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Arthrodesis as an Early Alternative to Nonoperative Management of Charcot Arthropathy of the Diabetic Foot*
SHELDON R. SIMON, M.D.†; SAMIR G. TEJWANI, M.D.‡; DEBORAH L. WILSON, M.D.§; THOMAS J. SANTNER, Ph.D.#; NANCY L. DENNISTON, M.S.**
View Disclosures and Other Information
Investigation performed at the Department of Orthopaedic Surgery, Ohio State University College of Medicine, Columbus, Ohio
*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. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were Grant H133E30009 from the National Institute on Disability and Rehabilitation Research of the Department of Education and the Samuel J. Roessler Memorial Scholarship Fund.
†Department of Orthopaedic Surgery, Beth Israel Medical Center, 170 East End Avenue, New York, N.Y. 10128. E-mail address: ssimon@bethisraelny.org.
‡Department of Orthopaedic Surgery, University of California at Los Angeles School of Medicine, Center for the Health Sciences, Box 956902, Los Angeles, California 90095-6902. E-mail address: samtejwani@yahoo.com.
§Department of Medical Education, Grant Medical Center, 111 South Grant Avenue, Columbus, Ohio 43215. E-mail address: whonoops@aol.com.
#Department of Statistics, Ohio State University, 405 Cockins Hall, 1958 Neil Avenue, Columbus, Ohio 43210. E-mail address: santner.1@osu.edu.
**The Center for Gait and Movement Analysis, The Children's Hospital, 1056 East 19th Avenue, Box 476, Denver, Colorado 80218. E-mail address: denniston.nancy@tchden.org.

J Bone Joint Surg Am, 2000 Jul 01;82(7):939-939
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Abstract

Background: This study was performed to evaluate the use of arthrodesis of the tarsal-metatarsal area for the treatment of Eichenholtz stage-I Charcot arthropathy in patients with diabetes. Currently, the standard treatment of stage-I Charcot arthropathy is the application of a non-weight-bearing total-contact cast. Although this treatment can be effective for allowing a patient to walk without undergoing an operation, a nonunion or malunion may still result. The subsequent deformities may lead to complications, including ulceration of the foot and the need for operative intervention. Recently, a group of patients who had had early operative intervention for a variety of reasons provided us with the opportunity to objectively evaluate the effects of such treatment. This analysis provided valuable information about whether this treatment is a reasonable alternative to current nonoperative approaches.

Methods: Between January 1991 and December 1996, fourteen patients had an operation because of Eichenholtz stage-I diabetic neuropathy. The classification of the disease as Eichenholtz stage I (the developmental stage) was based on radiographic evidence of varying degrees of articular-surface and subchondral-bone resorption and fragmentation as well as joint subluxation or dislocation without evidence of coalescence or callus formation. The operative procedure consisted of extensive d衲idement, open reduction, and internal fixation of the tarsal-metatarsal region with autologous bone graft. Postoperative treatment consisted of immobilization of the limb in a non-weight-bearing cast for a minimum of six weeks. All of the patients returned for a final follow-up visit at a mean of forty-one months (range, 25.3 to 77.3 months) postoperatively, at which time clinical and radiographic evaluations as well as gait analysis (with measurement of plantar pressures) were performed. The gait-analysis data was compared with similar data from a group of fourteen patients with diabetic neuropathy who had had a below-the-knee amputation and with that from a group of fourteen patients with diabetic neuropathy who had no history of plantar ulceration.

Results: All of the arthrodesis procedures were successful. Clinically, none of the patients had immediate or long-term complications postoperatively. No patient reported ulceration after the operation. The mean time to assisted weight-bearing was 10 ± 3.3 weeks (range, six to fifteen weeks), the mean time to unassisted weight-bearing was 15 ±8.8 weeks (range, eight to thirty-four weeks), and the mean time to return to the use of regular shoes was 27 ±14.4 weeks (range, twelve to sixty weeks). All of the patients regained the level of walking ability that they had had prior to the arthropathy. The calculated confidence intervals revealed no differences between the arthrodesis group and either of the two comparison groups with regard to the time-distance gait parameters of velocity, cadence, and stride length or with regard to the minimum, maximum, and total range of motion of each of the joints. In contrast to able-bodied subjects, all three groups showed a reduction in sagittal-plane ankle motion that was primarily related to loss of plantar flexion. The first metatarsal, great toe, and heel showed the highest peak plantar pressures, with little difference among the groups.

Conclusions: To our knowledge, the present study is the first to demonstrate the potential for early operative treatment to restore anatomical alignment and improve function of diabetic patients with stage-I Charcot arthropathy.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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