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Journal of the American Academy of Orthopaedic Surgeons
8
We are accustomed to thinking of
foot and ankle fractures in the
patient with diabetes as ÒCharcot
injuries.Ó Although this terminolo-
gy does describe a disease process,
it is now of historic interest only;
the term ÒneuroarthropathyÓ more
correctly describes the rapid onset
of painless and severe joint destruc-
tion. This disease process was dis-
cussed by Charcot in 1868 with ref-
erence to a patient with locomotor
ataxia and posterior column dys-
function of the spinal cord (tabes
dorsalis).
1
In 1936, Jordon was the
first to associate diabetes with neu-
roarthropathy.
2
Fractures and dis-
locations are part of the spectrum of
this arthropathy, which has a var-
ied presentation. The sine qua non
of neuroarthropathy is architectural
disruption and disorganization of
the foot either in the absence of
pain or without an appropriate
level of pain.

2
In the 19th century, syphilis was
a common cause of this form of
arthropathy. Today, although the
major cause of neuroarthropathy
worldwide is leprosy, most pa-
tients with neuroarthropathy in the
United States have diabetes. Other
causes include alcohol-induced
peripheral neuropathy, syringo-
myelia, and congenital indifference
to pain. In diabetic patients, the
incidence of neuropathy is high
(30% to 50%),
3
but neuropathic
fractures occur less commonly,
with an incidence of only 1.0% to
2.5%.
2,4
Typically, neuroarthropa-
thy occurs in patients who have
had diabetes for 10 years or more,
and the incidence of this condition
rises with the duration of dia-
betes.
2,5,6
On rare occasions, how-
ever, neuroarthropathy coexists
with the first presentation of dia-

betes mellitus.
2
Interestingly, neuro-
arthropathy in the contralateral
foot occurs at a higher frequency
(approximating 30%) than in the
initially involved foot.
2
Whether
this increased propensity repre-
sents a predisposition to the devel-
opment of neuroarthropathy or is a
result of increased load bearing in
the uninvolved foot is not under-
stood.
7
In diabetic patients with
renal disease, not only the inci-
dence but also the morbidity of
neuroarthropathy increases dra-
matically.
4,8
Pathophysiology
In the early stages of neuroar-
thropathy, cartilaginous fibrillation
and narrowing with subchondral
and endochondral bone formation
occur in the affected joint. In later
stages, the destructive changes are
marked at the points of contact

between the two articular surfaces,
Dr. Myerson is Director, Foot and Ankle
Service, Department of Orthopaedic Surgery,
Union Memorial Hospital, Baltimore. Dr.
Edwards was a Fellow, Department of
Orthopaedic Surgery, Union Memorial
Hospital.
Reprint requests: Dr. Myerson, Union
Memorial Hospital, Johnston Professional
Building No. 400, 3333 N. Calvert Street,
Baltimore, MD 21218.
Copyright 1999 by the American Academy of
Orthopaedic Surgeons.
Abstract
Neuroarthropathy, a rapid, painless destructive process, has become increasingly
prevalent among long-lived diabetic patients. It is characterized by warm,
swollen joints with a grossly disorganized radiographic appearance, in spite of
which the patient is often pain-free. Neglect of this condition results in progres-
sive deformity or instability, often complicated by ulceration and infection,
which can ultimately result in loss of independent mobility, loss of the affected
limb, and even death. In most cases, a plantigrade, stable, and functional foot
can be achieved with simple nonoperative techniques, such as the use of a total-
contact cast or shoe modification. A few patients in whom uncontrolled instabil-
ity or major osseous prominences cause recurrent ulceration will require recon-
structive surgery (either exostectomy or osteotomy/arthrodesis). Although some
patients will have an improvement in function, ongoing vigilance is necessary.
J Am Acad Orthop Surg 1999;7:8-18
Management of Neuropathic Fractures
in the Foot and Ankle
Mark S. Myerson, MD, and William H. B. Edwards, MB, BS, MS, FRACS

Mark S. Myerson, MD, and William H. B. Edwards, MB, BS, MS, FRACS
Vol 7, No 1, January/February 1999
9
resulting in fragmentation of artic-
ular cartilage, destruction of liga-
ments, eburnation, and bone ab-
sorption. Massive osteophytes,
loose bodies, and often periosteal
bone are formed. The joint capsule
and synovium become thickened
and edematous, initially with vas-
cular spaces but later with fibrous
tissue. Microscopic bone debris
and cartilage in the capsule are
considered by some to be pathog-
nomonic of the process.
9
Limited sensation combined with
active use (but not necessarily over-
activity) is required for a neuro-
pathic fracture to develop.
2,10,11
For
example, neuroarthropathy is seen
only in active patients with neurop-
athy, but not in inactive patients
with neuropathy (e.g., patients with
spinal injuries). Although neuro-
arthropathy seems to develop after
cumulative stress to the foot, it can

occur after a single episode of acute
trauma.
Patients with neuroarthropathy
have satisfactory (but not normal)
circulation to the foot; Doppler
indices are typically greater than
0.6 in most patients.
4,12
It is likely
that perfusion of the foot is in some
way related to this disease process,
which may be associated with
autosympathectomy,
13
producing
increased blood flow and bone
resorption.
The initial radiographic change
in acute neuroarthropathy is usual-
ly a fracture associated with joint
subluxation. This sequence is not
always present, and gross deformi-
ty may develop in the absence of a
fracture, particularly in the mid-
foot. This is clearly a stress-related
or overuse phenomenon in which
ligamentous failure occurs before
fracture. Altered collagen cross-
linking, because of either dia-
betes

