Hartig N, Krenn S, Trnka H-J
Abteilung für Kinderorthopädie und Fußchirurgie, Orthopädisches Krankenhaus Speising, Speisingerstraße 109, 1130, Wien, Österreich,
Orthopade. 2015 Jan;44(1):14-24. doi: 10.1007/s00132-014-3058-8.
Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.
The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.
In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.
After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.
Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.
由于广泛的骨质流失以及足部相关的复杂不稳定和畸形，夏科氏关节病或神经骨关节病对骨科医生来说是一项挑战。溃疡为各种细菌提供了入口；因此，感染是常见的严重问题和并发症。谨慎选择治疗方法不仅对足部的正确对线和负重能力非常重要，而且对预防皮肤刺激或现有溃疡的愈合也有显著贡献。最重要的是，由突出的外生骨疣或轴向排列不齐引起的慢性足底溃疡，若无手术治疗几乎无法治愈。由于诊断需要个体化方法，尚未建立严格的治疗方案。
主要目标是减少溃疡和感染的数量，并将截肢风险降至最低。此外，还确定了并发症和合并症。胫跟关节融合术是一种非常常用的手术治疗选择。因此，以下文章将特别关注这种方法。
在12年期间（1999 - 2011年），对43例（46足）患有夏科氏足的患者进行了手术治疗。采用了以下方法：三关节融合术、距舟关节融合术、距下关节融合术、胫跟关节融合术和中足融合螺栓。应用了与后足和跗骨相关的关节融合术，最常见的是胫跟关节融合术。术前和术后通过石膏固定、Aircast步行鞋或其他矫形器减轻患足的负重对治疗至关重要。为了获得长期满意的效果，术后必须定制矫形鞋。
对16例有溃疡的足部进行手术治疗后，14例愈合，仅2例出现并发症，如感染、骨不连、距骨坏死和伤口愈合障碍。尽管大多数并发症可以治疗，但翻修手术经常是必要的。在这个群体中，无法避免3例截肢。
即使采用严格的无菌技术和多年治疗夏科氏关节病的经验，仍可能发生并发症，甚至导致截肢。夏科氏足的早期发现是最重要的因素，有助于降低发病率和进一步的并发症。合并症（如糖尿病）需要特别护理和最佳治疗，因为它们往往是手术效果不佳的原因。最后，及时的手术治疗可以降低溃疡率和相关并发症，如截肢。不幸的是，疾病的进展过程往往需要后续手术。
