The Journal of Bone and Joint Surgery (American). 2009;91:812-820.
doi:10.2106/JBJS.G.01396
© 2009 The Journal of Bone and Joint Surgery, Inc.
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 Foot/Ankle Test 13: Summer 2009 (publication date August 14, 2009; expirati...
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Realignment and Extended Fusion with Use of a Medial Column Screw for Midfoot Deformities Secondary to Diabetic Neuropathy

Mathieu Assal, MD1 and Richard Stern, MD1

1 Service de Chirurgie Orthopédique et Traumatologie de l'Appareil Moteur, Hôpitaux Universitaires de Genève, 24 rue Micheli-du-Crest, 1211 Genève 14, Switzerland. E-mail address for R. Stern: richard.stern{at}hcuge.ch

Investigation performed at the Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: The failure of nonsurgical treatment of patients with midfoot and hindfoot deformity secondary to diabetic Charcot arthropathy may lead to a rocker-bottom foot deformity with recurrent or persistent plantar ulceration. We report our experience with realignment and extended fusion with primary use of a medial column screw for this midfoot deformity.

Methods: From July 2001 through July 2005, we performed reconstructive surgery on fifteen adults with diabetes mellitus who had a severe neuropathic midfoot deformity consisting of a collapsed plantar arch with a rocker-bottom foot deformity. Thirteen had a nonhealing midfoot plantar ulcer. All underwent realignment and arthrodesis with a medial column screw; some required additional fixation techniques depending on the extent of the deformity. Outcome measures included ulcer and surgical wound-healing, radiographic results, complications, and the need for amputation.

Results: The mean duration of clinical follow-up was forty-two months. Fourteen patients were able to walk, and there were no recurrent plantar ulcers. Thirteen patients were able to wear custom-made extra-depth, wide-toed shoes with molded inserts. One patient without prior ulceration had development of a deep infection that necessitated an amputation. Four feet had a nonunion, one of which was symptomatic requiring a revision to obtain union.

Conclusions: Surgical reconstruction of a collapsed neuropathic foot deformity is technically demanding, but a successful outcome can result in a plantigrade foot that is free of ulceration and abnormal pressure points and a patient who is able to walk. The procedure described has an acceptable degree of complications although it has a high rate of nonunion.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.


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