14,15
or autosympathectomy,
makes ligaments brittle, inelastic,
and susceptible to trauma. Minor
injury leads to disruption of the lig-
amentous support of the midfoot
and, in the absence of protective
sensation, a rapidly worsening and
unstable dislocation.
Evaluation and Diagnosis
The typical patient with acute neuro-
arthropathy presents with painless
deformity of the foot, erythema,
and swelling. Depending on the
length of time since the initial trau-
ma, minor instability, ligamentous
disruption, or fracture-dislocation
may be present. Unfortunately, the
diagnosis of acute neuroarthropa-
thy is frequently delayed and is
often missed completely. In the
acute phase, as a result of the asso-
ciated erythema and swelling,
patients are frequently treated for
presumed infection. Although
most patients do not report pain, it
is important to remember that
acute neuroarthropathy may be
painful.
2,9

If pain exists in the pres-
ence of acute or chronic neuro-
arthropathy, the clinician should
suspect associated infection.
The differential diagnosis in-
cludes gout, cellulitis, and osteo-
myelitis. The absence of systemic
signs (e.g., fever, elevated white
blood cell count, and elevated sedi-
mentation rate) and the presence of
a normal blood glucose level effec-
tively eliminate infection as part of
the differential diagnosis. If the
diagnosis of infection is still in
doubt, a trial of 2 hours of bed rest
and elevation of the limb will be
helpful; the swelling associated
with acute neuroarthropathy will
subside rapidly,
3
whereas that
associated with infection will not.
Patients with diabetes who pre-
sent with foot deformity or find-
ings suggestive of neuroarthropa-
thy should be carefully examined
for sensory deficit by assessment of
light-touch and two-point discrimi-
nation. The most accurate and clin-
ically applicable means of evaluat-

ing sensation in the office setting is
testing with Semmes-Weinstein
monofilaments. If a patient is able
to perceive sensation when the 5.07
monofilament is used, protective
sensation is present.
Although most patients with
neuroarthropathy have reasonable
perfusion of the foot, it may be
marginal or inadequate for those
who require surgical procedures.
A Doppler ultrasound evaluation
of the foot should be performed
routinely. Healing after surgery is
more likely if the Doppler ultra-
sound indicates pulsatile flow and
the ankle-brachial index is greater
than 0.45.
16
In our previous re-
port,
4
the average was 0.65, con-
firming adequate perfusion in most
feet.
Radiographs should be obtained
with the patient bearing weight;
however, this is often not possible
due to poor proprioception or con-
tralateral amputation. Radio-

graphs will usually display gross
disorganization related to the stage
of the arthropathy, although early
in the course of the disease these
findings may be extremely subtle.
2
Two patterns of neuroarthropathy
have been described: (1) an atrophic
pattern, with massive bone resorp-
tion and joint disintegration, and
(2) a hypertrophic pattern, with
joint destruction, periarticular bone
formation, fractures, osteophytes,
bone debris, and migration of the
bone fragments. The second pat-
tern is seen more often in the ankle
than in the foot.
17
Unless the fracture or disloca-
tion is associated with an ulcer or
an open wound on the foot, osteo-
myelitis is rare. Magnetic reso-
nance imaging can define the pres-
ence (or establish the absence) of
soft-tissue infection, but it does not
differentiate well between neuro-
arthropathy and osteomyelitis
because both are associated with
bone edema.
2

Simultaneous indium-
labeled white blood cell scanning
and technetium-labeled polyphos-
Neuropathic Foot and Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
10
phate scanning (dual-window
imaging) may be more helpful in
diagnosing infection.
2
Staging and Classification
In 1966, Eichenholtz
9
described a
combined clinical and radiograph-
ic staging system. In stage I, the
foot is inflamed, edematous, and
erythematous, occasionally with a
precipitous onset. Radiographs
typically show bone fragmenta-
tion. However, this finding may
be subtle, particularly in the pres-
ence of joint subluxation or dislo-
cation, rather than fracture. In
stage II, the reparative process
begins. The swelling, erythema,
and warmth regress, and radio-
graphs demonstrate coalescence
and resorption of bone fragments.
In stage III, inflammation is absent

