surgical reconstruction of the neuropathic foot

John RooneyMBBS, St VincentsHospital,Darlinghurst, NSW,Australia

Simon RachmatHutabarat MBBS,St GeorgeHospital, Kogarah,NSW, Australia

Leslie GrujicFRACS, Royal NorthShore Hospital, StLeonards, NSW,Australia

Sigvard T. Hansen Jr.MD (correspondingauthor),HarborviewMedical Center,Seattle, WA, USA

Original Article

Surgical reconstruction of theneuropathic footJohn Rooney, Simon Rachmat Hutabarat, Leslie Grujicand Sigvard T. Hansen, Jr.

Results of surgical reconstruction procedures performed on 43 Charcot feet in 36 patients werereviewed retrospectively and the results demonstrate that these cases are reconstructable byarthrodesis and soft-tissue balancing. The rationale is that deformity, pain and instabilityshould be corrected so that existing ulcers may heal and further ulcers are prevented. Thisprocedure gives the patient better function than traditional ways. The technique used inreconstruction is described. Reconstruction resulted in ulcer resolution and a stable foot thatcould fit a normal shoe.© 2002 Published by Elsevier Science Ltd

Introduction

A number of conditions may produce theneuropathic joint. These include diabetesmellitus, tertiary syphilis, syringomyelia, familialneuropathy, spina bifida and pernicious anaemia.Diabetes mellitus is recognised as the mostcommon cause in the Western world whilstleprosy is a common cause in the Third world(Aegerter & Kirkpatrick 1975).

The foot is the most common site affected byneuropathic joint disease. Single or multiplejoints in the foot may be affected. The tarsal ortarsometatarsal joints (TMJ) are involved in 60%of cases, the metatarsophalangeal (MP) joints in30% of cases and the tibiotalar joint in less than10% of cases (Kozac et al. 1997). The principleregions of neuropathic joint disruption have beenclassified by Brodsky into mid-foot (type I),hind-foot or subtalar complex (type II), tibiotalar(type IIIa) and os calcis (type IIIb) (Brodsky &Rouse 1993). This classification system was usedto document areas operated on because of itssimple application to anatomy and thereforesurgical technique.

Interphalangeal (IP) and MP involvementfrequently occurs as a result of the intrinsic minuseffect brought about by the motor neuropathy. Ittends to be understated in neuropathic jointdisease (Scurtozzi & Kanat 1990).

Two types of diabetic neuropathic joint diseasehave been described. They are the atrophic andhypertrophic forms, the latter form being the mostcommon. This latter form has been classified byEichenholtz into three stages: (1) development, (2)coalescence, (3) remodelling (Eichenholtz 1996).

The resultant neuropathic joint disease isprogressive deformity with an unstable extremityof little functional use. Ulceration may lead to achronic polymicrobial osteomyelitis and eventualamputation. Other authors have classifiedpatients in relation to Wagner’s ulcer classification(Bono et al. 1993, Brodsky & Rouse 1993). Anumber of patients did not have ulceration thusulceration, when applicable, was assessedpost-operatively as either resolved or unresolved.

The management of these problems is difficultand not without controversy. The key to earlymanagement is recognition and prevention of thedisease. Some believe that an acute presentationshould be rested and all weight-bearing avoided(Johnson 1992, Mann 1986, Scurtozzi & Kanat1990, Wilson 1991) and if severe joint destructionor fracture is present then it may be an indicationfor casting. The advantage of, for example, totalcontact casting is that it distributesweight-bearing more evenly and may allowpressure point ulceration to heal with touchweight-bearing (Helm et al. 1991, Jacobs &Karmody 1982, Lee & Noeller 1991, Wilson 1991).

© 2002 Published by Elsevier Science Ltd The Foot (2002) 12, 213–223 213doi: 10.1016/S0958-2592(02)00070-6, available online at http://www.idealibrary.com on

Reconstruction of the neuropathic foot

An ankle foot orthosis, accommodative footwear,bracing and shoe orthoses may also confer someprotection to the neuropathic foot (Mann 1986).

