Management of Midfoot Diabetic Neuroarthropathy

Abstract

Between 1986 and 1990, we treated 68 patients with diabetes and neuroarthropathy of the midfoot, 21 of whom had bilateral involvement. Patients were managed according to a strict protocol defined by activity of the neuroarthropathy, instability, ulceration, infection, and ischemia. Initial management of acute neuroarthropathy (18 feet) was open reduction and arthrodesis (8), a total-contact cast or brace (9), and amputation (1). All patients with subacute neuroarthropathy (30 feet) were initially treated in a total contact cast. Four of these feet subsequently required amputation, two required arthrodesis, and one required exostectomy. For chronic neuroarthropathy (41 feet), a total-contact cast or a molded orthotic insert with or without bracing was used initially in all feet. Subsequent surgical salvage for this group included arthrodesis (9), plantar exostectomy (6), amputation (2), and abscess drainage (2). Four patients died during this treatment period and 64 patients (85 feet) were evaluated at a mean interval of 3 years (range 1-6 years) after initiation of treatment. This treatment program was found to be successful in 82 of 85 feet treated.

Should One Consider Primary Surgical Reconstruction in Charcot Arthropathy of the Feet?

“…First, knowing which degree of instability and deformity will be at high risk of failure with nonsurgical treatment relies on judgment [21,23] and the risk factors are not well understood. Expert assessment of these key parameters represents the basis for most treatment protocols from centers with wide experience in Charcot feet [18,19,21,23,24,29]. On the other hand, we believe decision making for surgery in Charcot feet on the basis of any given algorithm requires assessment by someone with considerable experience with Charcot feet and it should not be left to the inexperienced [21].…”

“…Nonoperative immobilization techniques using specific orthoses or total contact casts still represent the mainstay for the initial phases of Charcot neuroarthropathy, while surgery is reserved for patients with infection, recurrent ulceration, and substantial deformity or joint instability not manageable by casting or orthotic devices [3,20,29]. As most Charcot feet manifest in the midfoot, the majority of studies describe lesions in the midfoot area [8,10,16,18,33,34,36]. However, the success of total contact casting even in the hands of a single experienced physician may result in subsequent ulcerations in 30% of the patients during the treatment [13].…”

Mid foot kinetics characterize structural polymorphism in diabetic foot disease

“…Mid foot force and pressures in diabetic, neuropathic subjects that exceed the upper 99% confidence limits for age-, gender-and race-matched control subjects should be used to signal the early need for off-loading particularly if feet are at risk for lower extremity amputation. A comparison of the magnitude and location of kinetic and pressure variables while walking barefoot and in therapeutic footwear may allow for a more precise evaluation of the ability of therapeutic shoes, bracing or a combination of both to protect the insensitive foot from further joint destruction, skin ulceration and lower extremity amputation (Bauman et al, 1963;Myerson et al, 1994). Elevated plantar forces and pressures during walking in subjects with neuropathy combined with bone loss may signal the onset of rapid and progressive deterioration in mid foot structure and alert the foot care specialist to prescribe improved methods of management to maintain walking while limiting disability.…”

Classifications in Brief: Eichenholtz Classification of Charcot Arthropathy

“…As such, in 1990 Shibata et al [21] added a fourth stage, Charcot foot Stage 0, to the conventional Eichenholtz classification ( Table 1). The addition of this prodromal stage has important therapeutic implications, because the immobilization and off-loading of feet with Stage 0 symptoms may prevent progression of skeletal destruction and deformity [13,16].…”

“…Charcot arthropathy can be challenging to diagnose, as its earliest manifestations (eg, swelling, inflammation and warmth) are similar to those seen with simple sprains, deep venous thrombosis, osteomyelitis, cellulitis, and rheumatoid arthritis [16]. In addition to joint deformity and instability, foot ulceration, infection, and, in the most severe cases, amputation, patients with Charcot arthropathy have a median survival of approximately 12 years less than that of the general population [23].…”