(resolved), and consolidation of
the bone is radiographically evi-
dent.
2,9
Stage III, therefore, implies
stability but not necessarily chroni-
city, because the foot may remain
unstable over a long period of time
despite coalition of fragments and
bone healing. This scenario is par-
ticularly applicable to the hindfoot,
where bone healing may have
occurred but the foot is clinically
unstable, with a rocker-bottom
deformity; in these circumstances,
regardless of chronicity, stage III
has not been reached.
3
The anatomic classification pro-
posed by Brodsky
2
is clinically useful
because it highlights the anticipated
duration of treatment required and
facilitates more accurate comparative
evaluation of deformity. Type I (60%
of cases) involves the tarsometatarsal
and naviculocuneiform joints. It is
rarely associated with chronic insta-
bility and is ultimately characterized

by symptomatic plantar osseous
prominences. Although feet with
type I neuroarthropathy are stable,
they are usually deformed, which
may cause ulceration depending on
the magnitude and location of the
deformity.
2,3
Type II (20% of cases)
involves the subtalar, talonavicular,
and/or calcaneocuboid joints; the feet
are often grossly deformed and
unstable and need longer periods of
immobilization. Type IIIA produces
the most severe instability, due to dis-
solution of the talus and ankle, and
frequently involves marked varus or
valgus with a prominent malleolus,
leading to ulceration and infection.
Type IIIB is a pathologic fracture of
the calcaneus that often leads to pro-
gressive secondary pes planus and
Achilles tendon insufficiency.
General Principles of
Management
The goal of treatment should be to
create or maintain a stable, biome-
chanically sound, plantigrade foot
that can fit in a shoe or brace.
When planning treatment, the clini-

cian must consider the particular
pattern of injury, the age and activ-
ity level of the patient, the degree
and expected progression of the
consequent deformity, the stage of
the disease process, and the pres-
ence of complications, such as
ulceration or infection.
4,18
The
problems caused by neuroarthrop-
athy are usually due to either os-
seous prominences or persistent
instability.
2
Although most patients can and
should receive nonoperative care
for neuroarthropathy, surgery may
be essential for some patients with
either acute or chronic disease. In
all cases, patient education in prop-
er foot care and the avoidance of
injury is vital. Whatever treatment
approach is selected, the patient
must be made aware of the severity
of the disease process. Because of
neuropathy, however, these pa-
tients simply do not recognize the
harmful effect of bearing weight on
the affected extremity and, despite

all advice to the contrary, continue
to damage their feet. The need for
vigilance regarding the onset of
ulceration and infection is therefore
essential.
Nonoperative Modalities
Most cases of neuropathy of the
foot or ankle can be satisfactorily
managed with nonoperative meth-
ods of treatment. Prolonged im-
mobilization is generally the key to
an ideal outcome.
2,4,10,11
The prin-
ciples of this approach are to con-
trol swelling, to provide skeletal
stability, to protect the soft tissues
for an extended period, and to
ensure even distribution of forces
on the weight-bearing surface of
the foot. In the acute stage (Eich-
enholtz stage I), closed manage-
ment involves the reduction of
swelling by elevation and rest; in
patients with severe swelling, the
use of intermittent compression
may also be necessary.
19
Once the
severe swelling has been reduced,

a total-contact cast provides some
stability, distributing pressure
across the plantar weight-bearing
surface of the foot more evenly
than a regular cast. When the
swelling decreases further and
stage II approaches, a removable
boot or short leg cast will provide
external stability for most pa-
tients.
20
In stage III, the goal is to
provide even distribution of force
over the weight-bearing surface of
the foot. This is usually accom-
plished with a custom-made ortho-
sis, an accommodative shoe, or a
protective brace, such as an ankle-
foot orthosis (usually necessary for
the long-term management of the
hindfoot).
There is the potential risk of devel-
oping neuroarthropathy after an
acute sprain or fracture.
3,10,11,18
In
general, these injuries are treated in a
manner similar to that utilized for
patients without neuropathy. If indi-
cated, surgery should not be delayed

or avoided simply because the
patient is diabetic. If the injury is
Mark S. Myerson, MD, and William H. B. Edwards, MB, BS, MS, FRACS
Vol 7, No 1, January/February 1999
11
managed with inadequate immobi-
lization, a rapidly developing neuro-
arthropathy may ensue. If the foot or
ankle fracture is nondisplaced or
minimally displaced and has a stable
configuration, closed management
with prolonged casting is an accept-
able alternative, but only with close
supervision. If the fracture is dis-
placed and either considerable
manipulation is needed to reduce it
or molding is required to maintain
the reduction, an open approach with
internal fixation is recommended.
Regardless of the method of treat-
ment, prolonged immobilization is
often necessary to prevent the devel-
opment of neuroarthropathy. Pa-
tients with diabetes and neuropathy
may require double the normal peri-
od of immobilization, maintaining
non-weight-bearing status for 10
weeks and then weight bearing in a
cast for an additional 2 to 4 months or
until all warmth and swelling have