Surgical intervention has been advocated bysome authors (Bono et al. 1993, Brodsky & Rouse1993). Amongst those who advocate a bonyprocedure it is generally accepted that operationsshould not be undertaken during the hyperaemicphase of the arthropathy, when bone resorptionmay occur. Surgery may be considered once thefoot has settled into the coalescent or remodellingphases described by Eichenholtz (1996).

It may be difficult at times to distinguishbetween hyperaemia of the immediatepost-traumatic period and that of the atrophicphase. Post-traumatic oedema and hyperaemiawill settle after a few days of elevation andcompressive bandaging and results in little delay,whereas the atrophic phase will take months topass.

We present a retrospective review of 43reconstructive procedures performed upon 36patients with neuropathic joint disease. Thepurpose of this study was to demonstrate that anearlier surgical intervention in the neuropathicfoot is an option.

Materials and methods

The patients were seen and operated on by theprimary author between 1987 and 1995. Therewere a total of 36 patients upon whom 43procedures were performed. A total of 19 patientswere female and 17 were male. The average age atoperation was 58 years (range 33–74). The patientswere seen at regular intervals after operation andassessed clinically and radiographically. Theaverage time of follow-up was 2 years and 7months (range 9 months–10 years after surgery).No patients were lost to follow-up.

Total contact casting was used in five patientspreviously and an orthosis had been tried inthree patients. Fifteen patients had been operatedon previously. Seven had prior attempts atarthrodesis which had failed. These involved thetibiotalar joint (1), the Chopart joint (3) and theLis Franc joint (3). These failures were due tonon-union alone in two patients [Lis Franc joint(1) and Chopart joint (1)], malunion alone in twopatients [Lis Franc joint (2)] and both malpositionand non-union in three patients [tibiotalar joint(1) and Chopart joint (2)]. Three patients had

failed previous surgery for a fracture of theankle, plafond or foot. There were two patientsthat had exostectomies previously performed forpainful pre-ulcerative lesions.

There were five patients with areas ofimminent ulceration and twenty with frankulceration. Of the twenty patients with frankulceration, five required ulcer debridment priorto artlirodesis, three of which had a documentedinfection. In addition to the three infected anddebrided ulcers, there were seven other patientsthat had a previously documented infection. Anartlirodesis was still attempted when ulcerationwas active as long as the ulcer was clean. Thismay have required a course of dressings and/orantibiotic therapy.

About 72% of the patients (26/36) haddiabetes mellitus. The remaining patients had anaetiology which was either idiopathic (6/36),meningomyelocele (1/36), pernicious anaemia(1/36), alcoholic (1/36) or traumatic (1/36). Itwas interesting to note that two of the patientswith an idiopathic cause were very tall (heightgreater than 195 cm).

Where a clinical diagnosis of peripheralneuropathy was not able to be made confidentlyon examination alone, a nerve conduction studyand/or an electromyographic study was used. Alevel of sensory change, evident on clinicalexamination, was documented in 18 patients. Thelevel of sensory deficit extended to the knee in4/18 patients to the mid-calf in 7/18, to theankles in 4/18, over the toes in 2/18 patients,and were not present in 1/18. Motor changes dueto the peripheral neuropathy were evidenced byclawing of the toes and wasting of the distalextremity.

The number of patients requiring more thanone arthrodesis was six, of these, four required aprocedure on the contralateral foot and tworequired a procedure for non-union.

Importantly, arthrodesis was always combinedwith soft-tissue balancing procedures. Virtuallyall patients reviewed had a short tendoachilleswhich needed to be lengthened before thehind-foot would reach neutral position.Progression of neuropathy and worsening of theintrinsic minus deformity commonly occurredover the years and required further soft-tissuesurgery. Long peroneal overpull occurred in onepatient and resulted in first metatarsal headoverload and pre-ulcerative symptoms. It was

214 The Foot (2002) 12, 213–223 © 2002 Published by Elsevier Science Ltd


relieved by percutaneous tenotomy of the longperoneal tendon.

