Midfoot Nail-Plate-Constructs for Charcot Neuroarthropathy: A Cohort Study with Midterm Follow Up

Abstract

Category: Midfoot/Forefoot; Diabetes; Other Introduction/Purpose: Charcot neuroarthropathy (CN) is a complex disease process with progressive degeneration of normal bone architecture. Treatment options for CN include both conservative measures and operative management with the goal of achieving or maintaining a plantigrade ulcer-free foot. Operative treatment of CN varies widely with regards to timing and type of interventions. Surgical interventions include debridement, exostectomy, and complex reconstructions. The technique of intramedullary beaming with supplemental medial locking plate (referred to here as a Midfoot Nail Plate Construct (MNPC)) utilizes large diameter intramedullary screws linked to a medial locked plate for midfoot stabilization which is the focus of this study. Methods: Nineteen patients (20 limbs) with midfoot CN treated at our institution by a single surgeon between January 2017 - December 2021 met inclusion criteria and were included in our MNPC cohort. Retrospective chart review was performed to obtain demographic data, comorbidities, previous treatment data, ambulation status pre/post intervention, radiographic (Brodsky) classification, time to intervention, number of operations, and outcomes after operative management with MNPCs with a descriptive statistical analysis. Furthermore, post-intervention outcomes (rates of post-operative ulceration, post-operative infection, and amputation) were compared to the our previously studied institutional baseline data of post- surgical complications of CN in 58 patients treated between 2005-2016 with limited and reconstructive techniques without MNPCs. Results: The mean age of the MNPC cohort was 56.3 (range 37 - 73 years), mean BMI was 39.4, and 73.7% of patients had diabetes (mean A1c 7.34, A1c range 5.8 to 10.5). 43% had undergone previous non-operative management and 19% received prior operative treatment. Mean follow up was 19.9 months (range 3 - 47 months). Average time from presentation to intervention was 10.1 months (range 1 - 32 months). Post-intervention rates of ulceration, infection, and amputation for the MNPC cohort were 30%, 25%, and 15% respectively. Compared to our institutional baseline data of complications after limited and reconstructive surgical techniques without MNPCs from 2005-2017, MNPC had a lower rate of ulceration and amputation. Ulceration rate after limited, reconstructive, and MNPC were 34.4%, 42.3%, and 30% respectively. Infection rates were 25%, 42.3%, and 25%, with amputation rates of 21.9%, 23%, and 15% respectively. Conclusion: Despite continued innovation in surgical management of CN of the foot, post-intervention complication rates remain high. This study provides patient and outcome data for Midfoot Nail Plate Constructs as a treatment for CN in a large cohort with midterm follow up. Compared to our own institutional historical data prior to adoption of this technique, MNPCs have an equivalent infection rate and lower rate of ulceration and amputation at an average of 19 month follow-up.