Volkering C, Kriegelstein S, Kessler S, Walther M
ORTHEGA-Orthopädie am Englischen Garten , Martiusstrasse 3, 80802, München, Deutschland,
Oper Orthop Traumatol. 2015 Apr;27(2):101-13. doi: 10.1007/s00064-014-0339-7. Epub 2015 Apr 10.
The main problem of patients with Charcot foot is their inability to off-load. Therefore the risk of internal fixation failure is increased, especially in hindfoot instability (Sanders type IV) with osteonecrosis of the talus. Combination of internal and additional external fixation guarantees the reconstruction and improves surgical outcome. The main objective of this surgery is to obtain a resilient, plantigrade foot that is shoeable in custom-made orthopedic shoes.
Charcot foot with instable collapse of the hindfoot with or without fragment dislocation, with or without (noninfected) ulceration not shoeable in custom-made orthopedic shoes.
Very poor general condition, non-reconstructible peripheral vascular disease, deep infection and defects in the region of surgery which makes amputation nescessary, and poor patient compliance.
Excision of the distal fibula and removal of the destroyed talus body using a lateral approach. Medial approach to remove the medial malleolus. Tibiocalcaneal fusion using screws for internal fixation. Fusion of the talus head to the anterior tibia. Ilizarov external fixateur to stabilize the internal fixation.
Off-loading for 3 months, then CT scan to verify bony fusion and according to the findings stepwise weight-bearing in a cast or walker over 4-6 weeks. Then custom-made orthopedic shoes with a high shaft and insoles for neuropathic patients and full weight-bearing.
In a retrospective cohort study, 14 of 16 patients could be fitted in custom-made shoes after undergoing tibiocalcaneal fusion. During follow-up, 2 patients required below-knee amputation, 3 patients had stress fractures of the tibia, one related to a pin track infection. All patients had a bony fusion of calcaneus and tibia; 10 of 16 patients had fusion of midfoot/talus head and the distal tibia. The 10 patients who had an ulcer before surgery could be healed. In 1 patient, a heel ulcer developed due to talipes calcaneus.
夏科氏足患者的主要问题是无法减轻负重。因此，内固定失败的风险增加，尤其是在距骨坏死的后足不稳（桑德斯IV型）患者中。内固定与额外的外固定相结合可确保重建并改善手术效果。该手术的主要目的是获得一个有弹性、足底着地的足部，使其能够穿着定制的矫形鞋。
伴有或不伴有骨折块脱位的后足不稳定塌陷的夏科氏足，伴有或不伴有（未感染的）溃疡，无法穿着定制的矫形鞋。
一般状况极差、不可重建的外周血管疾病、深部感染以及手术区域存在需要截肢的缺损，以及患者依从性差。
采用外侧入路切除腓骨远端并去除受损的距骨体。采用内侧入路切除内踝。使用螺钉进行胫跟融合内固定。将距骨头与胫骨前部融合。使用伊里扎洛夫外固定器稳定内固定。
减轻负重3个月，然后进行CT扫描以验证骨融合情况，并根据检查结果在4至6周内逐步在石膏或助行器辅助下负重。然后穿着为神经病变患者设计的高筒定制矫形鞋并完全负重。
在一项回顾性队列研究中，16例患者中有14例在接受胫跟融合术后能够穿上定制鞋。在随访期间，2例患者需要进行膝下截肢，3例患者发生胫骨应力性骨折，其中1例与针道感染有关。所有患者的跟骨和胫骨均实现骨融合；16例患者中有10例中足/距骨头与胫骨远端融合。术前有溃疡的10例患者溃疡得以愈合。1例患者因跟腱足畸形出现足跟溃疡。
