The Journal of Bone and Joint Surgery 82:939 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
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.# and
NANCY L. DENNISTON, M.S.**
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{at}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.
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 débridement, 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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