dissipated.
Reconstructive Surgery
Reconstructive surgery in the
setting of neuroarthropathy is tech-
nically challenging. If surgery is
contemplated, the risks of failure of
fixation, wound problems, sepsis,
and amputation should be made
clear to the patient. Furthermore,
surgery should not be undertaken
if the surgeon is unfamiliar with
treatment of the insensate foot.
Successful management requires a
sophisticated team approach, in-
volving specialists in infectious dis-
ease, vascular surgery, physical
therapy, rehabilitation, and pros-
thetics.
During the acute phase, the foot
is hypervascular, soft-tissue cover-
age is potentially compromised,
and, due to osteopenia, fragmenta-
tion of bone makes fixation chal-
lenging. Regardless of the location
of the arthropathy, open reduction
and internal fixation alone is gener-
ally unsatisfactory, and primary
arthrodesis is usually required to
stabilize the foot further.
4

In the
acute stage, surgery is needed pri-
marily to prevent soft-tissue dam-
age (i.e., skin necrosis due to pres-
sure of the dislocated bone or other
skin problems secondary to cast
molding necessary to maintain
reduction). Surgery should be con-
templated only if the bone will
support adequate fixation. For this
reason, it is rarely appropriate to
operate on the foot, regardless of
the pattern of dislocation, if more
than 6 weeks has elapsed since the
onset of acute neuroarthropathy. It
is often difficult to ascertain exactly
when the process commenced,
because the patient can rarely rec-
ognize the initial event or the onset
of neuroarthropathy. Surgical cor-
rection is more frequently an alter-
native when there is a dislocation
without fracture, but is contraindi-
cated if bone fragmentation is
already substantial.
Reconstruction of the more
chronically deformed, unstable foot
may be performed in either the
subacute or the chronic stage when
cast, brace, or shoe modifications

can no longer control recurrent
ulceration. However, one must
determine that the efforts at these
treatments have in fact been ade-
quate, because most stable defor-
mities, regardless of their magni-
tude or the appearance of the foot,
are well accommodated in an
appropriate brace or shoe. If recur-
rent ulceration occurs, one should
first determine whether the protec-
tion afforded the foot was adequate
before proceeding to surgery.
A successful reconstructive pro-
cedure depends on a minimum of
soft-tissue swelling, reasonable bone
quality to support solid fixation of
internal devices, adequate vasculari-
ty, and the absence of infection. The
last-mentioned criterion is some-
times difficult to achieve because
patients with chronically deformed
feet or ankles and severe destructive
neuroarthropathy often have associ-
ated infection. The surgical plan-
ning of the reconstruction must
therefore take this into account,
because the alternative is amputa-
tion. Surgery should not be per-
formed if the foot or extremity is

swollen. The reduction of swelling
before commencing surgery may be
accomplished with 24 hours of bed
rest, limb elevation, and mild diure-
sis. An intermittent foot compres-
sion pump can be used for 12 hours
immediately before surgery if
swelling remains a problem. How-
ever, in the patient with neuropathy,
this device should be used cautious-
ly because of the lack of protective
sensation.
In all patients, the operative tech-
nique is of paramount importance.
The soft tissues are marginally
viable and must be treated cautious-
ly; longitudinal incisions should be
made directly to bone without
superficial subcutaneous dissection.
Incisions on the plantar weight-
bearing surface of the foot should be
avoided while maintaining broad
skin bridges and using minimal skin
retraction.
21
Although this ap-
proach usually traumatizes superfi-
cial sensory nerves, in these cases
the foot is already insensate. A
tourniquet is not used, and all

surgery on the insensate foot is per-
formed with local or regional ankle-
block anesthesia. When bleeding
impairs visualization, an Esmarch
bandage can be applied temporari-
ly. In all cases, arthrodesis is ac-
complished with rigid fixation and
is accompanied by aggressive resec-
tion of fibrous tissue, cartilage
debris, and synovium; resection of
sclerotic bone to achieve congruent
bleeding surfaces that provide max-
imal contact and stability; judicious
use of bone graft; and reduction of
soft-tissue tension with wound clo-
sure.
22
Autogenous cancellous bone
graft is generally used, but if an
adequate quantity of autogenous
bone is not available, allograft may
be considered.
Neuropathic Foot and Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
12
Realignment with open reduc-
tion is followed by arthrodesis of
the involved joints. Wherever pos-
sible, rigid screw fixation of the
involved bones is used, but due to

the difficulty encountered with poor
bone quality and osteopenia, it may
be necessary to extend the screws
across joints into uninvolved bones.
When internal fixation is difficult,
supplemental external fixation may
be appropriate, but the use of any
external fixator must be approached
cautiously because of the possibility
of infection. However, excellent
results have been obtained with a
ring fixator, and in the presence of
gross instability (particularly of the
ankle), an external fixator may be
used to supplement internal fixa-
tion. A ring fixator can be used in
the presence of infection. When sta-
ble fixation of the hindfoot and
ankle is required, a tibiocalcaneal or
tibiotalocalcaneal arthrodesis can be
performed with the use of an
intramedullary nail.
Postoperatively, the extremity is
immobilized in a bulky bandage
with copious cotton padding and
posterior or U-shaped plaster
splints. Intravenous antibiotic pro-
phylaxis is used for 48 hours. Bed
rest with strict elevation of the limb
is required for the first week. Pa-

