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 fol lowed for an average of 3.6 years. Twenty-three initially presented wi thout 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 chro nic osteomyelitis. Twenty-two of these patients underwent 32 surgical procedures. Sixteen underwent debridement of the infected bone and sur rounding soft tissues. Excision of large, nonaccommodative boney promi nence, 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 s urgical patients were managed postoperatively with long-term custom ac commodative bracing. Follow-up at an average of 3.6 years revealed tha t all but one of the patients remained ambulatory. Six walk with accom modative shoe gear and persistent stable chronic open ulcers. None req uired below-knee amputation. Five amputations were performed, three at the Syme's ankle disarticulation level, one at the Chopart's hind-foo t level, and one at the mid-foot level. Neuropathic midfoot deformity is a disabling disorder that requires thorough patient education and c ompliance, prolonged palliative monitoring and care, accommodative ort hotic shoe management, and selective surgery. It can markedly limit th e patient's walking ability and independence. With careful monitoring and selective surgery to maintain a plantigrade foot, foot salvage and walking ability can be maintained. A treatment algorithm is presented to guide patient care.