The Journal of Foot & Ankle Surgery

Transcription

1 The Journal of Foot & Ankle Surgery 52 (2013) Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: Solid Bolt Fixation of the Medial Column in Charcot Midfoot Arthropathy Martin Wiewiorski, MD 1,2, Tetsuro Yasui, MD, PhD 3, Matthias Miska, MD 4, Arno Frigg, MD 1, Victor Valderrabano, MD, PhD 1 1 Orthopaedic Department, University Hospital Basel, Basel, Switzerland 2 Center for Advanced Orthopedic Studies, Beth Israel, Deaconess Medical Center, Harvard Medical School, Boston, MA 3 Department of Orthopaedic Surgery, University of Tokyo Hospital, Tokyo, Japan 4 Orthopaedic Department, Orthopaedic University Clinic Heidelberg, Heidelberg, Germany article info abstract Level of Clinical Evidence: 4 Keywords: beam stabilization diabetes intramedullary fixation midfoot fusion osteoarthropathy osteosynthesis surgery Charcot medial column and midfoot deformities are associated with rocker bottom foot, recurrent plantar ulceration, and consequent infection. The primary goal of surgical intervention is to realign and stabilize the plantar arch in a shoe-able, plantigrade alignment. Different fixation devices, including screws, plates, and external fixators, can be used to stabilize the Charcot foot; however, each of these methods has substantial disadvantages. To assess the effectiveness of rigid, minimally invasive fixation of the medial column and midfoot, 8 cases of solid intramedullary bolt fixation for symptomatic Charcot neuroarthropathy were reviewed. The patients included 6 males (75%) and 2 females (25%), with a mean age of 63 (range 46 to 80) years. The Charcot foot deformity was caused by diabetic neuropathy in 7 cases (87.5%) and alcoholic neuropathy in 1 (12.5%). The mean duration of postoperative follow-up period was 27 (range 12 to 44) months. The mean radiographic correction of the lateral talar first metatarsal angle was 15 (range 3 to 19 ), and the mean radiographic correction of the dorsal midfoot dislocation was 9 (range 4 to 23) mm. The mean loss of correction of the lateral talar first metatarsal angle and midfoot dislocation after surgery was 7 (range 0 to 26 ) and 1 (range 0 to 7) mm, respectively. No bolt breakage was observed, and no cases of recurrent or residual ulceration occurred during the observation period. Bolt removal was performed in 3 cases (37.5%), 2 (25%) because of axial migration of the bolt into the ankle joint and 1 (12.5%) because of infection. The results of the present review suggest that a solid intramedullary bolt provides reasonable fixation for realignment of the medial column in cases of Charcot neuroarthropathy. Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved. Charcot neuroarthropathy commonly causes chronic destructive arthropathy involving the joints of the foot and ankle. It occurs as a consequence of various peripheral neuropathies, most commonly as a result of diabetes mellitus (1,2). Tarsometatarsal joints are most frequently affected, followed by the hindfoot, ankle joint, and forefoot (3). Typically, destruction of the Lisfranc joint complex causes flattening of the longitudinal foot arch (rocker bottom deformity), leading to plantar ulceration, which, especially in the course of diabetes, often results in infection and significant morbidity. When conservative management fails to heal or prevent recurrent ulceration, surgical treatment options must be considered (4). The primary goal of surgical intervention is to realign and stabilize the plantar arch, often after first eradicating osteomyelitis and allowing Financial Disclosure: None reported. Conflict of Interest: None reported. Martin Wiewiorski and Tetsuro Yasui contributed equally to the article. Address correspondence to: Martin Wiewiorski, MD, PhD, Orthopaedic Department, University Hospital of Basel, Spitalstrasse 21, Basel 4031, Switzerland. address: mwiewiorski@uhbs.ch (M. Wiewiorski). the Charcot process to become quiescent (5,6). The commonly used surgical procedure entails arthrodesis of the midfoot with or without hindfoot arthrodesis and Achilles tendon release (2,7). Minimizing soft tissue damage during surgery is essential, because incomplete or slow healing is generally known to be associated with neuropathy, vasculopathy, dermopathy, and difficulty avoiding weightbearing activities, all of which are known to affect this patient population. Rigid osteosynthesis is also important owing to the high likelihood of uncontrolled postoperative weightbearing, which can lead to failure of the implants and reconstruction (4). Several different types of bone fixation devices, including screws, plates, and external fixators, can be used to stabilize the reconstructed Charcot foot; however, each of these devices has substantial disadvantages that can affect the clinical course. Cannulated screws break easily, and although a combination of plates and screws is stronger than screws alone (8), such constructs tend to be bulky and can cause soft tissue complications. External fixation is an excellent minimally invasive solution for accomplishing rigid fixation (7,9 11); however, the risk of pin site infection remains, and the fixators can be inconvenient to patients /$ - see front matter Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved. doi: /j.jfas

