical deformity in the
rearfoot and ankle; however, fortunately several
treatment options exist in which to address these
cases. Ultimately, the specic treatment modality
should aim to correct the identied primary and
secondary deformities in order to balance the
deforming forces about the extremity and do so in
an effective and denitive manner with the least
potential for morbidity to the patient. Exact procedure selection for rearfoot and ankle reconstruction is largely based in the specic anatomic
370
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J. S. Steinberg et al.
level(s) and plane(s) of involvement which is
often identiable by a careful physical examination and with use of imaging modalities of plain
lm radiography and computed tomography.
Those cases where deformity is either not sufciently reducible manually, even after soft tissue
release, or is severe in extent, are largely addressed
with osseous reconstructive procedures.
Tibiotalocalcaneal Arthrodesis
Concomitant ankle and subtalar joint fusions, collectively a tibiotalocalcaneal (TTC) arthrodesis, is
often considered as a limb salvage procedure in
patients with complex pathologic conditions of
the rearfoot and/or ankle that may otherwise warrant a below the knee amputation [26–28]
(Fig.26.5). The TTC fusion is dened by certain
risk factors of patients undergoing the procedure
and includes individuals with comorbidities associated with poor surgical healing or with local
healing decits that predispose to a high rate of
delayed healing, nonunion, and malunion, among
others. The TTC fusion can be a viable and functional option for those with signicant deformity
of the rearfoot and/or ankle including signicant
malalignment, bone loss, and/or instability.
Perhaps the stereotypical example of such a surgical candidate is the Charcot’s neuroarthropathy
Fig. 26.5 Radiographic imaging lateral ankle view—postoperative (a–d) status post-tibiotalocalcaneal arthrodesis of
four different patients with various xation constructs
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
371
ankle and/or rearfoot; however, many other
instances do occur. The greatest drawbacks to the
TTC fusion are that it introduces a relatively large
amount of indwelling hardware, increasing the
risk of infectious processes, and requires major
additional surgery and thus surgical dissection
and rehabilitation. However, in the scenario where
the alternative treatment is a more proximal
amputation, a TTC may be considered as a useful
option (Fig.26.6).
a b cd
ef g
hi jk
Fig. 26.6 Clinical images and radiographic imaging
multiple views—preoperative (a–d) and postoperative
(e–k) status post-staged approach to multi-level, multiplane, multi-tissue type deformity reconstruction in the
face of inciting wound formation with infection to the
plantar foot with eradication of infection, optimization of
healing potential, soft tissue envelope closure, ofoading
circular external xator, subsequent corrective lateral
approach bular “takedown” tibiotalocalcaneal arthrodesis with TAL and PT tendon transfer
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J. S. Steinberg et al.
Procedure
The patient is positioned supine on the operating
table with the heel just distal to the edge of the
bed. An ipsilateral hip bump is utilized as warranted to attain vertical orientation of the foot and
avoid external rotation of the extremity. A platform fashioned from several folded blankets or
operative foam is utilized to elevate the operative
extremity above the level of the contralateral
extremity for ease of operative performance,
including for unobstructed use and views of intraoperative uoroscopy. Alternatively, to remove
the potential for obstruction the contralateral
extremity may be placed into “frog leg” positioning or may be secured with foam padding off the
bed entirely into a surgical stirrup or the like. A
thigh tourniquet may be placed in patients without
existing peripheral vascular disease and used in
accordance with individual surgeon preference.
