Journal of Foot and Ankle Surgery (Asia Pacific)

Register      Login

VOLUME 10 , ISSUE 4 ( October-December, 2023 ) > List of Articles

ORIGINAL RESEARCH

Midfoot Charcot and Need for Arch Reconstruction and Superconstruct—“Lessons Learnt”: Multicentric Indian Experience

Rajagopalakrishnan Ramakanth, Rajesh Simon, Sundararajan Silvampatti Ramasamy, Abhishek Kini, Pratheeban Karthikeyan, Terence Dsouza, Shanmuganathan Rajasekaran, Madhu Periasamy

Keywords : Beam screws, Charcot's arthropathy, Diabetic mellitus, Lateral column fusion, Medial column fusion, Midfoot, Superconstruct

Citation Information : Ramakanth R, Simon R, Ramasamy SS, Kini A, Karthikeyan P, Dsouza T, Rajasekaran S, Periasamy M. Midfoot Charcot and Need for Arch Reconstruction and Superconstruct—“Lessons Learnt”: Multicentric Indian Experience. J Foot Ankle Surg Asia-Pacific 2023; 10 (4):198-207.

DOI: 10.5005/jp-journals-10040-1324

License: CC BY-NC 4.0

Published Online: 25-10-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Abstract

Aims and background: Charcot's neuroarthropathy (CN) affecting the midfoot leads to fractures and dislocation of the tarsal bones and displaced predominantly to the plantar aspect of the foot. Further, loading on these bony prominences leads to midfoot ulcers. Hence, corrective fusion of the involved medial and/or lateral columns is necessary to protect the foot from ulcers and recurrent infections. Our primary objective was to assess the radiological and functional outcomes of midfoot fusion in CN. A secondary aim was to estimate the incidence of complications such as loss of fixation, implant fracture, and wound dehiscence following the procedure. Materials and methods: This is a retrospective study of all patients operated in three different centers by four different surgeons, between 2018 and 2022. All patients who were diagnosed with Charcot's arthropathy of the midfoot were included in the study. Patients with hindfoot Charcot's arthropathy, arthritis due to posttraumatic, inflammatory, and infective sequelae were excluded. Data (radiological and functional) of all patients in the three orthopedic centers were collected. Functional outcomes were assessed using the midfoot—American Orthopaedic Foot and Ankle Society (AOFAS) and Foot and Ankle Outcome Score (FAOS) scoring system preoperatively and at the final follow-up. Radiological assessment was done for union and the lateral talometatarsal (TMT) (Meary's) angle, talo-first metatarsal angle in antero-posterior (AP) view, calcaneal pitch, and cuboid height were utilized for assessing the foot reconstruction in sagittal and axial planes. Results: We had a total of 98 patients (center-1—55), (center-2—15), and (center-3—28) with a mean follow-up ranging from 10 ± 2 to 79 ± 12 months. There was significant improvement in midfoot AOFAS scores and FAOS postoperatively across the centers; however, it was statistically significant in center-1 (p-value = 0.0005) and center-2 (p-value = 0.042). Stable union (bony/fibrous) ranged between 78.5 and 95%. Meary's angle improved in all centers, and it was statistically significant in center-1 (p-value = 0.0005), talar-1st MT angle in AP view, and cuboid height improved significantly in center-1 and 2 (p-value = 0.0005) while calcaneal pitch showed statistically significant improvement center-1 (p-value = 0.042), and center-3 (p-value = 0.0005). The total complication rate ranged between 46% and 51% [minor (6–23%), major (25–40%)] with screw breakage at the TMT junction being the most common complication encountered. The reoperation rate ranged from 0 to 27% across the centers. Only one patient needed amputation due to recurrent infection. Conclusion: Based on the observations in this study, we would recommend early surgical intervention in midfoot CN. Medial and lateral column fusion with intramedullary beam screws with or without superconstruct results in an acceptable bony union/fibrous union that provides a plantigrade stable foot despite complications like implant breakage, loss of fixation, and wound infections.