2 M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery 52 (2013) Recently, several investigators have proposed restoring the alignment of the medial column (medial metatarsocuneiform, medial naviculocuneiform, and talonavicular joints) by intramedullary placement of a cannulated screw (12,13). The clinical results have been favorable; however, screw breakage and migration is a substantial risk associated with this form of fixation owing to the decreased relative strength of a cannulated screw compared with a solid-core screw. With screw breakage, loss of alignment can occur, and additional surgical intervention can become necessary. In an effort to assess the clinical and radiographic outcomes of reconstruction of the Charcot foot using a solid fusion bolt for intramedullary beam stabilization of the medial column and midfoot, we undertook a review of 8 feet in 8 patients with neuroarthropathy and symptomatic rocker bottom foot. Patients and Methods Patient Population We conducted a review of consecutive patients who were seen in our clinic and treated for Charcot neuroarthropathy-associated midfoot collapse using midfoot fusion and a solid intramedullary fusion bolt. The regional ethics committed approved the investigation, and written informed consent for inclusion in the review was obtained. The medical records were reviewed by 1 of us (M.M.), who searched for patients using the diagnosis code for Charcot foot and the diagnosis code for arthropathy associated with other endocrine and metabolic disorders (International Classification of Diseases, 9th Revision, codes and 713.0, respectively, World Health Organization, Geneva, Switzerland). To be included in the case series, all that was required was the diagnosis of Charcot foot and treatment using intramedullary beaming and the solid fusion bolt, along with preoperative and postoperative radiographs of the involved foot. Surgical Procedure Alignment of the medial column and midfoot, specifically the medial metatarsocuneiform, medial naviculocuneiform, and talonavicular joints, was restored and fixed using intramedullary placement of a 6.5-mm diameter solid bolt (Midfoot Fusion Bolt, Synthes, Zuchwil, Switzerland) (14). Joint realignment was performed with a full, open dissection. Joint resection of the medial column in preparation for fusion was performed (cases 1 through 4 and 8); alternatively, the joint surfaces where left intact (cases 5 through 7). The intramedullary bolt was inserted in either a retrograde fashion, directed from the distal end of the first metatarsal into the talus, or an antegrade fashion, directed from the posterolateral aspect of the talus into the first metatarsal. Additional midfoot joints were fused, if needed, using additional large diameter screws or other forms of internal fixation. If the Achilles tendon was found to be tight, effecting ankle equinus, the aponeurosis of the gastrocnemius or the Achilles tendon was lengthened before bone realignment. Postoperative care consisted of the use of a non weightbearing orthosis for the first 12 weeks, followed by gradual progression to full weightbearing according to the clinical and radiographic findings. Clinical Assessment The medical records were reviewed, and the clinical history information was abstracted. The clinical examination at the last follow-up visit included the American Orthopaedic Foot and Ankle Society midfoot score (15), Wagner ulcer grading (16), and the Inlow 60-Second Diabetic Foot Screen (17). The Inlow screening score reflects the residual risk of foot ulceration and ranges from 0 (lowest risk) to 23 (highest risk). We were also interested in whether the patients could ambulate with supportive shoe gear with or without a cane after surgery and healing. Radiologic Assessment All patients underwent pre- and postoperative radiographic imaging. The patterns of osseous deformity as described by Sammarco et al (13) were assigned to each Charcot foot. The skeletal structures were also classified according to the classification of Schon et al (18). Radiographic measurements were taken with the patient weightbearing in the preoperative setting, non weightbearing in the immediate postoperative setting, and weightbearing at the last follow-up evaluation. The talar first metatarsal angle was measured in the anteroposterior view, with positive value representing valgus deformity (13). The talar first metatarsal angle and the calcaneal fifth metatarsal angle were measured on the lateral radiographs, with negative values representing valgus deformity (13). Dorsal midfoot displacement was measured