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Combined Lateral Column Arthrodesis, Medial Plantar Artery Flap, and Circular External Fixation for Charcot Midfoot Collapse with Chronic Plantar Ulceration

INTRODUCTION Charcot neuroarthropathy is a progressing debilitating disease that is most commonly seen in patients with diabetes mellitus, especially those with dense peripheral neuropathy. In the disease’s early stages, increased blood flow to the lower extremity leads to generalized osteopenia. Combined with substantial increased weight-bearing activity, this results in a severe deformity with subsequent high plantar pressures, ulceration, and infection. The incidence of Charcot neuroarthropathy and its related complications are increasing in the United States. – 6 The Charcot foot is the greatest single relative risk factor in the development of a foot ulceration when compared with other known risk factors such as insensitivity to a 5.07-g monofilament, obesity, or history of a previous amputation or ulceration. The final common pathway leading to amputation in the diabetic patient typically involves ulceration and subsequent infection. Historically, the treatment for Charcot neuroarthropathy-induced deformity has consisted of bed rest, immobilization, total contact casting, and customized footwear and/or bracing. The goal of any treatment for the diabetic Charcot foot deformity is to create a plantigrade, stable, and braceable foot that will be free from significant risk for further breakdown, ulceration, and/or infection. The actual decision between conservative and surgical intervention depends on the degree of deformity, instability and subluxation, infection, osteomyelitis, patient compliance, medical comorbidities including end-stage renal disease, psychosocial issues, obesity, and life expectancy. Unfortunately, the evidence supporting the more conservative nonoperative treatment option for the Charcot foot is equivocal. The increased risk of amputation related to the nonoperative treatment of Charcot foot should alert wound care practitioners to use caution and close monitoring when conservatively treating Charcot patients with midfoot collapse combined with ulceration. It is estimated that up to 40% of Charcot patients with midfoot collapse will ultimately require surgery to achieve a functional end point that involves the use of commercially available shoe gear and custom in-shoe foot orthoses to decrease the potential for progressive deformity, reulceration, infection, and amputation. Worldwide, surgeons are attempting reconstruction of severe Charcot foot deformities with variable protocols and techniques. – 18 As a result, the literature mainly focuses on small case series or ‘‘how-to’’ manuscripts which, when critically reviewed, produce inconclusive outcomes. The authors believe that these deformities require management by a multidisciplinary diabetic foot team that collectively possesses a comprehensive understanding of the diabetic foot, the whole patient, and the functional deficits associated with the deformed foot. The surgeon, as part of the transdisciplinary team, needs to be well versed in plastic surgery techniques specific to the foot, ankle, and lower leg; various forms and techniques of external fixation; and the principles and application of both acute and chronic deformity correction. A successful outcome can be reached when surgery of the Charcot foot incorporates osseous stability, deformity correction, and concomitant soft tissue reconstruction. This article presents an overview of the surgical techniques used in a lateral column fusion, medial plantar artery flap, and the application of a tensioned ring external fixation device for perioperative and postoperative stability. The authors believe the article is beneficial to all medical and surgical specialties related to the treatment of diabetic limb salvage. It offers an alternative method of treatment to the diabetic Charcot foot ulcer that can be potentially