The Journal of Bone & Joint Surgery

Introduction

Nonoperative treatment with use of a total-contact cast followed by appropriate bracing and footwear is the so-called gold standard for the treatment of most neuropathic (Charcot) fractures and dislocations of the foot and ankle. However, operative treatment is indicated for chronic recurrent ulceration, joint instability, or, in some instances, pain that has not responded to nonoperative treatment. Acute fractures may also be treated operatively if the patient is seen before demineralization of bone and inflammation of soft tissue have occurred. The goals of operative treatment are to preserve function with the aid of appropriate footwear or bracing and to avoid the need for amputation. These goals are achieved through restoration of the contour or alignment of the affected segment of the foot and ankle. Despite the potential for major operative complications, successful limb salvage and reconstruction was achieved in 124 (87 percent) of 143 patients in eight clinical series^{1,3,8,13,19,22,26,27}.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Printed with permission of the American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 48, American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1999.

‡Department of Orthopaedic Surgery, Washington University School of Medicine, Suite 11300, One Barnes Hospital Plaza, St. Louis, Missouri 63110.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Department of Orthopaedic Surgery, Washington University School of Medicine, Suite 11300, One Barnes Hospital Plaza, St. Louis, Missouri 63110.

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TABLE I* CLASSIFICATION SYSTEM OF EICHENHOLTZ⁹

*Reproduced, with modification, from: Johnson, J. E.: Surgical reconstruction of the diabetic Charcot foot and ankle. Foot and Ankle Clin., 2: 39—40, 1997. Reprinted with permission.

Stage	Radiographic Features	Clinical Features
I—Dissolution	Demineralization of regional bone, periarticular fragmentation, dislocation of joint	Acute inflammation (easily confused with infection): swelling, erythema, warmth
II—Coalescence	Absorption of osseous debris in soft tissues, organization and early healing of fracture fragments, periosteal new-bone formation	Less inflammation, less fluctuation in swelling, increased stability at fracture site
III—Resolution	Smoothing of edges of large fragments of bone, sclerosis, osseous or fibrous ankylosis	Permanent enlargement of foot and ankle, fixed deformity, minimum daily swelling or activity-related swelling, normalization of skin temperature

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TABLE I* CLASSIFICATION SYSTEM OF EICHENHOLTZ⁹

*Reproduced, with modification, from: Johnson, J. E.: Surgical reconstruction of the diabetic Charcot foot and ankle. Foot and Ankle Clin., 2: 39—40, 1997. Reprinted with permission.

Stage	Radiographic Features	Clinical Features
I—Dissolution	Demineralization of regional bone, periarticular fragmentation, dislocation of joint	Acute inflammation (easily confused with infection): swelling, erythema, warmth
II—Coalescence	Absorption of osseous debris in soft tissues, organization and early healing of fracture fragments, periosteal new-bone formation	Less inflammation, less fluctuation in swelling, increased stability at fracture site
III—Resolution	Smoothing of edges of large fragments of bone, sclerosis, osseous or fibrous ankylosis	Permanent enlargement of foot and ankle, fixed deformity, minimum daily swelling or activity-related swelling, normalization of skin temperature

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Fig. 1 Photograph of the right foot of a patient with Charcot arthropathy who had collapse of the midfoot and abduction of the forefoot after a fracture-dislocation of the midfoot, which resulted in ulceration of the medial and plantar aspects of the foot.

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Fig. 2 Postoperative radiograph, made four weeks after open reduction and internal fixation of a fracture of the distal part of the fibula with injury of the deltoid ligament, demonstrating valgus displacement and failure of the plate and screws in the fibula. The patient had been managed with a prefabricated removable brace for postoperative immobilization and was allowed toe-touch weight-bearing.

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Fig. 3 Anteroposterior radiograph showing percutaneously placed smooth Steinmann pins that were used to augment the internal fixation of a bimalleolar fracture of the ankle until fracture-healing.

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Figs. 4-A through 4-D: A patient who had a chronic recurrent plantar ulcer beneath a rocker-bottom deformity. Fig. 4-A: Photograph of the plantar aspect of the foot, made before treatment with a total-contact cast, which allowed the ulcer to heal before ostectomy.

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Fig. 4-B Lateral radiograph demonstrating a neuropathic rocker-bottom deformity of the midfoot with a large plantar prominence. Note the equinus position of the hindfoot secondary to contracture of the Achilles tendon.

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Fig. 4-C Intraoperative photograph demonstrating the incision, made lateral to the healed ulcer, for the resection of the plantar prominence, which was a portion of the cuboid bone. Percutaneous lengthening of the Achilles tendon was also performed.

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Fig. 4-D Postoperative photograph made six months after the plantar ostectomy, demonstrating the healed ulcer. Postoperatively, the patient was managed with a double-upright calf-lacer ankle-foot orthosis attached to an extra-depth shoe with a custom total-contact insert.

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Figs. 5-A through 5-E: A patient who had neuropathic arthropathy with marked valgus deformity of the hindfoot. Fig. 5-A: Preoperative photograph showing a subcutaneous prominence of the medial malleolus with impending breakdown of the skin.

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Fig. 5-B: Lateral radiograph demonstrating a neuropathic fracture-dislocation of the hindfoot with dissolution of the body of the talus.

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Fig. 5-C: Anteroposterior radiograph demonstrating lateral subluxation and valgus angulation of the hindfoot with neuropathic fragmentation of the distal part of the fibula.

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Fig. 5-D: Lateral radiograph made after open reduction, realignment, and tibiocalcaneal arthrodesis through lateral and medial incisions. The distal part of the tibia is fused to the anterior part of the calcaneus. Note the fixation of the talar head and neck to the anterior aspect of the distal part of the tibia.

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Fig. 5-E: Anteroposterior radiograph made after the tibiocalcaneal arthrodesis, demonstrating fixation with a 4.5-millimeter titanium blade-plate.

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Fig. 6: Lateral radiograph made seven months after a tibiotalocalcaneal arthrodesis through a posterior approach, showing fixation with a retrograde locked intramedullary nail.

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Fig. 7: Radiograph made after a tibiotalocalcaneal arthrodesis that was stabilized with multiple partially threaded cannulated screws augmented with a single threaded Steinmann pin. Note the healed stress fracture (arrow) through the proximal screw-hole in the tibia, which had occurred when the patient walked without a brace seven months postoperatively. The fracture was treated for twelve weeks with a total-contact cast followed by resumption of the use of a brace. This stress fracture might have been prevented by the insertion of a more distal screw, avoiding the crest of the tibia, and if the patient had complied better with the postoperative use of the brace.

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Fig. 8-A Photographs demonstrating the two-piece polypropylene clamshell-type ankle-foot orthosis used for immobilization of an Eichenholtz stage-II or stage-III neuropathic fracture or after arthrodesis of the hindfoot for the treatment of a neuropathic deformity.

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Fig. 8-B Photographs demonstrating the two-piece polypropylene clamshell-type ankle-foot orthosis used for immobilization of an Eichenholtz stage-II or stage-III neuropathic fracture or after arthrodesis of the hindfoot for the treatment of a neuropathic deformity.

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Fig. 9 Photograph of a double-upright modified calf-lacer ankle-foot orthosis attached to an extra-depth shoe with an extended steel shank and a rocker sole. This style of orthosis is used when there is a severe deformity of the foot that needs to be accommodated by specialized footwear.

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JEFFREY E. JOHNSON; Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Operative Treatment of Neuropathic Arthropathy of the Foot and Ankle*†. The Journal of Bone & Joint Surgery. 1998 Nov;80(11):1700-9.

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