SLR - August 2015 - Tania Kapila
Reference: Eschler A, Gradl G, Wussow A, Mittlmeier T. Late Corrective Arthrodesis in Nonplantigrade Diabetic Charcot Midfoot Disease is Associated with High Complication and Reoperation Rates. J Diabetes Res. 2015; 2015: 246792.Scientific Literature Review
Reviewed By: Tania Kapila, DPM
Residency Program: Wyckoff Heights Medical Center
Podiatric Relevance: In recent years, there has been an increased prevalence of diabetic Charcot arthropathy. This multifactorial condition often has severe and debilitating outcomes, including loss of plantigrade foot alignment, gait instability, tissue breakdown, infection, and limb loss. Initial treatment is nonoperative with advanced cases often requiring reconstructive surgical procedures. The objective of this study was to evaluate complications and reoperation rates in patients with late stage Charcot arthropathy who underwent reconstructive midfoot arthrodesis.
Methods: Between November 2005 and March 2012, 19 diabetics (21 feet) with severe, late stage Charcot arthropathy (Eichenholtz stages II/III) who underwent reconstructive midfoot arthrodesis were retrospectively reviewed. Prior to surgery, all patients had documented nonplantigrade foot alignment, midfoot instability, and had exhausted conservative management. In addition to a complete clinical and radiographic evaluation, the patients’ vascular status was assessed with duplex sonography and vascular intervention was performed as needed.
Medial column stabilization was performed using extramedullary implants (screws, plates, bolts, or combination) in 52 percent of patients, intramedullary devices in 24 percent and a combination in 24 percent. All lateral column stabilization involved an extramedullary implant. Autologous iliac crest grafts were utilized in 14 feet (67 percent) with resection of necrotic tissue necessary in 2 feet (10 percent). One patient underwent Achilles tendon lengthening based on preoperative assessment.
Postoperatively, a lower leg splint was applied, followed by a total contact cast with partial weight bearing advised. Follow-up assessments included American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, patient satisfaction surveys, and radiographic and clinical evaluations. The average follow up time was four years.
Results: Following midfoot arthrodesis for management of late stage Charcot arthropathy, 13 patients (62 percent) suffered from early complications occurring within 30 days of surgery. Twelve patients (57 percent) had intermediate complications (one to five months after surgery) and 10 patient (48 percent) suffered from late complications (more than six months from date of surgery). Only two patients remained complication free during the average four year follow up.
The most common reported complications were soft tissue infections (16 feet) followed by hardware loosening and breakage (11 feet), osteomyelitis (three feet) and nonunion (one foot). Most patients underwent further surgery during the follow up period with major surgery, including rearthrodesis and amputation, being performed in 33% and minor revision surgery (soft tissue debridement or wound lavage) occurring in 33 percent. The remaining one-third of patients did not require further surgical correction.
The mean AOFAS midfoot score demonstrated overall good patient satisfaction (mean 60 points, range 44–76 points) and 50 percent of patients reported that their foot’s condition had improved following arthrodesis. Clinical and radiographic evaluations supported these claims with significant improvement in alignment noted on standard foot radiographs.
Conclusions: Patients with late stage Charcot arthropathy present a treatment challenge to podiatric surgeons. Though reconstructive midfoot arthrodesis provides significantly improved foot stability and alignment, these patients are prone to high complication and reoperation rates. This study found soft tissue infection to be the most frequently encountered complication with 76 percent of patients presenting with an infection within six months of surgery. Fourteen out of the nineteen patients went onto require further surgery, including amputation and re-arthrodesis in 33 percent. Though this study is limited by its small sample size and discrepancy in surgical techniques, it highlights the difficulties in managing late stage Charcot arthropathy. The results indicate that although late corrective arthrodesis improves overall foot stability and alignment in Charcot patients, it is unlikely to be a final, definitive procedure, but rather one of many. Timing of surgical intervention is dependent on the stage and severity of the patient’s Charcot arthropathy, significant co-morbidities, as well as the patient’s goals and individual lifestyle. While some patients may elect to continue conservative management, others may be candidates for surgical intervention with proper patient education and selection. Clinicians and patients must both acknowledge that Charcot reconstruction with midfoot arthrodesis has high risks of complications and further surgery is anticipated in most cases.