Zusammenfassung
Hintergrund
Die Charcot-Arthropathie oder Neuroosteoarthropathie stellt aufgrund des ausgedehnten Knochenverlusts und der damit verbundenen komplexen Instabilität und Fußfehlstellung eine Herausforderung für den Orthopäden dar. Vorbestehende Ulzerationen erhöhen das Infektrisiko, da diese eine Eintrittspforte für diverse Keime darstellen können. Die Wahl der Behandlungsmethode ist also nicht nur für die korrekte Positionierung und die Endbelastbarkeit des Fußes entscheidend, sie trägt auch maßgeblich zur Vorbeugung von Hautirritationen bzw. der Sanierung von Ulzerationen bei. Vor allem plantare, durch prominente Exostosen oder Achsfehlstellungen hervorgerufene chronische Ulzerationen sind ohne operativen Eingriff nahezu nicht therapierbar. Die Diagnose verlangt eine individuelle Vorgehensweise, weshalb bisher noch kein strenges Therapieregime etabliert werden konnte.
Fragestellung
Zielsetzung war es, durch Senkung der Ulzerationsrate die Anzahl an Infektionen und damit auch der Gefahr einer Amputation zu minimieren. Zusätzlich wurden Komplikationen sowie Begleiterkrankungen ermittelt. Neben verschiedensten Osteosyntheseverfahren ist die tibiokalkaneare Arthrodese eine häufig angewandte Operationstechnik, auf die im Folgenden das Hauptaugenmerk gerichtet wurde.
Material und Methoden
Im Zeitraum von 12 Jahren (1999–2011) wurden 43 Patienten mit Charcot-Fuß (46 Füße) operativ versorgt. Zur Anwendung kamen Triple-, Talonavikular-, subtalare und tibiokalkaneare Arthrodesen sowie „Midfoot Fusion Bolts”. Die Versteifungen betrafen also den Rückfuß und Tarsus, wobei am häufigsten die tibiokalkaneare Arthrodese angewandt wurde. Essentieller Bestandteil der Behandlung war die sowohl prä- als auch postoperative Entlastung der betroffenen Extremität durch Unterschenkelgips, Aircast®-Walker-Stiefel oder Orthese. Nach Beendigung des postoperativen Procederes ist der orthopädische Maßschuh zur langfristigen Beschwerdefreiheit unverzichtbar.
Ergebnisse
Durch die operative Therapie konnten 16 präoperativ bestehende Ulzerationen auf verringert werden. Leider traten bei diesem Patientenstamm auch gehäuft Komplikationen, wie Infektionen, Pseudoarthrosen, Talusnekrosen und Wundheilungsstörungen auf. Es kam in Folge gehäuft zu Revisionsoperationen, wodurch der Großteil an Komplikationen behandelt werden konnte. Leider mussten in diesem Kollektiv dennoch 3 Amputationen durchgeführt werden.
Schlussfolgerung
Selbst durch striktes aseptisches Vorgehen und langjähriger Erfahrung kann es immer wieder zu Komplikationen kommen, die bis zum Verlust einer Extremität führen. Die Früherkennung ist der wichtigste Faktor beim Charcot-Fuß. Dadurch können Komplikationen vermieden und die Morbidität gesenkt werden. Begleiterkrankungen, wie Diabetes mellitus, bedürfen spezieller Betreuung und optimaler Therapie, da diese für ein schlechtes Outcome der chirurgischen Intervention wesentlich mitverantwortlich sind. Durch einen zeitnahen operativen Eingriff kann ein plantigrader, voll belastbarer Fuß rekonstruiert und Komplikationen vermieden werden. Langfristig erfordert der progrediente Krankheitsverlauf jedoch vielfach Folgeoperationen.
Abstract
Background
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.
Objectives
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.
Materials and methods
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.
Results
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.
Conclusion
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.
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N. Hartig, S. Krenn und H.-J. Trnka geben an, dass kein Interessenkonflikt besteht.
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Hartig, N., Krenn, S. & Trnka, HJ. Operative Versorgung des Charcot-Fußes am Rückfuß. Orthopäde 44, 14–24 (2015). https://doi.org/10.1007/s00132-014-3058-8
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DOI: https://doi.org/10.1007/s00132-014-3058-8