Diabetic Midfoot Charcot- When to operate, a staged approach to decision making.

M Tiruveedhula

Introduction: Diabetic midfoot Charcot neuroarthropathy (CN) is a progressive condition which presents as a hot swollen foot to a rocker bottom deformity with ulcer and resultant osteomyelitis. Literature report of a subjective indications for surgery generally after a failed prolonged immobilization in a total contact cast. The aim of this study is to define objective indications of progression of midfoot CN and interventions at each stage of the disease.

Patients and Methods: Notes and radiographs of consecutive patients presented to Basildon Diabetic foot unit since 2018 with midfoot CN were reviewed. Inclusion criteria were all patients with midfoot CN and were followed for a minimum 12 months with radiographs. Exclusion criteria were patients lost to follow before 12 months or where inadequate radiographs were available. Patients with ankle/ subtalar Charcot were excluded.

Results: A total of 182 patients with midfoot CN were seen since 2018, of these 88 patients underwent surgical reconstruction. 3 radiographs features: lateral Mearys angle, calcaneal pitch and cuboid height were noted to be diagnostic for diagnosis and monitoring of the progression of the midfoot CN. 5 stages of disease were described (Basildon classification) with stage 1 and 2 were managed with percutaneous tendo-Achilles lengthening (TAL).
Progression of above radiological parameters is an indication for surgical stabilisation. Lateral column involvement is indicated by the drop in cuboid height which rapidly progresses to ulcer formation.

Conclusion: Motor neuropathy induced stiff and contracted muscles results in progressive midfoot CN. The radiological markers described are shown to be reliable and reproducible indices for the progression of the disease process. In-clinic procedures such as TAL has shown to slow or revert the earlier stages of disease, however worsening of these markers are reliable guide for indication for surgical stabilisation.