A treatment algorithm for neuropathic (Charcot) midfoot deformity

Forty-nine feet in 47 patients with midfoot neuropathic foot deformity were referred for care to a comprehensive foot salvage clinic and followed for an average of 3.6 years. Twenty-three initially presented without open ulcers. Two underwent elective Syme's ankle disarticulation amputation, and the others were kept ambulatory with a combination of periods of nonweightbearing cast immobilization, accommodative extra-depth shoes with custom orthotics, and ankle-foot orthoses. Twenty-six of the feet initially presented for care with open ulcers and/or chronic osteomyelitis. Twenty-two of these patients underwent 32 surgical procedures. Sixteen underwent debridement of the infected bone and surrounding soft tissues. Excision of large, nonaccommodative boney prominence, termed exostectomy, was performed in eight. Partial excision of the deformed midfoot combined with boney stabilization and attempted arthrodesis, termed partial tarsectomy, were performed in seven. All surgical patients were managed postoperatively with long-term custom accommodative bracing. Follow-up at an average of 3.6 years revealed that all but one of the patients remained ambulatory. Six walk with accommodative shoe gear and persistent stable chronic open ulcers. None required below-knee amputation. Five amputations were performed, three at the Syme's ankle disarticulation level, one at the Chopart's hind-foot level, and one at the mid-foot level.(ABSTRACT TRUNCATED AT 250 WORDS)