Fausto J. Ramos, DPM
Bon Secours NJ Health System/St. Mary Hospital Residency Program
drfaustoramos@hotmail.com

PRESENT MEMBER FEEDBACK

The following commentary was sent in by PRESENT members after reading the case presentation last week.  If you wish to add your comments, click on this EMAIL LINK

- My comment is concerning the decision to utilize a triple arthrodesis along with the ORIF of the ankle joint. It seems to me that staging this surgery would have been an alternative. Doing so may have maintained the ankle joint's function.

- It appears the ankle is fused in plantarflexion, which will only increase the load on the osteolytic metatarsals. The screw placement in the ankle fusion does not appear optimal. Also, I don't understand why the STJ and CC joints were fused. I wonder if the fixation in the 1st met fracture is stable enough for this disease. It's apparent the patient has atrophic charcot of the metatarsals and what appears to be proliferative charcot of the ankle. I would place the patient on fosamax and put in a posterior splint with a cold therapy bladder inside. In 1 -2 weeks I would operate, once the swelling is decreased. Surgical procedure: TAL, fuse the ankle and apply an external fixator frame.

- The case is very interesting. From the x-rays, the talus is not positioned correctly under the tibia, it is displaced laterally. In the lateral view, the talus is positioned anterior to the tibia, this causes significant mal-alignment problems with the midfoot. The foot appears to be plantarflexed and the calcaneous looks to be in a severe valgus position from the x-rays. The fixation that was used appears to be placed with disregard to the fusion surfaces and the thread lengths. From the films shown, there was no need to address the cc joint or the stj. They are clearly visualized and no compression of the joints is seen in the post operative films. The position of the hindfoot in the ankle mortise must be optimal and the calcaneal position must be correct. If the midfoot and hindfoot are not properly positioned the fusion of the medial column causes the patient to have a severe limp and painful lesions on the bottom of the foot.

- this sounds like Charcot before even seeing the x-rays. As for the procedure choice, I may be wrong, but it does not seem as if this was treated with Charcot in mind. Even if treating this purely as an orthopedic problem with ankle dislocation +the forefoot fxs w/o considering Charcot, why fuse the C-C and STJ?

- With this type of injury and chronicity, I think and IM nail or monolateral Ex Fix along with fixture of the metatarsal fx in the same manner would have been a better option. Also the Talus looks to be translated more lateral than it should be. The 2nd and 3rd metatarsal heads appear to be fractured and mal-positioned 4 weeks post injury. Was there an attempt to relocate and fixate? This is a great case to learn from. Thank you for sharing.

- The ankle fusion is controversial but based on the x-rays, one cannot argue against this. Were there any thoughts of a reduction with ankle arthrodiastasis with external fixation? Why fuse the STJ and CC joint? How neuropathic was this diabetic? Was ankle Charcot ruled out? There appears to be a body fx of the calcaneus. On the post op x-rays, why was the foot anteriorly translated on the tibia (it should be posterior) and why does the foot appear to have been fused in equinus?

This case certainly stimulated some great clinical discussion. I appreciate all the responses and would welcome any future comments. Hindsight is of course always 20:20, but there is much to be learned from complicated cases such as this one. We appreciate the author submitting this for discussion and welcome future cases for all of us to learn from.