Abstract
Category:
Diabetes; Midfoot/Forefoot
Introduction/Purpose:
Charcot neuroarthropathy is associated with a progressive deformity that can result in wound breakdown, ulceration and ultimately amputation. Conservative management with total contact casting can allow ulcers to heal. However conservative treatment is dependent on continual podiatry and orthotic input. Surgical correction of the 'rocker bottom deformity has evolved. Minimally invasive surgical techniques utilising beams and bolts for a 'super-construct' to correct the Charcot deformity is possible through percutaneous incisions. We report the 5-year outcomes of a cohort of patients with diabetic neuroarthropathy treated with neuropathic minimally invasive surgeries including modifications of the surgical technique to reduce complications and improve outcomes.
Methods:
A cohort of 16 patients with diabetic neuroarthropathy was treated using neuropathic minimally invasive surgeries. Patients were recruited from the multidisciplinary diabetic foot clinic. Patients had been treated with total contact casting to heal ulcers and prevent future wound breakdown. Surgery was performed as a day case or overnight stay under general anaesthetic. Using fluoroscopy, closing wedge osteotomy was performed with minimally invasive 'Shannon' cutting and wedge burrs to create a triplane closing wedge osteotomy of the midfoot. Reduction of the forefoot to the midfoot was achieved using percutaneous beams and bolts. The void was filled with antibiotic bone graft substitute. Post-operatively patients were immobilised in total contact cast for eight to twelve weeks non-weight-bearing, followed by six weight-bearing in a moon-boot with total contact insole for six weeks.
Results:
The aim of surgical intervention is to create a stable plantigrade shoe able foot. Whilst osseous union is desirable, a stable fibrous union allows the patient to transition to footwear, with reduced risk of recurrence of deformity, wound breakdown or ulceration, Minimally invasive surgery with antibiotic bone graft substitutes reduces the risk of post-operative infection. The most common complication was the breakage of metalwork at the tip of the bolts. Infection was the second most common complication. Removal of metalwork, minimally invasive debridement and irrigation, allowed the infection to be irradicated. Lost of correction of deformity requiring revision surgery occurred in three patients with good outcomes. There was one amputation.
Conclusion:
Significant midfoot deformity correction can be performed using minimally invasive surgical techniques with beams and bolts to create a super-construct for stabilisation of midfoot Charcot deformity. The advantages of percutaneous incisions allow for earlier intervention before a major deformity has occurred. Neuropathic minimally invasive surgeries are optimal for patients who have no active ulceration and are systemically well but require prophylactic intervention to prevent further deformity and risk of amputation.