on the lateral radiographs according to the method described by Sammarco et al (13). A paired Student s t-test was performed to compare the radiographic measurements from the pre- and postoperative periods, with statistical significance defined at the 5% (p.05) level. Results From October 2007 to July 2010, we performed 10 unilateral midfoot arthrodeses in 10 patients using solid intramedullary bolt fixation of the medial column and midfoot. Two patients were lost to follow-up because they died, which was determined to be unrelated to their foot operation. We reviewed the clinical and radiographic data pertaining to the 8 remaining cases, and the demographic data are listed in Table 1. The study cohort consisted of 6 males (75%) and 2 females (25%), and their mean age was 63 (range 46 to 80) years. The mean postoperative follow-up duration was 27 (range 12 to 44) months. Of the 8 patients, 7 (87.5%) had diabetes mellitus, and 1 (12.5%) had alcoholic neuropathy. Of the 8 feet, 3 (37.5%) were stabilized with the bolt inserted in an antegrade fashion, and 5 (62.5%) were stabilized in a retrograde fashion. At surgery, 4 patients (50%) Table 1 Patient characteristics (n ¼ 8 feet in 8 patients) Patient No. Age (y) Gender Follow-up Period (months) Charcot Foot Etiology Sammarco Classification (13) Schon Classification * (18) Preoperative Ulcer Preoperative Wagner Ulcer Grade (16) Mid-tarsal Bolt Insertion Other Fused Sites 1 55 Male 23 Diabetes 3 IIIBb No 0 Antegrade Second TMT (plate) 2 63 Female 43 Diabetes NA NA Yes 3 Antegrade None 3 68 Male 40 Diabetes 5 IVCb No 0 Retrograde None 4 59 Male 12 Diabetes 3 IIICb Yes 3 Retrograde First and second metatarsal, medial intermediate cuneiform (plates) 5 46 Female 28 Diabetes 3 IIICa Yes 2 Retrograde None 6 80 Male 16 Diabetes 1 IBa No 0 Retrograde First and second metatarsal, second, third, and fourth TMT, medial intermediate cuneiform (screws) 7 64 Male 44 Diabetes 1 IBb No 0 Antegrade First and second metatarsal, second and third TMT (screws) 8 71 Male 12 Alcoholism 1 ICb Yes 3 Retrograde First and second metatarsal, third TMT (screws) Mean 63 (46 80) 27 (12 44) Abbreviations: NA, not available; TMT, tarsometatarsal joint. Data in parentheses are ranges. * Type I, LisFranc s joint; type II, naviculocuneiform; type III, perinavicular; type IV, Chopart s joint; subclasses: A, above metatarsal calcaneus plane; B, coplanar; C, below; a b stage is assigned if 1 of the following criteria is met: dislocation is present, the lateral talar first metatarsal angle is 30, the lateral calcaneal fifth metatarsal angle is 0, or the anteroposterior talar first metatarsal angle is 35 ;anastage can be assigned when all 4 features are absent.

3 90 M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery 52 (2013) Fig. 1. Exemplary case of successful treatment. (A and B) Preoperative weightbearing radiographs demonstrating failed previous midfoot fusion in patient 3. (C) Immediate postoperative non weightbearing radiographs showing a realigned medial plantar arch, fixed by the antegrade inserted bolt. (D and E) Midfoot alignment was maintained at 40 months postoperatively. had a plantar ulcer. According to the Wagner ulcer grading system (16), 3 (37.5%) of the ulcers were grade 3 and 1 (12.5%) was grade 2. Of the 8 feet, 3 (37.5%) had a Sammarco grade 3 Charcot foot deformation, 3 (37.5%) had grade 1 deformation, and 1 (12.5%) had Sammarco grade 5 deformation (13). For the Schon classification of osseous deformation (18), 3 (37.5%) were type I, 3 (37.5%) were type III, and 1 (12.5%) was type IV. Five of the feet (62.5%) underwent concomitant fusion of other joints in the same foot. As can be seen in the radiographs (Figs. 1 and 2), stability after bolt insertion need not be associated with complete osseous fusion of the splinted joints. The clinical and radiographic data are presented in Tables 2 and 3 and Fig. 3. No cases resulted in limb amputation, and all the patients were able to walk at least 1 block, with a cane in 2 (25%) and without a cane in 6 (75%) at the last follow-up evaluation. The mean American Orthopaedic Foot and Ankle Society midfoot score (15) at the final follow-up evaluation was 67 (range 58 to 83). In addition, at the final follow-up visit, no cases of recurrent or residual ulceration had developed. The mean Inlow 60-Second Diabetic Foot Screen (17) score was 8 (range 5 to 11). Preoperative conventional radiographs were unavailable for 1 patient (12.5%; patient 2). Bolt migration occurred in a total of 3 cases (cases 5 through 7). Bolt removal became necessary in 3 patients (37.5%), 1 (12.5%) because of a deep infection followed by massive osteolysis and collapse of bone structure (patient 8) and 2 (25%) because of axial migration of the bolt into the ankle (patients 6 and 7). None of the bolts deformed or broke. The amount of surgical correction was determined by comparing the preoperative weightbearing and immediate postoperative non weightbearing radiographs taken immediately after surgery (Table 3). The mean correction values were as follows: anteroposterior talar