The anatomical locations which requiredsurgery were:

mid-foot only (type I) 24/43hind-foot and subtalar complex only (type II)5/43tibiotalar only (type IIIa) 3/43types I and II combined 9/43types I, II and IIIa combined 2/43.

Note that there were multiple types of jointdisruption present in 11/43 cases. It was notuncommon for the neuropathic joint disruptionto cross different zones haphazardly.

The patients’ main complaints were ofswelling, deformity, inability to wear their usualfootwear, pain and ulceration. There were fivepatients with impending ulceration, fifteen withfrank plantar mid-foot ulceration and two withsubtaiar ulceration resulting from severe lateralsubtalar subluxation. Three patients had two ormore ulcers. These involved a combination ofulcers over the plantar surface of the metatarsalheads, the plantar mid-foot, the subtalar regionand the dorsum of the toes.

Treatment

Infection was treated with appropriateantibiotics, drainage and debridement before anoperation was considered. An infectious diseasesphysician was frequently involved in guiding themanagement of any infected foot.

Oedema and hyperaemia due to a recentfracture were treated with a compressionbandage and elevation until swelling reducedsufficiently to allow an operation. No attempt atcorrection was performed if the patient was inthe atrophic or resorptive phase of their jointdisease as described by Eichenholtz (1996).

The principle followed was the correction ofbony architecture, in the hope that functionwould be restored. All patients were counselledwith regard to the risk of amputation as aconsequence of deep infection.

Surgical technique

Prophylactic antibiotic therapy was administeredprior to the inflation of the tourniquet and wasusually a first generation Cephalosporin.

Care was taken with incision placement anddissection to ensure that narrow skin bridgeswere not created and that soft-tissue was notunduly undermined or traumatised. Theapproach used was dependent on the joint to bearthrodesed, previous scars and the location ofulcers. Joints to be arthrodesed were debrided ofcartilage or fibrous tissue, cut with an oscillatingsaw in the appropriate plane, held in the positionof correction with Kirschner wires, checkedradiologically on the intra-operative imageintensifier and then fixed with two or morescrews. Wherever possible wires were passedpercutaneously and were followed withcannulated screws through small stab incisions.This technique minimised soft-tissue traumaand achieved better compression across bonesurfaces.

The ankle joint was typically fused usingposterior tibial screws passed down into the neckof the talus. Subtalar fusion was generallyperformed using a 6.5mm diameter percutaneousscrew with a 16mm thread length, through thepoint of the heel into the body of the talus. In asimilar fashion, the mid-foot and TMJ could befused with a long screw directed from the heel,through the tarsus and into the base of themetatarsals. The long heel screw was augmentedin a triple arthrodesis with 3.5–4.5mm screwspassed from the medial or lateral sides of the footthrough the tarsus and into the talus. Forobvious reasons calcaneal osteotomy and heelrealignment were performed before passing anylong heel screws. In the TMJ and mid-footregions 3.5 or 4.5mm cortical lag screws werefrequently used in place of cannulated screws.Every attempt was made to restore thelongitudinal and transverse arches of thefoot so that normal biomechanics werereplicated.

The following corrective procedures wereperformed:

1. Tarsometatarsal arthrodesis in twenty-threecases;

2. Mid-foot arthrodesis in three cases;3. Triple arthrodesis in ten cases;4. Subtalar arthrodesis in six cases;5. Ankle arthrodesis in four cases.

Multiple arthrodesis were combined whereappropriate (see Table 1). Fusions of proximaljoints were combined with percutaneous Achilles

© 2002 Published by Elsevier Science Ltd The Foot (2002) 12, 213–223 215


Table 1 Combinations of multiple sites of arthrodesis

TMTJ Mid-foot Primary arthrodesistriple

Subtalar Ankle

Alone 18 1 9 2 4

With TMTJ arthrodesis N/A 1 0 0 0

With mid-foot arthrodesis 3 N/A 1 4 0

With triple arthrodesis 0 1 N/A 0 0

With subtalar arthrodesis 2 0 0 N/A 0

With ankle arthrodesis 0 0 0 0 N/A

tendon lengthening and other tendon releases,lengthenings or transfers to balance soft-tissues(see Table 2). Figures 1–4 show pre-operativeneuropathic destruction and post-operativesurgical reconstruction.