tients should be carefully evaluated
to ensure compliance with respect
to restricted weight bearing. If the
patient is totally unable to comply,
transfer to a chronic-care facility for
the appropriate duration is neces-
sary until unrestricted ambulation
can begin. Ten days after surgery,
the first dressing change is per-
formed, and a short leg cast is ap-
plied. Sutures are typically left in
place for 3 to 4 weeks, unless
wound healing is clearly complete
at an earlier time.
The length of postoperative cast-
ing and protected weight bearing is
determined on the basis of the loca-
tion of the reconstructive proce-
dure and the extent of apparent
healing. Typically, a non-weight-
bearing cast is used for 2 months,
followed by a weight-bearing cast
or a cast brace for 4 (midfoot), 6
(hindfoot), or 9 (ankle) months.
These times are quite variable,
however; the temperature of the
foot and the presence of swelling
are used as indications of bone and
soft-tissue healing. Once tempera-
ture and swelling have subsided to

more normal levels as compared
with the contralateral foot, weight
bearing in a cast can commence. A
cast brace or shoe is gradually
introduced as early as possible
without jeopardizing the recon-
structive effort. If the patient is
reliable and the fracture or arthro-
desis is healing, a removable cast
brace is applied at 4 to 6 months and
remains in place until the extremity
is completely stable.
Management of
Neuroarthropathy in the
Midfoot
Neither the initial nor the final
appearance of the foot should be of
major concern to the patient or the
treating physician because, despite
gross deformity of the midfoot, a
shoe can still be fitted. The vast
majority of patients with acute
midfoot neuroarthropathy may be
treated nonoperatively.
Nonoperative Approach
Although manipulation of the
midfoot might temporarily reduce a
dislocation, this procedure should
not be attempted because of the
pressure required to obtain and

maintain the reduction. Any undue
pressure in the insensate foot will
lead to superficial and possibly
deep skin loss and infection. Fur-
thermore, there are such rapid fluc-
tuations in the swelling of the foot
that the reduction is rarely main-
tained. However, when treating an
early neuroarthropathy with mini-
mal subluxation and little fragmen-
tation, application of a well-padded
and molded cast is preferable in an
effort to prevent increasing defor-
mity. Unfortunately, the deformity
may worsen in spite of these pre-
cautions. Such worsening occurs
predominantly because the patient
is unable to comply with restricted
weight bearing, although it is possi-
ble that increasing deformity may
occur due to gross ligamentous lax-
ity and tendon forces across unsta-
ble joints.
The cast should be changed at
weekly intervals for 2 to 3 weeks
and then at 2- to 3-week intervals,
depending on the amount of swell-
ing. A total-contact cast is not neces-
sary, as non-weight-bearing status
should be maintained. Ambulation

in a cast is begun after the extreme
swelling and warmth begin to sub-
side (usually at about 6 to 8 weeks),
signifying the beginning of bone
healing and the commencement of
Eichenholtz stage II. At this time,
the cast is changed at 3- to 4-week
intervals until a stable stage III is
reached.
Surgical Approach
If the fracture or dislocation is
grossly unstable, if the presence of
severe deformity precludes fitting
into a shoe, or if the soft tissue is at
risk from an underlying bone
prominence, then open reduction
with internal fixation and arthrode-
sis should be considered (Fig. 1).
Although this approach to opera-
tive treatment of the insensate foot
may seem aggressive, there is suffi-
cient clinical evidence that a care-
fully monitored operative approach
to the acute unstable midfoot has
substantial benefit.
4
Before deciding on a surgical
treatment regimen, the clinician
should assess the magnitude of the
deformity and determine whether

the surgical support team can ade-
quately manage the patient. It is
preferable to treat a patient nonoper-
Mark S. Myerson, MD, and William H. B. Edwards, MB, BS, MS, FRACS
Vol 7, No 1, January/February 1999
13
atively than to embark on a compli-
cated and time-intensive treatment
program with potentially disastrous
consequences attributable to an ill-
prepared or inexperienced team.
Acute Stage (Eichenholtz Stage I)
The procedure begins with two
or three longitudinal incisions,
depending on the severity of the
dislocation. The first incision is
medial, between the plane of the
anterior and posterior tibial ten-
dons, exposing the medial column
(which is invariably involved). A
second dorsal longitudinal incision
is made between the second and
third metatarsal bases, extending
from the middle of the shafts of the
metatarsals proximally to the navic-
ular or talus, depending on the
need for exposure of these bones.
Occasionally, a third incision is
made along the lateral column, dor-
sal to the fifth metatarsal, exposing

