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University of Virginia Orthopaedic Surgery
Disclosures
- OTA- Education Committee
- DepuySynthes- Consulting
- Globus Medical- Consulting
- AO North America- Teach Courses
- Elsevier- Royalties
- METRC- Site PI
David B. Weiss, MD Division Head Orthopaedic Trauma University of - - PowerPoint PPT Presentation
David B. Weiss, MD Division Head Orthopaedic Trauma University of - - PowerPoint PPT Presentation
David B. Weiss, MD Division Head Orthopaedic Trauma University of Virginia Disclosures OTA- Education Committee DepuySynthes- Consulting Globus Medical- Consulting AO North America- Teach Courses Elsevier- Royalties
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University of Virginia Orthopaedic Surgery
The Problem
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University of Virginia Orthopaedic Surgery
The Problem
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University of Virginia Orthopaedic Surgery
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University of Virginia Orthopaedic Surgery
Neuropathy
- Diabetes
- Diabetes
- Diabetes
- But also can see in other medical conditions
- Vasculopathy plays role in ability to heal
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University of Virginia Orthopaedic Surgery
Neuropathy
- Can’t protect repair
- No pain sensors to limit activity
Louettafootandankle.com
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University of Virginia Orthopaedic Surgery
Options for treatment
- Casting
- CRPP
- Ex-fix (circular vs uniplanar)
- TTC Nail
- ORIF plates and screws
- Amputation (always a salvage option)
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University of Virginia Orthopaedic Surgery
Treatment
- Ex-fix-
– Need to have compliant patient – Uniplanar- long bars to limit weightbearing – Limited correction power – Circular/multi-planar
- More complicated to apply
- Needs frequent monitoring (pin loosening/infection)
- Committed patient and surgeon (and office staff)
- I use in obese- May allow some weight bearing
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University of Virginia Orthopaedic Surgery
TSF
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University of Virginia Orthopaedic Surgery
Treatment
- TTC Nail
– Good option if poor soft tissue envelope – May add biomechanical strength – Joint preparation limited (none?) – Compromise sub-talar (unaffected) joint – I use in elderly with pre-existing DJD or dementia
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University of Virginia Orthopaedic Surgery
TTC Nail
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University of Virginia Orthopaedic Surgery
Treatment
- ORIF- plates and screws
– Most familiar – Allows for anatomic reduction – Use larger plates and more screws – May also add trans-articular pins – Double time on immobilization/weight bearing restrictions – I use on most neuropathic ankles- esp if well controlled
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University of Virginia Orthopaedic Surgery
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University of Virginia Orthopaedic Surgery
Post op
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University of Virginia Orthopaedic Surgery
Evidence
Trans-articular steinman pins as adjuncts NWB 12 weeks Cast x 3 mos for wb Then AFO or appropriate inserts 13/15 successful
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University of Virginia Orthopaedic Surgery
Evidence
Protected wb at 2 weeks in FAW/Cast retrospective 60% neuropathy, 33 % A1C >7 48 pts with ORIF- 25% complication rate. Overall relatively healthy group
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University of Virginia Orthopaedic Surgery
Rehab
- Slow down rehab
- Double the limitations time
- Longer follow up to ensure healed/stable
- Accept some HW breakage if stable
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University of Virginia Orthopaedic Surgery
What if disaster strikes?
- Can always default to
– Fusion with TTC nail or open fusion – BKA
- Important to lay crepe early in treatment to
set realistic expectations
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University of Virginia Orthopaedic Surgery
Summary
- Challenging cases/patients
- Need thorough eval and optimization of
medical co-morbidities
- Assume worst with fixation choices
- Set expectations early
- Know your limitations- refer to specialist if
needed
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University of Virginia Orthopaedic Surgery