The contralateral achilles tendon waslengthened percutaneously in one patient toimprove post-operative mobilisation. More distalfusions were also used to correct fore-foot

Table 2 Soft-tissue procedures associated with arthrodesis

TMTJarthrodesis

Mid-footarthrodesis

Triplearthrodesis

Subtalararthrodesis

Anklearthrodesis

Lengthening/releaseEHL/EHB 2 2 – – –Dorsal MTP capsule – 3 1 – –FDL 2 1 – – –Tibialis posterior – 1 – – –Peroneus longus/brevis – 1 1 – –Tendoachilles 6 15 5 1 –

Tendon transfersExtensor to extensorEDL–tibialis anterior – 1 – – –EDU–medial cuneiform 1 1 – – –EDL–peroneus tertius 1 5 1 – –EDB–EDL (distal) 1 1 – – –EHL–first metatarsal (base) – 2 – – –Tibialis anterior–navicular 3 2 1 – –Peroneus tertius–distalreattachment

– – 1 – –

No extensor to flexor

Flexor to flexorFDC–first cuneiform – – 1 – –FDL–proxirnai phalanx – 1 – – –FDL–tibialis posterior – – 2 – –FHL–proximal phalanx (base) 2 4 – – –Peroneus brevis–peroneus longus – 1 – – –Peroneus longus–tendoachilles – 1 – – –

Flexor to extensorGirdlestone 1 3 – – –FDL–peroneus tertius – – 1 – –Peroneus brevis–peroneus tertius – – 1 – –

deformity, these included IP joint arthrodesis (9)and MP joint arthrodesis (5). A calcanealosteotomy was performed when the heelrequired realignment.

Wounds were closed in layers without tension.A plaster backslab with toe plate was appliedwith a bandage and the tourniquet was deflated.If procedures exceeded 90min the tourniquetwas deflated. It was only reinflated if absolutely



Fig. 1 Lateral radiograph demonstrating mid-foot Charcot collapse and rocker bottom sole.

necessary, as neuropathic limbs are particularlysensitive to tourniquet compression.

On the first post-operative day the limb waskept elevated and antibiotics continued.Intravenous antibiotics were replaced after 1–2days with an oral, first generation Cephalosporinor Ciprofloxacin if indicated by pre-operativewound swabs. When post-operative swelling hadsettled the patient’s wounds were reassessedbefore a full cast was applied. The cast remainedin place for 6–12 weeks, being removed only toinspect wounds. The patient was keptnon-weight-bearing on the affected limb until atleast the second post-operative week, whenselected compliant patients were allowed to

Fig. 2 Pre-operative anteroposterior radiograph demonstrating planned mid-foot resection.

touch weight-bear. Patients then progressed to acam-walker and partial weight-bearing by the6–12 weeks post-operation as long as the woundwas healed, the swelling was subsiding and thesite of attempted artlirodesis was rigid and painfree. If there was early radiological evidence ofbony union, full weight-bearing was permitted.This was allowed within the confines of theprotective cast or cam-walker. The patientgradually progressed from the cam-walker to amoulded, extra-depth shoe and then to a normalshoe. The speed at which this occurred dependedupon bony union, tissue swelling and patientcomfort. Neuropathy made it difficult for somepatients to judge the amount of weight they put



Fig. 3 (a) Intra-operative lateral radiograph demonstrating fixation across the calcaneocuboid joint and throughthe first ray and talonavicular joint. (b) Anteroposterior view. (c) Final anteroposterior radiograph.



Fig. 4 (a) Earlier generation screws in a TMJ arthrodesis. (b) Evolution to longer stronger hardware in this triplearthrodesis.

through their newly constructed feet. Thesepatients avoided any weight-bearing and used awheelchair until there was evidence of union.

