Abstract
Charcot neuroarthropathy is a severe complication of peripheral neuropathy associated with progressive deformity, ulceration, and increased risk of amputation. Surgical reconstruction of midfoot deformity using medial column intramedullary beaming is an established technique for achieving a stable, plantigrade foot. However, complications related to altered forefoot biomechanics remain limited in the literature. We present two patients who developed plantar ulceration beneath the first metatarsal head following medial column beaming for midfoot Charcot reconstruction, despite achieving successful midfoot consolidation. Both patients were initially managed with sesamoidectomy to offload plantar pressure, which subsequently resulted in instability and dislocation of the first metatarsophalangeal joint. Ultimately, both patients required first metatarsophalangeal arthrodesis to restore alignment, reduce plantar pressure, and promote wound healing. These cases highlight an underrecognized complication of medial column beaming and suggest that isolated sesamoidectomy may be insufficient to address forefoot instability in this setting. Consideration of first-ray stability and forefoot biomechanics at the time of initial reconstruction or revision is important for preventing recurrent ulceration and the need for additional surgical intervention.
Introduction
Charcot neuroarthropathy is a complex, multifactorial complication of peripheral neuropathy, characterized by progressive bone and joint destruction leading to instability and deformity, that frequently affects the lower extremities and is most often linked to long-standing diabetes mellitus. Charcot neuroarthropathy increases the risk of amputation sevenfold without ulceration and twelvefold with ulceration, highlighting the critical need for prompt and accurate diagnosis. Early detection is essential, yet the ideal timing and strategy for surgical management remain controversial. Korst et al. reported an average diagnostic delay of 106.5 days, with many cases initially mistaken for cellulitis or other skin infections.
Surgical reconstruction of midfoot deformity aims to restore a stable, plantigrade foot and reduce the risk of recurrent ulceration. Medial column intramedullary beaming for midfoot charcot neuroarthropathy has been widely utilized to achieve structural stability and consolidation. While prior studies have demonstrated favorable outcomes with this technique, complication rates remain high, including hardware failure, infection, and need for reoperation. ,,
While medial column intramedullary beaming has demonstrated success in achieving midfoot stability and consolidation, alterations in first-ray alignment and load distribution following reconstruction may increase plantar pressure beneath the first metatarsal head, predisposing patients to ulceration. Despite the high overall complication rates associated with Charcot reconstruction, literature regarding sub-first metatarsal ulceration and its management is limited.
The goal of this study is to present two cases in which patients developed plantar ulceration beneath the first metatarsal head following medial column intramedullary beam fixation for midfoot Charcot deformity, highlighting a complication with important implications for surgical planning and forefoot management.
Case reports
Patient 1
A 59-year-old female with a history of Charcot neuroarthropathy presented with a severe midfoot deformity and underwent surgical reconstruction consisting of triple arthrodesis, naviculocuneiform and first tarsometatarsal joint arthrodesis, gastrocnemius recession, bone marrow aspirate (BMA) harvest, and cuboid ostectomy.
Postoperatively, the patient remained non-weight-bearing in a total contact cast for 3.5 months and gradually transitioned to weight-bearing in a controlled ankle motion (CAM) boot over another 4 weeks. The initial postoperative course was uneventful; however, approximately 7 months following the index procedure, the patient developed a plantar ulceration beneath the first metatarsal head. Notably, the chart review revealed no documented plantar prominence on examination or radiographic malalignment that would have otherwise explained the development of the ulceration.
Initial management consisted of serial in-office debridements, local wound care, offloading measures, and multiple courses of oral antibiotics. Despite these interventions, the plantar first metatarsal head ulcer failed to resolve. Additionally, the patient developed a plantar-lateral midfoot wound secondary to a prominent plantar cuboid. One year following the index Charcot reconstruction, the patient underwent tibial and fibular sesamoidectomy to reduce plantar pressure beneath the first metatarsal head in conjunction with a repeat cuboid ostectomy to address the plantar-lateral midfoot prominence and promote wound healing. Intraoperative pathology was negative for osteomyelitis.
Immediately following the sesamoidectomy and ostectomy, the patient was immobilized in a posterior splint for 3 weeks and subsequently transitioned to a CAM boot. Following sesamoid resection, dorsal dislocation of the hallux at the metatarsophalangeal (MTP) joint was evident on radiographs obtained at the first postoperative visit, approximately 3 weeks after surgery, resulting in altered forefoot biomechanics and persistent plantar pressure beneath the first metatarsal head ( Fig. 1 ). The sub–first metatarsal ulceration persisted despite continued offloading, debridements, and wound care.
Patient 1. A1 & A2: status post charcot reconstruction with medial column beaming. B: persistent nonhealing ulceration following sesamoidectomy. C1 & C2: dorsal dislocation of hallux status post sesamoidectomy. D: Postoperative X-ray after 1st MTP arthrodesis with medial column IM beam removal. D1 & D2: Postoperative X-ray one year post MTP arthrodesis with incomplete fusion consolidation with stable hardware. E: Clinical improvement in sub-1st metatarsal ulceration following 1st MTP arthrodesis.
Given ongoing ulceration and instability, the patient underwent removal of the intramedullary locking nail and first MTP joint arthrodesis approximately 1.5 years after the index procedure. Postoperatively, she was maintained non-weight-bearing in a CAM boot. Her postoperative course was complicated by wound dehiscence, requiring two additional operative interventions for incision and drainage and subsequent management with negative pressure wound therapy.
With continued wound care and offloading, both the surgical site and the plantar ulceration progressively healed. The sub–first metatarsal head ulceration was documented as fully healed approximately 6.5 months following the first MTP arthrodesis. At one-year follow-up from the MTP fusion, there was no recurrence of ulceration, and radiographs demonstrated stable hardware; although the first MTP arthrodesis site was not fully consolidated, chart review noted maintained alignment and stable fixation.
Patient 2
A 42-year-old female with Charcot neuroarthropathy presented with a complex midfoot deformity and underwent surgical reconstruction consisting of first through third tarsometatarsal arthrodesis, naviculocuneiform arthrodesis, subtalar and talonavicular arthrodesis, gastrocnemius recession, and BMA harvest.
Postoperatively, the patient remained non-weight-bearing in a total contact cast for 3 months and subsequently transitioned to a CAM boot. Shortly thereafter, she was fitted for a Charcot restraint orthotic walker (CROW) boot for continued offloading. The initial postoperative course was unremarkable; however, approximately 8 months following the index procedure, the patient developed a plantar ulceration beneath the first metatarsal head.
At approximately 9 months following the index procedure, the patient underwent tibial and fibular sesamoidectomy to reduce plantar pressure. Postoperatively, she remained non-weight-bearing for 4 weeks before transitioning back into her CROW boot. Despite this intervention, the patient developed progressive hallux valgus deformity with dorsal subluxation and eventual dislocation of the first MTP joint approximately 3 months following sesamoidectomy, resulting in persistent abnormal forefoot biomechanics and a chronic, non-healing plantar ulcer beneath the first metatarsal head ( Fig. 2 ).
