Treating Undiagnosed Charcot Neuroarthropathy Following Traumatic Hallux Varus Repair

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

   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.

   Although the patient was non-adherent and at high risk for surgery, due to the extensive deformity present, the senior author performed a metatarsocuneiform fusion after carefully discussing all alternatives, risks and complications. The patient again wore a below-knee cast at that time.

   At three months post-op, the patient presented for evaluation. Her foot was edematous and the deformity had worsened clinically. Radiographs revealed continued adductus deformity of the first ray with diffuse osteoarthritic changes at the tarsometatarsal and calcaneocuboid joints. Charcot neuroarthropathy, osteomyelitis and/or septic arthritis were all part of the differential diagnosis at that time.

   At this time, a bone biopsy was negative for osteomyelitis and we diagnosed Charcot neuroarthropathy. The patient received a controlled ankle motion (CAM) walker after refusing a cast and the senior author advised her to be non-weightbearing until the swelling had reduced. The patient eventually transitioned into custom-molded diabetic shoes.

   A year and a half later, the Charcot changes had resolved and the senior author removed the loose hardware. No attempts at further reconstruction occurred due to her non-adherence.

In Conclusion

Undiagnosed Charcot neuroarthropathy often leads to devastating results. Our patient developed Charcot following surgical repair of the hallux varus deformity, which initially went undiagnosed. The senior author thought the severe edema was due to a missed first metatarsocuneiform injury, her non-adherence and obesity. The patient subsequently underwent a metatarsocuneiform fusion. The undiagnosed Charcot neuroarthropathy continued and degenerative changes progressed. Once diagnosed, the patient had conservative treatment and eventually, even with the continued non-adherence, the Charcot neuroarthropathy ceased.

   Dr. Pontious is a Professor and the Chair of the Department of Podiatric Surgery at the Temple University School of Podiatric Medicine in Philadelphia. She is a Fellow of the American College of Foot and Ankle Surgeons.

   Mr. Ahsan is a fourth-year student at the Temple University School of Podiatric Medicine.

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