The extremity is prepped and draped to at least the
level of the tibial tuberosity in order to maintain
accurate visualization for intraoperative alignment and orientation of the extremity as well as
for access during concomitantly performed procedures. Soft tissue procedures are largely performed rst in order to initiate, if not attain,
appropriate reducibility of the existing rearfoot
and/or ankle deformity. Equinus ankle deformity,
for instance, may be addressed rst either by a
tendo-achilles lengthening or tenotomy or gastrocnemius recession. Incision placement for the
tibiotalocalcaneal arthrodesis is largely dependent
upon the preferred surgical approach and hardware construct in which the surgeon will gain
access to the ankle and subtalar joints and place
denitive internal xation, respectively. An anterior, anteromedial, and anterolateral ankle incision will provide for direct access to the ankle
joint alone. An Ollier’s style dorsolateral foot
incision will provide for direct access to the subtalar joint alone. A utilitarian lateral incision will
provide for direct access to the ankle joint and
subtalar joint concomitantly; however, a distal
bular “takedown” osteotomy may be required in
order to appropriately gain surgical access to the
ankle joint. This approach does provide for concomitant access to both the ankle and subtalar
joints with the added benet of direct access to the
distal bular bone which may be utilized for both
structural and/or non- structural bone grafting as
warranted. Additionally, minimally invasive surgical joint preparation may be utilized from standard arthroscopic port locations at the
anterolateral, anteromedial, and posterolateral
and posteromedial ankle, as well as the anterolateral and posterolateral subtalar joint. This
approach has the benet of minimizing surgical
dissection; however, it requires greater surgical
skill and precision than the standard open
approach, requires additional equipment, and will
ultimately restrict one’s options for denitive xation construct. Standard open approach surgical
dissection is carried from skin, supercial fascia,
deep fascia, and periosteum/capsule to the level of
bone of the ankle and subtalar joints. A plethora
of instrumentation are available in which the cartilage of the corresponding surfaces of both the
ankle and subtalar joint is denuded to the level of
healthy and bleeding subchondral bone. Care is
taken in which to provide for a maintenance of
bone stock so as not to create an excessive amount
of bony resection which may add to a loss of
length and integrity of the extremity while simultaneously achieving any additional bony angular
or translational correction of the existing
deformity(ies) which was not attained in soft tissue corrective procedures. Once the joints are sufciently prepared, ushed, grafted as preferred,
and reduction is attainable, the ankle and subtalar
joints are neutralized into the reduced positions
and preferred denitive xation is placed. Given
the extent and location of the procedures a surgical drain is placed and a layered closure is performed. The extremity is placed into a thick,
well-padded, and compressive splint and the
patient is maintained in a non-weight-bearing status for a minimum of 2 months with monitoring
of appropriate clinical and radiographic healing.
Pantalar Arthrodesis
When signicant deformity, represented by complex malalignment, bone loss, bone infection or
necrosis, and/or instability occurs at both the level
of the ankle and/or foot and within the foot, a pantalar arthrodesis may be considered as a functional
means of limb preservation [29]. This option pro-
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
abc
de f
373
Fig. 26.7 Radiographic images (a–f) multiple views—
preoperative (a–c) and postoperative (d–f) status post
staged approach to multi-level, multiplanar, multi-tissue
type deformity reconstruction in the face of inciting wound
formation with infection to the plantar-lateral foot with
subsequent acute Charcot neuroarthropathy of the ankle
duces rigid stability and, when performed correctly, adequate reduction of malalignment of the
foot and ankle complexes for ambulation
(Fig.26.7). Numerous approaches and constructs
are available to the surgeon and specic selection
is largely driven by individual patient presentation,
including but not limited to the exact anatomic
location(s), plane(s), and severity of involvement
of their pathology. As is the case with the tibiotalocalcaneal arthrodesis, the pantalar arthrodesis
requires additional surgery and rehabilitation,
including the ubiquitous placement of internal
xation. Additionally, with absolute stability and
rigidity to the ankle and foot, patients require a
rocker-bottom sole modication to their shoe gear
in order to afford appropriate midstance rocker for
more normal gait. However, the alternative, and
perhaps quite viable and functional option in the
face of failure of the pantalar arthrodesis, may well
be a below the knee amputation. Herscovici etal.
[30] saw acceptable outcomes including zero
amputations in their 20 patients undergoing panta-
joint with eradication of infection, optimization of healing
potential, soft tissue envelope closure, ofoading circular
external xator with antibiotic spacer and, progression of
ankle Charcot neuroarthropathy to consolidated state, and
subsequent corrective combined lateral approach bular
“takedown” and medial approach Pantalar arthrodesis
lar arthrodesis from either severe post-traumatic or
neuropathic arthropathy with an average of
46month follow-up. They concluded that pantalar
arthrodesis is a reasonable limb salvage option
regardless of the cause of disability or specic
internal xation device.
