Treating Undiagnosed Charcot Neuroarthropathy Following Traumatic Hallux Varus Repair

Author(s): 
Jane Pontious, DPM, FACFAS, and Irfan Ahsan, BS

These authors present the treatment of a non-adherent 53-year-old patient with diabetes who received treatment for previously undiagnosed Charcot following hallux varus surgery.

Hallux varus is a condition in which the great toe deviates medially away from the lesser toes. The condition is often uncomfortable or even painful for the patient to the extent that surgery is necessary to correct the underlying problem.

   Hallux varus deformity generally has three possible components: medial deviation of the hallux at the first metatarsophalangeal joint (MPJ); supination of the phalanx; and interphalangeal flexion or claw toe deformity.1 Any combination of these factors can make it difficult for a patient to wear shoes or even walk in a stable manner. Hallux varus can be congenital or acquired. The incidence is relatively rare with reports ranging between 2 and 15.4 percent in the literature. The etiologies of acquired hallux varus include trauma, severe burn injury with contracture, systemic inflammatory disorders such as rheumatoid or psoriatic arthritis, Charcot-Marie-Tooth disease, avascular necrosis of the first metatarsal head, and paralysis or poliomyelitis.

   Hallux varus most commonly arises as an iatrogenic complication of bunion surgery, resulting from overcorrection of hallux valgus.1 This includes staking of the first metatarsal head, overcorrection of the intermetatarsal angle, overzealous medial capsulorrhaphy, fibular sesamoidectomy, over-extensive lateral release, overcorrection of the proximal articular set angle and even overzealous post-op bandaging. Iatrogenic hallux varus is often poorly tolerated.

   Due to the inevitable pain, instability and discomfort, effective treatment is crucial. Conservative treatments for mild hallux varus include taping of the hallux to adjacent toes to prevent further deviation and/or a shoe with a wider toe box to accommodate widening of the digits. Prior to surgical treatment, one should consider several factors, including hallux flexibility and mobility, along with pain. It is also crucial to consider the patient’s expectations, adherence, ability to undergo complex revision surgery, and potential acceptance of joint-sacrificing options such as arthrodesis. Appropriate treatment requires careful clinical and radiographic assessment to identify the involved factors. One would address all of these to correct all elements of the deformity.1

   On another note, Charcot neuroarthropathy is a disease that typically occurs in patients with diabetes, tabes dorsalis, syringomyelia, chronic alcoholism, leprosy, trauma or infection after fractures and dislocations.2 There has even been evidence of Charcot-like joints in the presence of tophaceous gout.3

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