Treating Undiagnosed Charcot Neuroarthropathy Following Traumatic Hallux Varus Repair

Jane Pontious, DPM, FACFAS, and Irfan Ahsan, BS

   The patient’s initial clinical examination revealed non-palpable pedal pulses secondary to severe edema and a dried blood blister on the medial aspect of her right hallux. The hallux was significantly deviated to the midline of her body and it was more pronounced when she was weightbearing. The hallux position was non-reducible and there was pain on range of motion of the first ray. Neurologic status revealed normal reflexes, diminished vibratory sensation, intact proprioception and intact protective sensation via a 5.01 Semmes Weinstein monofilament.

   Radiographs of her right foot indicated severe hallux varus deformity with injury to the lateral proximal phalanx base at the insertion of the adductor hallucis muscle. There were also two small bony fragments at the medial aspect of the first MPJ. There was significant amount of soft tissue edema. There was also a gap at the base of the first and second metatarsals. Fractures of the third and fourth toes were present.

   Treatment at the initial presentation included immobilization by a posterior splint. The patient received crutches in an attempt to reduce the significant amount of edema. We discussed surgical repair due to the severity of the injury and the unlikelihood of a satisfactory conservative treatment. The senior author also ordered a non-invasive arterial vascular study to ascertain the patient’s preoperative arterial status. We discussed the risks and complications of surgery. She got specific instructions to stay off her right foot. We scheduled close re-evaluation after the necessary tests were complete.

What Transpired At The Follow-Up Appointments

The patient missed several appointments and presented for re-evaluation eight weeks after the injury. At this time, she was fully weightbearing in a sandal. No positive progression of her hallux varus deformity had occurred. Her radiographic evaluation was unchanged with the exception of healing fractures of the third and fourth toes.

   Her pulse volume recording/ankle brachial index (PVR/ABI) results showed no evidence of significant peripheral vascular occlusive disease in her legs at rest. The right and left ABIs were 1.19 and 1.07 respectively.

   At three months post-injury, the patient had surgery, which included an arthrodesis of the first MPJ with cross screw fixation along with pin fixation of her third proximal phalanx fracture. She wore a below knee cast, was non-weightbearing and the senior author advised her to use the crutches she received at an earlier visit.

   After missing her first postoperative visit, the patient had an exam approximately two weeks post-op. The cast had broken down on the plantar aspect due to weightbearing. Her clinical exam revealed mild amounts of maceration at the incision site around the first MPJ and edema of the right foot. Her X-ray evaluation revealed significant bending of the third digit pin. She wore another below-knee cast and the senior author advised her again to keep weight completely off the right foot. The patient received a prescription for a wheelchair.

   At post-op visit two, the patient continued to bear weight. Clinically, moderate to severe edema was present and the senior author felt this to be due to her non-adherence and severe increased weight gain. Radiographs taken at the two-month post-op period revealed abduction of her hallux. The screws were intact. A medial shift at the first metatarsocuneiform at the Lisfranc joint was present. Her diagnosis was a missed Lisfranc injury.

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