HTML PDF Share
  1. Silvampatti S, Nagaraja HS, Rajasekaran S. Midfoot Charcot arthropathy: overview and surgical management. J Foot Ankle Surg (Asia-Pacific) 2016;3(2):97–106. DOI: 10.5005/jp-journals-10040-1056
  2. Campbell JT. Intra-articular neuropathic fracture of the calcaneal body treated by open reduction and subtalar arthrodesis. Foot Ankle Int 2001;22(5):440–444. DOI: 10.1177/107110070102200514
  3. Saltzman CL, Hagy ML, Zimmerman B, et al. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet? Clin Orthop Relat Res 2005;435:185–190. DOI: 10.1097/00003086-200506000-00026
  4. Burns PR, Wukich DK. Surgical reconstruction of the Charcot rearfoot and ankle. Clin Podiatr Med Surg 2008;25(1):95–120. DOI: 10.1016/j.cpm.2007.10.008
  5. Stone NC, Daniels TR. Midfoot and hindfoot arthrodeses in diabetic Charcot arthropathy. Can J Surg 2000;43(6):449–455. PMID: 11129834.
  6. Fujita T, Shiba H, Van Dyke TE, et al. Differential effects of growth factors and cytokines on the synthesis of SPARC, DNA, fibronectin and alkaline phosphatase activity in human periodontal cells. Cell Biol Int 2004;28(4):281–286. DOI: 10.1016/j.cellbi.2003.12.007
  7. Simon SR, Tejwani SG, Wilson DL, et al. Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82-A(7):939–950. DOI: 10.2106/00004623-200007000-00005
  8. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a salvageapproach for midfoot collapse. Foot Ankle Int 1996;17(6):325–330. DOI: 10.1177/107110079601700605
  9. Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabeticneuropathic arthropathy of the foot and ankle. J Bone Joint Surg Am 1993;75(7):1056–1066. DOI: 10.2106/00004623-199307000-00012
  10. Sammarco VJ, Sammarco GJ, Walker EW Jr, et al. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. J Bone Joint Surg Am 2009;91(1):80–91. DOI: 10.2106/JBJS.G.01629
  11. Rooney J, Hutabarat S, Grujic L, et al. Surgical reconstruction of the neuropathic foot. The Foot 2002;12(4):213–223. DOI: 10.1016/S0958259202000706
  12. Ferreira FC, Simões da Silva AP, Costa MT, et al. Epidemiological aspects of foot and ankle injury in the diabetic patient. Acta Orthop Bras 2010;18(3).
  13. Brodsky JW, Rouse AM. Exostectomy for symptomatic bony prominences in diabetic Charcot feet. Clin Orthop Relat Res 1993;296:21–26. PMID: 8222428.
  14. Eichenholtz SN. Charcot joints. Springfield, IL: Charles C. Thomas; 1966. pp. 3–8.
  15. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle int 1994;15(7):349–353. DOI: 10.1177/107110079401500701
  16. Roos E M, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int 2001;22(10):788–794. DOI: 10.1177/107110070102201004
  17. Wukich DK, Raspovic KM, Hobizal KB, et al. Radiographic analysis of diabetic midfoot Charcot neuroarthropathy with and without midfoot ulceration. Foot Ankle Int 2014;35(11):1108–1115. DOI: 10.1177/1071100714547218
  18. Lowery NJ, Woods JB, Armstrong DG, et al. Surgical management of Charcot neuroarthropathy of the foot and ankle: a systematic review. Foot Ankle Int 2012;33(2):113–121. DOI: 10.3113/FAI.2012.0113
  19. Richter M, Mittlmeier T, Rammelt S, et al. Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction - results from a multi-centre study. Foot Ankle Surg 2015;21(4):269–276. DOI: 10.1016/j.fas.2015.02.003
  20. Pakarinen TK, Laine HJ, Mäenpää H, et al. Long-term outcome and quality of life in patients with Charcot foot. Foot Ankle Surg 2009;15(4):187–191. DOI: 10.1016/j.fas.2009.02.005
  21. Eschler A, Gradl G, Wussow A, et al. Late corrective arthrodesis in nonplantigrade diabetic Charcot midfoot disease is associated with high complication and reoperation rates. J Diabetes Res 2015;2015:246792. DOI: 10.1155/2015/246792
  22. Ford SE, Cohen BE, Davis WH, et al. Clinical outcomes and complications of midfoot Charcot reconstruction with intramedullary beaming. Foot Ankle Int 2019;40(1):18–23. DOI: 10.1177/1071100718799966
  23. Kavarthapu V, Vris A. Charcot midfoot reconstruction—surgical technique based on deformity patterns. Ann Joint 2020;5:28. DOI: 10.21037/aoj.2020.02.01
  24. Bevan WP, Tomlinson MP. Radiographic measures as a predictor of ulcer formation in diabetic Charcot midfoot. Foot Ankle Int 2008;29(6):568–573. DOI: 10.3113/FAI.2008.0568
  25. Regauer M, Grasegger V, Fürmetz J, et al. High rate of complications after corrective midfoot/subtalar arthrodesis and achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3. Int Orthop 2023;47(1):141–150. DOI: 10.1007/s00264-022-05567-y
  26. Conway, JD. Charcot salvage of the foot and ankle using external fixation. Foot Ankle Clin 2008;13(1):157–173. DOI: 10.1016/j.fcl.2007.12.002
  27. Consul D, So E, Shah N, et al. Internal amputation in Charcot neuroarthropathy complicated by diabetic foot osteomyelitis. J Foot Ankle Surg 2020;59(4):853–856. DOI: 10.1053/j.jfas.2020.02.002
  28. Laurinaviciene R, Kirketerp-Moeller K, Holstein PE. Exostectomy for chronic midfoot plantar ulcer in Charcot deformity. J Wound Care 2008;17(2):53–55, 57–58. DOI: 10.12968/jowc.2008.17.2.28178
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.