Procedure
Generally, for a combined medial and lateral
approach the patient is positioned supine on the
operating table with the heel just distal to the edge
of the bed. An ipsilateral hip bump is utilized as
warranted to attain vertical orientation of the foot
and avoid external rotation of the extremity. A
platform fashioned from several folded blankets or
operative foam is utilized to elevate the operative
extremity above the level of the contralateral
extremity for ease of operative performance,
including for unobstructed use of intraoperative
uoroscopy. Alternatively, to remove the potential
for obstruction the contralateral extremity may be
placed into “frog leg” positioning or may be
374
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J. S. Steinberg et al.
secured with foam padding off the bed entirely
into a surgical stirrup or the like. A thigh tourniquet may be placed in patients without existing
peripheral vascular disease and used according to
surgeon preference. The extremity is prepped and
draped to at least the level of the tibial tuberosity in
order to maintain accurate visualization for intraoperative alignment and orientation of the extremity as well as for access during concomitantly
performed procedures. Soft tissue procedures are
largely performed rst in order to initiate, if not
attain, appropriate reducibility of the existing rearfoot and/or ankle deformity. Equinus ankle deformity, for instance, may be addressed rst either by
a tendo-achilles lengthening or tenotomy or gastrocnemius recession. Incision placement for the
combined medial and lateral approach pantalar
arthrodesis is dictated by access for appropriate
performance of bony preparation and hardware
placement in which the surgeon will gain access to
the ankle and subtalar joints, as well as the talonavicular and calcaneocuboid joints. A curvilinear
lateral incision will provide for direct access to the
ankle, subtalar, and calcaneocuboid joints concomitantly; however, a distal bular “takedown”
osteotomy must be performed in order to appropriately gain surgical access to the ankle joint. As
with the tibiotalocalcaneal arthrodesis, this
approach provides for concomitant access to multiple joints with the added benet of direct access
to the distal bular bone which may be utilized for
both structural and/or non-structural bone grafting. A medial incision from the tip of the medial
malleolus to the skin overlying the naviculocuneiform joint provides direct access to the talonavicular joint. Standard open approach surgical
dissection at each incision is carried from skin,
supercial fascia, deep fascia, and capsule to the
level of bone of the ankle, subtalar, calcaneocuboid, and talonavicular joints. A plethora of instrumentation are available in which the cartilage of
the corresponding surfaces of the joints of interest
is denuded to the level of healthy and bleeding
subchondral bone. Again, care is taken in which to
provide for a maintenance of bone stock so as not
to create an excessive amount of bony resection
which may add to a loss of length and integrity of
the extremity while simultaneously achieving any
additional bony angular or translational correction
of the existing deformity(ies) which was not
attained in soft tissue corrective procedures. Once
the joints are sufciently prepared, ushed, grafted
as preferred, and reduction is attainable, the ankle,
subtalar, talonavicular, and calcaneocuboid joints
are neutralized into their, respectively, reduced
positions and preferred denitive xation is
placed. Given the extent and location of the procedures a surgical drain is placed and a layered closure is performed. The extremity is placed into a
thick, well-padded, and compressive splint and the
patient is maintained in a non- weight- bearing status for a minimum of 2 months with monitoring of
appropriate clinical and radiographic healing.
Adjunctive Procedures
Outside of the auspices of this discussion, but
rather important for considerations in osseous
reconstruction of the rearfoot and ankle are
adjunctive procedures often performed as a supplementary portion of the aforementioned tibiotalocalcaneal and pantalar fusions in the complex
patient population. The talectomy and the supramalleolar osteotomy are extraordinarily useful
adjuncts to the already advantageous osseous
reconstruction procedure options and should be
considered as viable adjuncts in the surgeons
perioperative planning.
Talectomy
Surgical correction of severe osseous deformity
and/or osteonecrosis and/or osteomyelitis using a
talectomy procedure has previously been
described in many lower extremity pathologies
and remains a powerful adjunct within the reconstructive options in the limb salvage patient population. It appears that the mere removal of
chronically infected and/or necrotic bone of the
talus can provide the means in which to appropriately reduce existing malalignment and rid the
body of potentially harmful and unstable tissues.
In the complex patient population talectomy is
combined as part of a reconstructive procedure in
the form of tibiocalcaneal fusion or pantalar
fusion (Fig.26.8). Langan etal. saw limb salvage
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