4 M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery 52 (2013) Fig. 2. Bolt migration. (A and B) Preoperative weightbearing radiographs demonstrating failed previous midfoot fusion in patient 7. (C and D) Postoperative radiographs showing correct position of the retrograde bolt. At 27 months after bolt fixation, the patient visited our clinic because of severe pain in the ankle joint. (E) Radiography revealed axial migration of the bolt into the ankle joint. The bolt was removed and the pain immediately resolved. (F) At the final follow-up examination, 13 months after bolt removal, the radiographs showed a slight loss of correction. However, the medial midfoot alignment was still improved compared with before bolt implantation. first metatarsal angle, 12 (range 2 to 30 ); lateral talar first metatarsal angle, 15 (range 3 to 21 ); lateral calcaneal fifth metatarsal angle, 11 (range 4 to 20 ); and midfoot dorsal displacement, 9 (range 4 to 23) mm. These differences were all statistically significant (p <.05). Maintenance of the correction was determined by comparing the immediate postoperative non weightbearing and long-term postoperative weightbearing foot radiographs (Table 3). The mean loss of correction was as follows: anteroposterior talar first metatarsal angle, 2 (range 3 to 7 ), lateral talar first metatarsal angle, 7 (range 0 to 26 ); lateral calcaneal fifth metatarsal angle, 9 (range 1 to 16 ); and midfoot dorsal displacement 1 (range 0 to 7) mm. A statistically significant (p <.05) postoperative decrease was seen in the lateral calcaneal fifth metatarsal angle (p.05) but not in the other 3 measurements. A representative case of successful midfoot fusion with a solid bolt (patient 3) is shown in Fig. 1, and a case in which the bolt migrated and required subsequent removal (patient 7) is shown in Fig. 2. Discussion Charcot midfoot deformity is associated with recurrent plantar ulceration and consequent morbidity. The aim of surgery is, therefore, to achieve a plantigrade foot with normal plantar pressure distribution (2,19). Although conservative treatment options are widely accepted as the first choice of treatment, the results are often unsatisfactory. Saltzman et al (20) reported that nonoperative treatment is associated with an approximately 2.7% annual rate of amputation, a 23% risk of requiring bracing for more than 18 months, and a 49% risk of recurrent ulceration. Surgical intervention to restore the plantar arch is typically a last resort option for patients in whom conservative treatment is not feasible or has failed. Therefore, patients undergoing reconstructive surgery usually present with a severe deformity. In our case series, the mean preoperative radiologic lateral talar first metatarsal angle was 18, and the mean midfoot dorsal dislocation was 11 mm. Such

5 92 M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery 52 (2013) Fig. 3. Radiologic alignment. (A) talar first metatarsal angle and (B) dorsal displacement were measured on the preoperative weightbearing radiographs, immediate postoperative non weightbearing radiographs, and weightbearing radiographs at the final follow-up examination. The results for all cases are shown. Dotted lines indicate bolt removal cases (patients 6 through 8). severe deformities require a substantial amount of realignment to effect satisfactory correction. In our case series, the mean correction of the lateral talar first metatarsal angle and midfoot dorsal displacement angle was 15 and 9 mm, respectively. As such, a firm fixation method was necessary to try and maintain this amount of correction. Table 2 Postoperative clinical and radiologic data at last follow-up visit * (n ¼ 8 feet in 8 patients) Patient No. Follow-up (months) Inlow Diabetic Score (17) AOFAS Midfoot Score (15) Cane Used Axial Bolt to Aid Migration Removal Ambulation of Bolt No No No No No No No No No No No No No Yes No No Yes Yes y Yes Yes Yes y 8 z Yes No Yes x Mean 27 (12 24) 8 (5 11) 67 (58 83) Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society. Data in parentheses are ranges. * None of the patients displayed neuropathic foot ulcer at the time of final follow-up, and none of the fusion bolts were broken. y Bolt migration. z Alcoholic peripheral neuropathy. x Operative site infection. Table 3 Comparison of preoperative and postoperative radiologic results (n ¼ 8 feet in 8 patients) Patient No. Preoperative Immediate Postoperative Long-term Postoperative Dorsal Midfoot Displacement (mm) Calcaneal Fifth Talar First AP Talar First Dorsal Midfoot Displacement (mm) Calcaneal Fifth Talar First AP Talar First Dorsal Midfoot Displacement (mm) Calcaneal Fifth Talar First AP Talar First NA NA NA NA Mean SD Maximum Minimum Abbreviations: AP, anteroposterior; NA, not available; SD, standard deviation.

