Charcot neuroarthropathy: realignment of diabetic foot by means of osteosynthesis using intramedullary screws – case report

Santos, Alexandre Leme Godoy dos; Albino, Rômulo Ballarin; Ortiz, Rafael Trevisan; Sakaki, Marcos Hideyo; Corsato, Marcos de Andrade; Fernandes, Tulio Diniz

doi:10.1016/j.rboe.2014.08.006

Alexandre Leme Godoy dos Santos ^**Corresponding author. E-mail: alexandrelemegodoy@gmail.com (A.L.G Santos).

Institute of Orthopedics and Traumatology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Rômulo Ballarin Albino

Institute of Orthopedics and Traumatology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Rafael Trevisan Ortiz

Institute of Orthopedics and Traumatology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Marcos Hideyo Sakaki

Institute of Orthopedics and Traumatology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Marcos de Andrade Corsato

Institute of Orthopedics and Traumatology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Tulio Diniz Fernandes

Institute of Orthopedics and Traumatology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

*Corresponding author. E-mail: alexandrelemegodoy@gmail.com (A.L.G Santos).

Conflicts of interest

The authors declare no conflicts of interest.

Figures (5)
Tables (2)

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Fig. 1
(A) Plantar appearance of the foot at the first consultation; (B) plantar appearance of the foot after serial debridement and use of full contact plaster cast.

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Fig. 2
Initial radiographic investigation: (A) anteroposterior view of the left foot showing bone fragmentation in the tarsometatarsal region; (B) lateral view showing loss of the medial longitudinal arch of the foot and alteration of the alignment of the talus with the first metatarsal.

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Fig. 3
Intraoperative control radioscopy to check the provisional stabilization: (A) lateral view showing reestablishment of the alignment of the talus with the first metatarsal and absence of plantar bone salience; (B) anteroposterior view showing adequate alignment of the talus with the first metatarsal, and of the cuboid with the fourth metatarsal.

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Fig. 4
Clinical photos of the patient showing the foot alignment 12 months after the operation: (A) posterior image of the foot showing the hindfoot realignment achieved; (B) medial image of the foot showing the realignment between the hindfoot and midfoot; (C) image of the plantar region of the foot showing the achievement of a plantigrade foot.

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Fig. 5
Radiographic control 12 months after the operation: (A) lateral view of the foot showing evidence of correction of the alignment of the axis of the talus with the first metatarsal; (B) anteroposterior view of the foot showing maintenance of the alignment of the screws and the alignment of the axis of the talus with the first metatarsal; (C) anteroposterior view of the ankle showing maintenance of the tibiotalar joint.

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Table 1
Eichenholtz classification.⁵5. Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am. 2000;82(7):939–50.,⁶6. Lamm BM, Gottlieb HD, Paley D. A two-stage percutaneous approach to Charcot diabetic foot reconstruction. J Foot Ankle Surg. 2010;49(6):517–22.

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Table 2
PEDIS classification.

	Stage		Clinical characteristics
0	Initial presentation	Pre-fragmentation	Acute inflammatory phase: edematous, erythematous, hot and hyperemic foot
I	Acute Charcot	Fragmentation or development	Periarticular fracture, development of joint subluxation, risk of instability and deformity
II	Subacute Charcot	Coalescence	Reabsorption of bone debris, homeostasis of soft tissues
III	Chronic Charcot	Consolidation or reparation	Bone or fibrous stabilization of deformity repair

Grade	Lesion characteristics
I-No infection	Wound without purulent secretion, without signs of inflammation
II – Mild infection	Lesion involving only the skin or subcutaneous layer, with the presence of more than two signs: local heat, erythema >0.4–2 cm around the ulcer, local pain, local edema, drainage of pus
III – Moderate infection	Erythema >2 cm, with one of the signs cited or involving infection of structures deeper than the skin and subcutaneous layers (fasciitis, deep abscess, osteomyelitis or arthritis)
IV – Severe infection	Any infection of the foot in the presence of SIRS (two of the following conditions: temperature >38°C or <36°C, heart rate >90 bpm, respiratory rate >20/min, PaCO2 <32 mmHg, leukocytes >12,000 or <4000/mm³3. Assal M, Stern R. Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg Am. 2009;91(4):812–20. and immature forms 10%)

[1] *Corresponding author. E-mail: alexandrelemegodoy@gmail.com (A.L.G Santos).

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