the metatarsocuboid joint.
Rigid internal fixation should be
used. Cannulated self-drilling and
self-tapping partially threaded
screws of various diameters offer
the greatest ease of insertion (Fig. 1,
C and D). Smaller screws may not
hold dislocations adequately, par-
ticularly if it is necessary to gain
purchase more proximally in bone
of better quality. Insertion of a
larger screw from the first meta-
tarsal proximally into the cuboid or
calcaneus (i.e., from one stable sec-
tion through an unstable segment
into another stable portion of the
foot) provides the desired greater
bone purchase.
On occasion, a medially or plan-
tarly applied one-third tubular
plate or an H plate can be used to
increase stability.
18,23
The applica-
tion of a plate on the plantar surface
of the midfoot has been particularly
useful for stabilizing the metatarso-
cuneiform and cuneiform-navicular
joints.
18

Although this system is
biomechanically stronger than the
use of dorsally applied screws, the
exposure is considerably more diffi-
cult.
Postoperatively, a short leg cast
is applied. This cast is changed
every 2 to 3 weeks, and weight
bearing is not allowed for 8 to 10
weeks. Once swelling and warmth
settle (stage II), weight bearing is
commenced in a well-fitted and
well-padded short leg cast, which
is changed every 2 weeks until the
foot is stable, as indicated by the
absence of swelling and warmth
and the appearance of fusion on
radiographs. A removable cast-
boot may be used instead of a cast,
but the patient must be informed
about the risks of walking without
support.
Subacute Stage (Eichenholtz Stage II)
During this stage, inflammation
decreases, and there is radiographic
evidence of progressive bone frag-
mentation and resorption, making
surgical fixation extremely tenuous.
A B
C D

Fig. 1 Preoperative anteroposterior (A) and lateral (B) radiographs of a patient with mid-
foot neuroarthropathy. Postoperative anteroposterior (C) and lateral (D) radiographs
were obtained after reduction and stabilization with cannulated screws.
Neuropathic Foot and Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
14
Therefore, surgery is avoided except
for the treatment of infection or
truly recalcitrant ulceration, which
is seen if the foot is grossly unstable.
The ideal treatment is nonoperative
management with weight-bearing
in a total-contact cast or cast-boot,
similar to the approach described
for stage I. Once the foot has stabi-
lized, a gradual transition is made
to custom-made orthoses and shoes.
A severely unstable foot with a
rocker-bottom deformity may not
adequately fit in a shoe; a molded
ankle-foot orthosis may be required.
The unstable midfoot is extremely
difficult to manage, and recurrent
ulceration is most likely to occur.
If surgery is required, the ap-
proach is similar to that described
for stage I midfoot disease. How-
ever, ulceration is often present,
and whenever possible, one should
avoid surgery if there is an open

wound. In these situations, a total-
contact cast should be applied.
24
When the ulcer has healed, surgery
should be performed immediately.
If the ulcer will not heal but sur-
gery is deemed necessary, extreme
care should be exercised to prevent
postoperative wound complica-
tions.
During the period of transition
from contact casting to orthotic
management, close monitoring is
required to prevent recurrence of
stage II signs or the development of
ulceration.
4,18
Occasionally, the foot
does not regain stability; in such
cases, long-term management in a
molded total-contact Òclam shellÓ
brace or a Charcot restraint orthotic
walker, or ÒCROW,Ó
20
is an excel-
lent option.
Chronic Stage (Eichenholtz Stage III)
When the condition stabilizes
(stage III), patients typically have
relatively rigid and often deformed

feet.
4
As previously described,
2,4,21
management with custom-molded
insoles and shoe modifications is
most often effective. However, sur-
veillance for additional foot prob-
lems (particularly ulceration) is
essential; patient education in this
regard is vital. It must also be
remembered that neuroarthropathy
may occur in the same foot at a later
date, although it is rarely at the same
site; this is particularly so in the case
of neuroarthropathy of the midfoot.
4
In cases of recurrent ulceration
and underlying bony prominence in
a stable midfoot, the deformity
should be surgically addressed by
simple exostectomy.
2,4,21
However,
it is important to be aware that a
stable midfoot with an exostosis can
be converted to an unstable midfoot
by performing an exostectomy.
4
It

is unusual for a stable foot to
require a realignment osteotomy
and arthrodesis to prevent recur-
rent ulceration, particularly if the
prominence is medial and lateral
and off the weight-bearing surface.
An unstable midfoot requires
realignment and stabilization, usu-
ally via a closing-wedge osteotomy
and arthrodesis with internal screw
fixation
4
or use of a medial or plan-
tar plate (Fig. 2).
18,23
Achilles ten-
don lengthening is always neces-
sary in treating hindfoot equinus.
In patients with marked bone loss,
threaded Steinmann pins may pro-
vide better stability.
After a realignment procedure,
the foot needs an extended time (5
to 10 months) in cast immobiliza-
tion until the osseous surfaces are
united.
4
Amputation may be a
more acceptable option for patients
in whom the condition recurs after