6 M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery 52 (2013) Because patients with Charcot foot cannot control the weightbearing load owing to a lack of sensation and other morbidities (e.g., obesity, concomitant arthritis, visual deficits, cardiovascular disease), repetitive peak loads can lead to implant failure. To secure the realignment of the Charcot foot, skeletal fixation with screws, plates, and external fixation have been used (7,9 11,19,21,22). Fixation of a single joint with conventional screws is no longer favored by many surgeons because of the frequent occurrence of screw breakage and loss of fixation (12). Plates are stronger, and several investigators have addressed the successful fusion of midfoot bones by placement of a plate along the medial column (8,19,21,22). Marks et al (8) demonstrated the biomechanical superiority of plantar plates for midfoot stabilization in a cadaver study. However, placement of a plate usually requires extensive dissection and exposure, resulting in accompanying soft tissue damage. Additionally, the implant construct can be bulky and increase tension in the overlying skin. External fixation has been recommended by several investigators (7,9 11). Pinzur and Sostak (11) reported a series of 51 such patients with a minimum follow-up period of 1 year, in which the mean lateral talar first metatarsal angle was reduced from 27.6 to 6.4. However, external fixation is known to be associated with a substantial risk of pin site infection and patient inconvenience owing to the prominence of the frame. Rooney et al (23) reported a method of fixing the medial column using intramedullary screws, and several investigators recently reported obtaining favorable results with this procedure (12,13). Sammarco et al (13) reviewed 22 cases of midfoot arthrodesis with a cannulated screw and reported significant reduction and maintenance of the talar first metatarsal and calcaneal fifth metatarsal angles after a mean follow-up period of 52 months. The key advantage of this method is that a long incision and wide exposure is not required for fixation. However, the implants usually used for such procedures are large-diameter cannulated screws, and it has been shown that these screws carry a substantial risk of breakage. Sammarco et al (13) used 6.5-mm cannulated screws and reported breakage of the screws in 8 (36.4%) of 22 cases. The main form of fixation used in the present patients was a 6.5-mm diameter, solid, headless bolt. At a mean follow-up duration of 27 months, no bolt breakage had occurred, and the midfoot alignment was maintained in all but 1 patient, in whom postoperative infection caused massive osteolysis and failure (patient 8). In our case series, correction of the calcaneal fifth metatarsal angle was not maintained at the last follow-up examination. We believe this was because we did not always beam the lateral column, and the radiographic angle was determined using the non weightbearing radiographs immediately after surgery. We believe that the lateral column fixation is, however, less important for favorable clinical results, although a longer follow-up period is needed to determine whether this theory is likely to be valid. Because 1 of the most important aims of realignment surgery for patients with Charcot foot is to avoid recurrent ulceration, and none of the patients in our series experienced postoperative ulceration or amputation during the observation period, it seems that beam stabilization of the medial column and midfoot is clinically beneficial, and the residual risk of foot ulceration is low according to the Inlow 60-Second Diabetic Screen. A drawback of the fusion bolt used in our patients is the predilection for axial migration, which we observed in 3 patients (37.5%). In 2 of those patients, the midfoot bolt penetrated into the ankle joint and necessitated subsequent implant removal. Interestingly, bolt migration occurred only in cases in which the intramedullary bolt was used to stabilize the medial column without necessarily aiming to fuse (no joint surface resection). We believe the reason for this was the short and shallow thread of the bolt, poor bone stock in patients with Charcot disease, and subsequent weightbearing on a foot that had not, in all cases, achieved solid, radiographic evidence of arthrodesis along the beamed column of bones. We hypothesized that changing the design of the bolt to 1 with a deeper and longer thread pattern might decrease the possibility of axial bolt migration. Also, the use of an interlocking mechanism, similar to that used in femoral and tibial intramedullary nails, might also minimize the risk