Midfoot Charcot Reconstruction with Intramedullary Beaming

Abstract

Category: Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Methods: A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients (Median Age: 60; Median BMI: 32.5; Diabetic: 79%; Insulin Dependent: 74%) were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer- free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, post-operative infection, and amputation. Results: The lateral Meary’s angle median improved from -29° preoperatively to -21° on final postoperative radiographs (p<0.001). Likewise, the AP Meary’s angle median improved from 17° to 2° (p<0.001). 43% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.04); all six deep infections occurred in patients with preoperative ulceration. 63% of patients required reoperation. Three (13%) patients progressed to amputation at a median nine postoperative months, all for deep infection. The final postoperative median FAAM score was 21. The VR-12 median score was also 21 (PCS: 32, MCS: 67). Conclusion: Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with ADLs, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in both the lateral and AP Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.