midfoot realignment; in such cases,
a great effort should be made to
maintain limb length.
4
Fig. 2 Midfoot neuropathy. A, Preoperative lateral radiograph. B, Lateral radiograph obtained after application of plantar plates.
A B
Mark S. Myerson, MD, and William H. B. Edwards, MB, BS, MS, FRACS
Vol 7, No 1, January/February 1999
15
Management of
Arthropathy in the
Hindfoot and Ankle
General Principles
It is important to identify neurop-
athy in a patient with an acute
ankle fracture because such a pa-
tient is at risk for rapidly worsening
neuroarthropathy. Therefore, the
patient must be carefully monitored
during treatment. Diabetes is not a
contraindication to open reduction
and internal fixation, but the pres-
ence of neuropathy means that pro-
longed immobilization is required
to prevent the development of neuro-
arthropathy.
18
This scenario is dif-
ferent from that of the patient who
presents in an acute, subacute, or

chronic stage of established neuro-
arthropathy and is therefore at
marked risk for worsening defor-
mity regardless of the form of im-
mobilization used. In such patients,
the weight-bearing axis of the lower
extremity no longer falls within the
center of the ankle joint due to
varus or valgus deformity, but is
usually medial or lateral to it. For
this reason, despite adequate brace
or cast support, the deformity may
worsen.
In the acute and subacute stages,
management primarily involves a
well-molded short leg cast until sta-
bility is reached.
12
In many cases,
however, weight-bearing must be
delayed until the acute inflamma-
tion and swelling have subsided.
For example, it is difficult to deter-
mine accurately whether a stable
stage has been reached with chronic
dissolution and fragmentation of
the talus (Fig. 3). In such cases,
weight-bearing can commence
when the subacute phase is reached,
provided the talus is centered under

the tibia and remains in the line of
the weight-bearing axis of the lower
limb. If progressive dissolution of
the talus occurs, the consequences
are not as serious as they are when
medial and lateral talar subluxation
occur because the foot remains
plantigrade, and varus or valgus
instability and deformity are less
likely to occur.
The indications for operative
intervention include marked insta-
bility, fixed deformity not manage-
able with a total-contact cast, and
recurrent ulceration and infection
refractory to brace and cast treat-
ment.
12
In these settings, open
reduction and arthrodesis of the
involved joints is the procedure of
choice and may require tibiotalar
arthrodesis, tibiocalcaneal arthro-
desis after talectomy, or triple or
pantalar arthrodesis.
12
Ideally, rigid
internal fixation with large cannu-
lated screws is used, but persistent
ulceration, infection, or osteopenia

may dictate the use of an external
fixation device. Accurate alignment
(ankle in neutral to 5 degrees of
dorsiflexion, 5 to 10 degrees of
hindfoot valgus, and external rota-
tion matching that on the contralat-
eral side) is essential to prevent
maldistribution of force and ulcera-
tion in the postoperative period.
12
Postoperatively, non-weight-
bearing status should be main-
tained with use of a cast for 2 to 3
months. Thereafter, protected
weight bearing is allowed until
arthrodesis is evident both clinical-
ly and radiographically or until a
stable pseudarthrosis is believed to
be present. It is important to real-
ize that arthrodesis is not necessary
to achieve a successful outcome
because stability is the goal of
surgery. In our previously reported
series,
12
more than 90% of the
patients achieved a successful out-
come with salvage of a severe
deformity. Success should be
equated with a stable, noninfected

extremity that fits in a brace.
Most patients who have under-
gone an extended hindfoot or
ankle fusion must be protected in
a brace, usually an ankle-foot
orthosis. Stress fracture of the dis-
tal tibia may occur if no brace is
used, probably due to the in-
creased concentration of force in
the distal portion of the leg (Fig. 4).
The use of intramedullary devices
has proved invaluable in decreas-
ing the incidence of stress fracture
and increasing the rate of arthro-
desis.
Fig. 3 Fragmentation of the talar dome, as visualized on anteroposterior (A) and lateral
(B) radiographs.
A B
Neuropathic Foot and Ankle Fractures
Journal of the American Academy of Orthopaedic Surgeons
16
cannulated screws are inserted.
Occasionally, as a result of frag-
mentation, bone loss, or osteo-
penia, the bone and joints to be
fused are not substantial enough to
support these large screws. In such
situations, the stability of the
fusion may be improved by ex-
tending the screws across a normal

joint into a healthier bone.
As an alternative to the use of
cannulated screws, a blade plate
25
or an intramedullary device has
been successfully used in patients
with neuroarthropathy (Fig. 5). A
retrograde intramedullary nail has
been extremely useful in these
patients, but closed insertion of
this nail is not recommended be-
cause of the difficulty in achieving
adequate reduction without open-
ing the joint. The insertion tech-
nique is important because some-
times only one locking screw will
fit into the calcaneus if the entry
site of the nail is more anterior on
the neck of the calcaneus than opti-
mal.
In the presence of acute or
chronic infection, a decision has to
be made whether an amputation or
a lengthy attempt at salvage and
reconstruction would be better for
the patient. Many patients are
unable to tolerate the prolonged
period of convalescence and reha-
Surgical Techniques
The goal of operative treatment is

