Surgical Reconstruction of the Diabetic Foot: A Salvage Approach for Midfoot Collapse

Abstract

Between 1985 and 1993, 18 patients representing 21 feet underwent surgical reconstruction for diabetic neuroarthropathy with collapse of the midfoot. Forty-seven percent (10/21) of these feet presented with plantar pressure ulcers. Reconstruction involved reduction and fusion of collapsed joints, using internal fixation to restore foot shape and improve weightbearing alignment. The average follow-up in these patients was 28 months (range, 6-84 months). Limb salvage was obtained in 18 of 21 feet. Average time to radiographic union was 5 months (range, 3-9 months). Improvement in shoe fit and ambulatory status was noted for 13 of the 15 patients who had successful reconstruction. Forty-seven percent of the reviewed cases were without any complication throughout their postoperative course. Seventy percent of the presenting ulcers healed without incident. There were no recurrent midfoot ulcers.

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

“…Despite the fact that an open wound may increase the risk for complications [4], we observed no major infectious complications. Other complications in our series were high when compared to studies with secondary intervention strategy [3,10,16,17]. Hardware failure often coincides with the nonunion rate which was substantially high in our (23%) as in other series (0-30%, Table 7).…”

“…Limbs with open ulceration at the initial presentation and limbs with recurrent ulceration have decreased limb survival rate compared to feet without ulcers, adding to an annual limb amputation rate of approximately 1% to 5% [21,23,29]. The goals of treatment should not be merely to save the limb [10,[19][20][21][22]: Pinzur proposed the goal include a long-term infection-and ulcer-free plantigrade and stable foot that allows the patient to walk with commercially available depth-inlay therapeutic footwear [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].…”

Casting of Recurrent Diabetic Foot Ulcers

“…Part of this lack of efficacy is probably related to poor compliance and partly to ineffective reduction of increased biomechical stress in patients with foot deformities. Several surgical procedures, such as corrective foot surgery (12,13) and Achilles tendon lengthening (14), have been proposed to improve the altered biomechanics and to prevent reulceration. However, in our experience, the ulcer did not recur on the same area in most patients, suggesting that the whole foot, and not a specific area, is at risk.…”

Charcot neuroarthropathy in diabetes mellitus

“…Surgical correction of deformities has been used with variable results in chronic CN. Techniques such as arthrodesis [82,116], exostectomies [117], reconstruction [118,119,120] and Achilles tendon lengthening [121] have been carried out. In one of the largest series, 221 cases of CN were reported, whereby surgical arthrodesis was indicated in two-thirds of the hind foot in CN patients, whereas only one-third of the mid-tarsal joint CN required surgery [123].…”