Is Rocker Bottom Reconstruction A Viable Option For Limb Preservation?

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Here is a preoperative view of an ulcer secondary to a rocker bottom foot.
Here is a view of the same foot after surgeons performed an excision with a midfoot osteotomy.
One can now see a stable, braceable and functional foot with intact integument.
Here is a preoperative view of an ulceration secondary to a rocker bottom foot.
Here is a view of the same foot after a midfoot osteotomy with rotational flap coverage.
After surgeons utilized external fixation to protect flap closure, one can now see a stable, braceable and functional foot with intact integument.
Is Rocker Bottom Reconstruction A Viable Option For Limb Preservation?
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Author(s): 
By Scott Neville, DPM, Peter Blume, DPM, and Jonathan Key, DPM

   Although amputations have their place in the treatment of the Charcot foot, reconstruction is an attractive alternative for limb salvage. Rocker bottom feet can be classified into two groups based on the motion available at the midtarsal joint: stable or unstable. Stable forefeet that have failed conservative care may be candidates for exostectomy with plastic surgery closure. As a rule, lateral rocker bottom ulcerations are the result of a stable deformity. In the event that an exostectomy will allow for relief of the deforming forces, one should consider this the treatment of choice.

   One must also address the associated biomechanical flaws if long-term closure is to be successful. The unstable rocker bottom foot will not allow the forefoot to function as a rigid lever during the propulsive phase of gait. The rocker bottom collapse allows excess force to be distributed to the midfoot, leading to progressive midtarsal joint destruction.

   When it comes to ulcerations that result from an unstable forefoot, clinicians will often locate these at the medial midfoot. If one performs a simple exostectomy on this unstable foot, further forefoot collapse will result in reulceration. Although we must evaluate every surgical candidate individually, a reconstructive midfoot osteotomy is often indicated for the unstable rocker bottom foot.

Why Internal Fixation Should Be Avoided With Chronic Midfoot Ulcerations

   Several procedures have been proposed to correct the osseous etiology that causes midfoot ulcerations. Several authors have discussed the use of internal fixation for Charcot reconstruction. However, there are many complications associated with this approach. The severe osteopenia associated with the Charcot disease process makes screw purchase problematic. According to AO principles, poor bone stock is a relative contraindication for the use of internal fixation. This osteopenic bone often leads to internal fixation failure.

   The typical chronic Charcot ulceration that has been present for several months is often colonized with deleterious bacteria. Even meticulous debridement cannot remove all bacterial contaminants. This colonization leads to an increased risk for postoperative infection. This risk is compounded by utilizing internal fixation, which may act as a nidus for infection. Therefore, our contention is that an integument breakdown is a relative contraindication to using internal fixation. This argument is made even stronger by the availability of a viable, if not superior, alternative method of fixation.

Assessing The Benefits Of External Fixation

   External fixation provides several advantages over the previously mentioned options. The Ilizarov fine wire methodology avoids the need for screw thread purchase because the fixation is based on non-threaded fine wires under tension. These tensioned fine wires provide multiple points of fixation oriented in multiple planes. When these wires are bowed prior to tensioning, they also provide compression. External fixation avoids the need for retained hardware, which may be a source of infection.

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