to provide maximum stability with
either internal or external fixation,
while facilitating soft-tissue healing
and ultimate arthrodesis. The limb
is surgically prepared and draped
above the knee to improve visual-
ization to attain correct alignment.
For almost all ankle, tibiotalocal-
caneal, tibiocalcaneal, and pantalar
procedures, an extensile lateral
approach to the ankle is made after
resecting the fibula. Bone graft is
harvested from the fibula; a small
acetabular reamer is directed with
pressure onto the fibula, and the
cancellous reamings are preserved
for later use. The reamer is also
used to decorticate the lateral tibia
and calcaneus where appropriate.
The medial side of the ankle is usu-
ally exposed by resecting the medial
malleolus, although it may be best
to leave it in place as a medial but-
tress to improve the stability of
internal fixation. The talus is pre-
served and incorporated into the
fusion mass (i.e., ankle, tibiotalocal-
caneal, or pantalar arthrodesis), pro-
vided there is perfusion to the body
and no extensive osteonecrosis. If

osteonecrosis is present, the head
and neck of the talus may be pre-
served because they are invariably
perfused and will be incorporated
into the fusion mass.
The avascular and necrotic seg-
ments are debrided until bleeding
bone is identified. The hindfoot is
then positioned and temporarily
secured with guide pins, and radio-
graphs are obtained. If the desired
position has been attained, large
Fig. 4 Fracture of the distal tibia (arrow-
head) after ankle arthrodesis with screw
fixation.
Fig. 5 Fragmentation or dislocation of the talus and talonavicular joint, depicted on preoperative AP
(A) and lateral (B) views, is best treated with talectomy. Postoperative lateral (C) and oblique (D)
views illustrate use of a blade plate, supplemented by local allograft bone, for arthrodesis.
A B C
D
Mark S. Myerson, MD, and William H. B. Edwards, MB, BS, MS, FRACS
Vol 7, No 1, January/February 1999
17
bilitation essential to recovery from
reconstructive surgery; for them,
amputation may be the better
choice. For those who will under-
go a salvage or reconstruction
attempt, a staged process is ad-
vised, gaining initial stabilization

with a ring fixator, usually fol-
lowed by rigid internal fixation
with cannulated screws once the
infection is under control.
In the absence of infection, an
external fixator can be used to sup-
plement tenuous internal fixation.
A standard construct includes
three tibial 5-mm half-pins (two in
line on a single block and one at 45
degrees to them) proximally with
an anterior half-ring. A 1.8-mm
wire is placed in the calcaneus
from posteromedial to antero-
lateral, attached to a posterior half-
ring, and tensioned. Another 1.8-
mm wire is then placed in line
with the ring from posterolateral to
anteromedial, taking care to avoid
the neurovascular bundle, and is
tensioned. The construct is sup-
plemented with two threaded 5-
mm half-pins introduced into the
posterior calcaneus at approxi-
mately a 45-degree angle to each
other. The construct is completed
and compressed with connecting
rods.
If the fixator is used in conjunc-
tion with internal fixation, it is left

in place for 2 to 3 months until
there is soft-tissue stability, as indi-
cated by decreased swelling and
absence of wound breakdown or
erythema. If the fixator is to be
used as the definitive form of stabi-
lization, it should remain in place
until bone stability is present (usu-
ally 4 to 6 months).
Summary
Neuroarthropathy is a disabling
disease for the patient and a chal-
lenging problem for the ortho-
paedic surgeon. Not only is the
diagnosis of acute disease often
delayed, but the management of all
stages requires intensive and pro-
longed care with considerable at-
tention to detail and the coordina-
tion of a sizable team. The problem
is frequently exacerbated by indif-
ference to the disease process on
the part of the patient. Untreated,
the disease progresses to gross
instability, loss of mobility, recur-
rent ulceration, and sepsis. Treat-
ment is aimed at creating or main-
taining a stable, biomechanically
sound foot that can be accommo-
dated in a shoe and that has no

osseous protuberances (which
might cause recurrent ulceration).
In most cases, this can be achieved
with nonoperative measures; major
reconstructive surgery is only occa-
sionally needed.
Closed management of neuro-
arthropathy with the use of such
modalities as a total-contact cast or
a brace is effective for approxi-
mately 75% of patients with stage I
or stage II disease. Reconstructive
surgery is challenging and should
not be contemplated unless an
experienced team is available to the
surgeon. Exostectomy for stage III
midfoot ulcers reliably heals the
ulcer and permits a return to more
normal footwear.
21
Operative cor-
rection and salvage result in stabili-
ty in 93% of the patients who pre-
sent with severe deformity.
12
Re-
construction as an alternative to
amputation remains the preferred
method of treatment for selected
patients.

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