of this complication. As with all retrospective case series, we appreciate that numerous methodologic limitations threaten the validity of any conclusions we have made. For instance, coding biases could have influenced our ability to identify potentially eligible patients, and we omitted 2 patients who had undergone the procedure but died of causes determined to be unrelated to Charcot foot surgery. Similarly, the retrospective design limited our ability to undertake an explanatory analysis, and we could not determine whether the comorbidities such as renal disease, obesity, or any other factors influenced our outcomes. Furthermore, we could not compare the pre- and postoperative clinical outcomes meaningfully. Still further, our emphasis was on radiographic measurement suggestive of a more normal pedal alignment, although the precise meaning of such measurements, whether weightbearing or not, in regard to subjective patient satisfaction is not known. We were also unable to determine the association of solid radiographic evidence of fusion with satisfactory long-term outcomes compared with the influence of beam stabilization without radiographic arthrodesis. Despite these shortcomings, we believe the results from the present series of patients imply that the solid fusion bolt can be used to stabilize the realigned foot in most patients with symptomatic medial column and midfoot Charcot deformation. In conclusion, the results of the present preliminary series of patients could be useful in the design of future prospective cohort studies and randomized controlled trials focusing on surgical repair of the Charcot foot. References 1. Gupta R. A short history of neuropathic arthropathy. Clin Orthop Relat Res 296:43 49, Yablon CM, Duggal N, Wu JS, Shetty SK, Dawson F, Hochman MG. A review of Charcot neuroarthropathy of the midfoot and hindfoot: what every radiologist needs to know. Curr Probl Diagn Radiol 39: , Robinson AH, Pasapula C, Brodsky JW. Surgical aspects of the diabetic foot. J Bone Joint Surg Br 91:1 7, Johnson J. Operative treatment of neuropathic arthropathy of the foot and ankle. J Bone Joint Surg Am 80: , Grant WP, Garcia-Lavin S, Sabo R. Beaming the columns for Charcot diabetic foot reconstruction: a retrospective analysis. J Foot Ankle Surg 50: , Lamm BM, Gottlieb HD, Paley D. A two-stage percutaneous approach to Charcot diabetic foot reconstruction. J Foot Ankle Surg 49: , Dalla Paola L, Brocco E, Ceccacci T, Ninkovic S, Sorgentone S, Marinescu MG, Volpe A. Limb salvage in Charcot foot and ankle osteomyelitis: combined use single stage/double stage of arthrodesis and external fixation. Foot Ankle Int 30: , Marks RM, Parks BG, Schon LC. Midfoot fusion technique for neuroarthropathic feet: biomechanical analysis and rationale. Foot Ankle Int 19: , Cooper PS. Application of external fixators for management of Charcot deformities of the foot and ankle. Foot Ankle Clin 7: , Farber DC, Juliano PJ, Cavanagh PR, Ulbrecht J, Caputo G. Single stage correction with external fixation of the ulcerated foot in individuals with Charcot neuroarthropathy. Foot Ankle Int 23: , Pinzur MS, Sostak J. Surgical stabilization of nonplantigrade Charcot arthropathy of the midfoot. Am J Orthop (Belle Mead NJ) 36: , 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 91: , Sammarco VJ, Sammarco GJ, Walker EW Jr, Guiao RP. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. J Bone Joint Surg Am 91:80 91, Wiewiorski M, Valderrabano V. Intramedullary fixation of the medial column of the foot with a solid bolt in Charcot midfoot arthropathy: case report. J Foot Ankle Surg 51: , Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15: , 1994.

7 94 M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery 52 (2013) Wagner FW. A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. Instr Course Lect 28: , Inlow S. The 60-second foot exam for people with diabetes. Wound Care Canada 2:10 11, Schon LC, Easley ME, Cohen I, Lam PW, Badekas A, Anderson CD. The acquired midtarsus deformity classification systemdinterobserver reliability and intraobserver reproducibility. Foot Ankle Int 23:30 36, 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 82-A: , Saltzman CL, Hagy ML, Zimmerman B, Estin M, Cooper R. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet? Clin Orthop Relat Res 435: , Embil JM, Trepman E. A case of diabetic Charcot arthropathy of the foot and ankle. Nat Rev Endocrinol 5: , Horton GA, Olney BW. Deformity correction and arthrodesis of the midfoot with a medial plate. Foot Ankle 14: , Rooney J, Hutabarat SR, Grujic L, Hansen ST Jr. Surgical reconstruction of the neuropathic foot. Foot 12: , 2002.