Results

After treatment 19/20 patients had resolution ofulceration and 5/5 patients had resolution ofpre-ulcerative lesions. The one patient in whomthe ulcer did not heal required a below kneeamputation (BKA) within 18 days ofreconstructive surgery (TMTJ fusion) as a resultof deep infection. This patient had a past historyof chronic osteomyelitis due to his long-standingplantar ulcer and was treated pre-operativelywith a regime of intravenous antibiotics. It wasbelieved that the infection in this patient had

resolved prior to the attempt at TMTJarthrodesis. One patient developed a new ulcerin the follow-up period as a result of an ill-fittingplaster. There was no development of newulceration in the remainder of the patients whohad had frank or impending ulcerspre-operatively. Long peroneal overpull alsocontributed to pre-ulcerative symptoms underthe first metatarsal head in one patient. This wasrelieved by percutaneous release of the longperoneal tendon under local anaesthesia in theoutpatient department. (See Table 2 for a list ofother tenotomies performed.)

About 35 of the 43 operative wounds healeduneventfully. Wound necrosis occurred in onecase and wound infection occurred in sevencases. In two cases, the infection was deep and in



five cases superficial. The superficial woundinfections were all treated with oral antibiotics(usually Ciprofloxacin) and resolved withoutconsequence. A superficial infection wasdiagnosed if there were clinical signs of infection.One superficial infection had a mixed growth ofenterobacter and staphylococcus. The other casesof superficial infection did not have anydocumentation as to whether a swab had beentaken or whether growth of any particularorganism had occurred. One case of deepinfection required intravenous Vancomycin andeventually settled with no serious sequelae. Theother deep infection resulted in amputation asdescribed earlier. A small number of cases hadwound dehiscence noticed at change of plaster.This was always a result of oedema and wastreated with bandaging and elevation withoutany significant morbidity.

The average time of non-weight-bearing was39 days. Patients then took progressively moreweight through the foot until they were fullweight-bearing. Full weight-bearing wasachieved on average by 75 days. The foot shapewas monitored closely for loss of position. Anyearly changes in position required a well mouldedplaster for protected weight-bearing. Seventeen(17/43) patients required protection of the fusedjoint by the use of a cam-walker during the earlyperiod of full weight-bearing. In these patients thecam-walker was used for an average of 45 days.

The average time to radiological union was136 days. This was determined when there wasbridging callus or trabeculae across the site offusion. In general it was possible to get a patientout of a cam-walker and into normal orextra-depth footwear by 4 months. Extra-depthfootwear was sometimes worn with a speciallymoulded sole for added protection. All but theBKA patient achieved the use of shoe wear.

Loss of position was reported in 6/43 cases.These were in three TMTJ fusions, one anklefusion, one talonavicular fusion and onecalcaneocuboid fusion, respectively. The reasonsfor loss of position were: accidental fall (1),non-compliance with weight-bearing orders (4)and early full weight-bearing (1). Only one ofthese required a revision arthrodesis (anklefusion). The other patients were treated with aperiod of plaster immobilisation and/or a delayin progression to full weight-bearing until therewas bony consolidation. Six (6/43) cases had

screw fracture however bony position wassatisfactory. Screw fractures were evenlydistributed between TMTJ (3) and mid-footfusions (3) and were also associated with the useof smaller diameter (3.5mm) screws. Symptomsdue to prominent or impinging hardwarenecessitated removal of screws in 4/43 cases. Painpersisted in one patient as a result of persistentperipheral neuralgia. Another patient hadneuralgic pain that settled with Carbamazepine.One patient complained of weakness ofplantarfiexion which was a result of anassociated tendoachilles lengthening procedure.

Discussion

The rationale behind the management of thesepatients was that the Charcot joint does notpreclude operative treatment. Historically,neuropathic deformity has been treatednon-operatively. As such the natural course wasprogressive deformity, chronic ulceration andeventual amputation as a result of deep infectionwith the prolonged periods of disuse as ulcersheal and recur.

