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

   Another advantage of external fixation is related to the relative noninvasive nature of the fixation. Since external fixation is done percutaneously, there is no need for excessive dissection. Plastic reconstruction of ulcerations, whether it is flap closure and/or a split thickness skin graft, requires immobilization for proper healing. External fixation acts as a pseudo cast, providing immobilization for a superior wound healing environment. Since there is no need for a cast with external fixation, it becomes possible to visualize and access the plastic surgery closure daily if necessary. Unlike internal fixation, external fixation is accessible at all times. Therefore, the surgeon has the ability to make postoperative adjustments to optimize the fixation.

What Constitutes Success With Charcot Reconstruction?

   One should make every attempt to treat the rocker bottom foot with conservative care first. If the Charcot foot is braceable (i.e., the foot is suitable for ambulation without cutaneous breakdown), one should consider bracing the treatment of choice. Pinzur reported that 87 of the 147 (59.2 percent) feet treated for midfoot disease achieved long-term closure without surgical intervention.5 When conservative care fails, podiatric clinicians should consider reconstruction.

   Keep in mind that midfoot Charcot reconstruction is a salvage procedure. Therefore, we cannot judge reconstruction with the same criteria as an elective midfoot arthrodesis. A growing body of research describes a change in the way we measure the success of Charcot reconstruction.6 Remember, the goal is limb salvage. We are starting with an unstable, non-braceable, rocker bottom, ulcerative foot that has failed conservative care. Under these criteria, the patient has very few treatment options. A midfoot arthrodesis gives the patient the chance to heal a chronic wound while maintaining a functional limb.

   Therefore, the goal of reconstruction is to return the patient to his or her previous level of function by giving the patient a functional, braceable foot with intact integument. Using this definition of success, complications such as osteotomy site pseudoarthrosis may be insignificant. If the patient is able to heal the ulceration and return to his or her previous level of function, the Charcot reconstruction is a success.

What The Research Reveals About Midfoot Reconstruction

   The research on midfoot reconstruction over the past several years has focused on internal fixation for midfoot arthrodesis. Unfortunately, success rates with internal fixation have often been unsatisfactory. Although external fixation for Charcot reconstruction is relatively new, recent literature reports exciting success rates. Again it must be stressed that success represents patients who had functional, braceable feet with intact integument.

   Cooper reported on the use of Ilizarov external fixation for midfoot arthrodesis. Fourteen patients underwent midfoot arthrodesis with bone graft. At a mean follow-up of 41 months, 100 percent of these patients went on to function at a level equal to the ability they had prior to the Charcot deformity.1 Farber reported 10 of 11 patents who had undergone midfoot reconstruction with external fixation returned to therapeutic footwear at an average of 24 months.7
   Although these results are promising, they are still early results. Further research with long-term follow-up is necessary before the rocker bottom reconstruction becomes the definitive treatment for a collapsed Charcot midfoot.

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