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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


  1. David B. Weiss, MD Division Head Orthopaedic Trauma University of Virginia

  2. Disclosures • OTA- Education Committee • DepuySynthes- Consulting • Globus Medical- Consulting • AO North America- Teach Courses • Elsevier- Royalties • METRC- Site PI University of Virginia Orthopaedic Surgery

  3. The Problem University of Virginia Orthopaedic Surgery

  4. The Problem University of Virginia Orthopaedic Surgery

  5. University of Virginia Orthopaedic Surgery

  6. Neuropathy • Diabetes • Diabetes • Diabetes • But also can see in other medical conditions • Vasculopathy plays role in ability to heal University of Virginia Orthopaedic Surgery

  7. Neuropathy • Can’t protect repair • No pain sensors to limit activity Louettafootandankle.com University of Virginia Orthopaedic Surgery

  8. Options for treatment • Casting • CRPP • Ex-fix (circular vs uniplanar) • TTC Nail • ORIF plates and screws • Amputation (always a salvage option) University of Virginia Orthopaedic Surgery

  9. 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 University of Virginia Orthopaedic Surgery

  10. TSF University of Virginia Orthopaedic Surgery

  11. 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 University of Virginia Orthopaedic Surgery

  12. TTC Nail University of Virginia Orthopaedic Surgery

  13. 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 University of Virginia Orthopaedic Surgery

  14. University of Virginia Orthopaedic Surgery

  15. Post op University of Virginia Orthopaedic Surgery

  16. Evidence Trans-articular steinman pins as adjuncts NWB 12 weeks Cast x 3 mos for wb Then AFO or appropriate inserts 13/15 successful University of Virginia Orthopaedic Surgery

  17. 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 University of Virginia Orthopaedic Surgery

  18. Rehab • Slow down rehab • Double the limitations time • Longer follow up to ensure healed/stable • Accept some HW breakage if stable University of Virginia Orthopaedic Surgery

  19. 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 University of Virginia Orthopaedic Surgery

  20. 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 University of Virginia Orthopaedic Surgery

  21. Questions/Discussion University of Virginia Orthopaedic Surgery

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