Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot

Background: This study was performed to evaluate the use of arthrodesis of the tarsal-metatarsal area for the treatment of Eichenholtz stage-I Charcot arthropathy in patients,vith diabetes. Currently, the standard treatment o f stage-I Charcot arthropathy is the application of a non-weight-bearing to tal-contact cast. Although this treatment can be effective for allowing a p atient to walk without undergoing an operation, a nonunion or malunion may still result. The subsequent deformities may lead to complications, includi ng ulceration of the foot and the need for operative intervention. Recently , a group of patients who had had early operative intervention for a variet y of reasons provided us with the opportunity to objectively evaluate the e ffects of such treatment. This analysis provided valuable information about whether this treatment is a reasonable alternative to current nonoperative approaches. Methods: Between January 1991 and December 1996, fourteen patients had an o peration because of Eichenholtz stage-I diabetic neuropathy. The classifica tion of the disease as Eichenholtz stage I (the developmental stage) was ba sed on radiographic evidence of varying degrees of articular-surface and su bchondral-bone resorption and fragmentation as well as joint subluxation or dislocation without evidence of coalescence or callus formation. The opera tive procedure consisted of extensive debridement, open reduction, and inte rnal fixation of the tarsal-metatarsal region with autologous bone graft. P ostoperative treatment consisted of immobilization of the limb in a non-wei ght-bearing cast for a minimum of six weeks. All of the patients returned f or a final follow-up visit at a mean of forty-one months (range, 25.3 to 77 .3 months) postoperatively, at which time clinical and radiographic evaluat ions as well as gait analysis (with measurement of plantar pressures) were performed. The gait-analysis data was compared with similar data from a gro up of fourteen patients,vith diabetic neuropathy who had had a below-the-kn ee amputation and with that from a group of fourteen patients with diabetic neuropathy who had no history of plantar ulceration. Results: All of the arthrodesis procedures were successful. Clinically, non e of the patients had immediate or long-term complications postoperatively. No patient reported ulceration after the operation. The mean time to assis ted weight-bearing was 10 +/- 3.3 weeks (range, six to fifteen weeks), the mean time to unassisted weightbearing was 15 +/- 8.8 weeks (range, eight to thirty-four weeks), and the mean time to return to the use of regular shoe s was 27 +/- 14.4 weeks (range, twelve to sixty weeks). All of the patients regained the level of walking ability that they had had prior to the arthr opathy. The calculated confidence intervals revealed no differences between the arthrodesis group and either of the two comparison groups with regard to the time-distance gait parameters of velocity, cadence, and stride lengt h or with regard to the minimum, maximum, and total range of motion of each of the joints. In contrast to able-bodied subjects, all three groups showe d a reduction in sagittal-plane ankle motion that was primarily related to loss of plantar flexion. The first metatarsal, great toe, and heel showed t he highest peak plantar pressures, with little difference among the groups. Conclusions: To our knowledge, the present study is the first to demonstrat e the potential for early operative treatment to restore anatomical alignme nt and improve function of diabetic patients with stage-I Charcot arthropat hy.