The authors believe that deformity should becorrected if it is the cause of ulceration orimpending ulceration and/or pain. Surgicalcorrection of deformity was preferably attemptedin impending ulceration before there was frankulceration and the potential for infection.Operative correction of these cases may be moresuccessful with the better operative and fixationtechniques available today. The correction of bonydeformity in the presence of frank ulceration,allows ulcers to heal, diminishes their recurrenceand therefore diminishes the long-term risk ofsubsequent deep infection and amputation.

This series presents 43 cases of Charcot feetwhich were treated by reconstruction of the bonyarchitecture and soft-tissue balancing. Thetraditional teaching with regard to neuropathicdeformity has been that operative treatment isbest avoided. The standard of non-operativemanagement is the total contact cast (TCC) (Jacobs& Karmody 1982, Wilson 1991). This allows evendistribution of pressure and resolution of plantarulceration. Without correction of underlyingbony prominences however (Helm et al. 1991),recurrence frequently occurs. Plantar surface painwas frequently associated with impendingulceration. Plantar pain could also be



Fig. 5 Treatment algorithm for the neuropathic foot.



neuropathic, ischaemic or inflammatory inorigin. The ultimate sequelae in this groupof patients is progressive deformity,ulceration, secondary infection and eventualamputation.

Exostectomy has been advocated but webelieve that unless the bony architecture isreconstructed the patient may not achieve ashigh a level of function or a longer-lasting result,as well as this, ulceration may recur with furthermid-foot collapse. A review of other literaturesuggests that the amputation and woundcomplication rates of reconstruction arecomparable to that of exostectomy (Brodsky &Rouse 1993). Additional complications sustainedin the reconstructed patients included loss ofposition and symptoms due to impinging orpalpable hardware.

Some of the patients treated with thistechnique had problems with screw breakageand as a result, fixation has evolved over theyears to longer and stronger hardware(4.5–6.5mm screws). As the weakest parts of ascrew are at the shank-thread and shank-headjunctions, a short threaded (16mm) screw is nowused. This enables the shank-thread junction tobe as far as possible from the point where themaximum fatigue stress will be. Mid-foot fixationwas also occasionally extended into the hind-footto allow use of longer screws. Patient compliancewas important in preventing screw breakage.

Soft-tissue balance was regarded as important.In particular, tendoachilles lengthening, wasrequired in almost all cases to enable thehind-foot to come to a neutral position. This wasregarded as an important step for success. Thereare few other references that stress theimportance of lengthening the tendoachilles. Onestudy comprised 22 patients with paediatricmobile flat feet which were treated by Miller’sprocedure (Fraser et al. 1995). About 92%required tendoachilles lengthening. The successrate after 12 years was 84%, however, nocorrelation between the tendoachilleslengthening and a successful outcome was made.A more recent article by Armstrong et al. (1999)has also suggested that metatarsal pressures aresignificantly reduced after percutaneouslengthening of the tendoachilles (Armstronget al. 1999). This principle, we believe, applies inparticular to the patient in our series with longperoneal overpull, first metatarsal plantar

ulceration and resolution of the ulceration withlong peroneal tendon release.

In this series, fore-foot deformity due to theintrinsic minus effect would frequently requiresoft-tissue transfer or release, tendon lengtheningor fusion of MP or IP joints.

These results are a retrospective review of theprimary author’s experience with reconstructionof Charcot feet. Admittedly, the proceduresconsidered are not all the same and the variablesare poorly controlled. A treatment algorithm(Fig. 5) has therefore been included in an attemptto clarify the treatment process.

Long-term, well-controlled, randomisedprospective studies in which patient satisfaction,ulcer healing, function and complication rates aremeasured would be useful in comparing variousmodalities of treatment. The authors believe thatthis type of reconstruction and soft-tissuebalancing can be considered as an alternative forthe experienced foot surgeon.

Acknowledgements

The authors would like to thank Tom Kimmelland Jane Gorman for their assistance throughoutthis study.

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