Long-term results of corrective surgical interventions in patients with diabetic midfoot neuroosteoarthropathy

BACKGROUND: Diabetic neuroosteoarthropathy is a disabling complication of diabetes mellitus that develops as a result of impaired peripheral innervation and characterized by damage to bones and joints of non-infectious origin. As a result of pathological bone fractures, gross deformities of the foot are formed, which entails development of chronic ulcerative defects in areas of excessive load pressure. Currently, a number of surgical interventions are used to correct deformities, such as resection of bone structures, correction with metal structures and external fixation devices, but there is practically no data on their long-term results in the domestic literature.

AIM: To study the results of orthopedic corrective interventions in patients with diabetes mellitus and midfoot neuroosteoarthropathy.

MATERIALS AND METHODS: An analysis was made the data collected by questionnaire method of 55 patients operated in the diabetic foot department in the Endocrinology research centre from 2009-2019. All patients underwent a reconstructive operation aimed correcting a gross deformity of the midfoot. In postoperative period, the affected limb was off-loaded by total contact cast for a period of 3-6 months, and in the future, complex orthopedic shoes for permanent use and regular podiatric care were recommended to patients.

RESULTS: After the first surgical intervention, 16 patients developed a recurrence of deformity, which required a second surgical intervention. The median period between interventions was 3 years. Chronic wounds of various localization of the operated foot were found in 25 patients.

The median period between surgery and ulcer formation was 5 years. 9 patients with chronic wounds underwent minor amputations at the same foot. Amputations on the contralateral limb were performed in 7 patients. None of the patients underwent major amputations.

CONCLUSION: Charcot foot is a severe complication of diabetes mellitus that can lead to loss of a lower limb. Due to results of the research orthopedic corrections of the midfoot deformities in patients with DNOAP can reduce the risk of ulcer developement and possible major amputations. Active monitoring and adequate orthopedic care in the postoperative period significantly reduce the risk of deformity recurrence and the need for repeated surgical interventions.

1. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129. doi: https://doi.org/10.2337/dc11-0844

2. Sanders LJ, Frykberg RG. The Charcot foot (pied de Charcot). In: Levin and O'Neal's The Diabetic Foot. Elsevier; 2008. Vol. 9. P. 257-283. doi: https://doi.org/10.1016/B978-0-323-04145-4.50019-3

3. Chantelau E, Grutzner G. Is the Eichenholtz classification still valid for the diabetic Charcot foot? Swiss Med Wkly. 2014;9(2):257-283. doi: https://doi.org/10.4414/smw.2014.13948

4. Armstrong DG, Peters EJG. Charcot's arthropathy of the foot. J Am Podiatr Med Assoc. 2002;92(7):390-394. doi: https://doi.org/10.7547/87507315-92-7-390

5. Kroin E, Chaharbakhshi EO, Schiff A, Pinzur MS. Improvement in quality of life following operative correction of midtarsal charcot foot deformity. Foot Ankle Int. 2018;39(7):808-811. doi: https://doi.org/10.1177/1071100718762138

6. McGregor PC, Lyons MM, Pinzur MS. Quality of life improvement following reconstruction of midtarsal charcot foot deformity: A five year follow-up. Iowa Orthop J. 2022;42(1):109-112.

7. Busse JW, Bhandari M, Guyatt GH, et al. Use of both short musculoskeletal function assessment questionnaire and short form-36 among tibial-fracture patients was redundant. J Clin Epidemiol. 2009;62(11):1210-1217. doi: https://doi.org/10.1016/j.jclinepi.2009.01.014

8. Kroin E, Chaharbakhshi EO, Schiff A, Pinzur MS. Improvement in quality of life following operative correction of midtarsal Charcot foot deformity. Foot Ankle Int. 2018;39(7):808-811. doi: https://doi.org/10.1177/1071100718762138

9. Pinzur MS, Schiff AP. Deformity and clinical outcomes following operative correction of charcot foot: A new classification with implications for treatment. Foot Ankle Int. 2018;39(3):265-270. doi: https://doi.org/10.1177/1071100717742371

10. Lee CR, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129. doi: https://doi.org/10.2337/dc11-0844

11. Ford SE, Cohen BE, Davis WH, et all. Clinical outcomes and complications of midfoot Charcot reconstruction with intramedullary Beaming. Foot Ank Int. 2019;40(1):18-23. doi: https://doi.org/10.1177/1071100718799966

12. Lowery NJ, Woods JB, Armstrong DG, et al. Surgical management of charcot neuroarthropathy of the foot and ankle: a systematic review. Foot and Ankle International. 2012;33(2):113-121. doi: https://doi.org/10.3113/fai.2012.0113

13. Baravarian B, Van Gils CC. Arthrodesis of the Charcot foot and ankle. Clin Podiatr Med Surg. 2004;21(2):271-289. doi: https://doi.org/10.1016/j.cpm.2004.01.007

14. Pakarinen T-K, Laine H-J, Honkonen SE, et al. Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases. Scand J Surg. 2002;91(2):195-201. doi: https://doi.org/10.1177/145749690209100212

15. 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;2015:1-8. doi: https://doi.org/10.1155/2015/246792

16. Finkler ES, Kasia C, Kroin E, et al. Pin tract infection following correction of Charcot foot with static circular fixation. Foot Ankle Int. 2015;36(11):1310-1315 doi: https://doi.org/10.1177/1071100715593476