Deformity following fracture in diabetic neuropathic osteoarthropathy. Operative management of adults who have type-I diabetes

We studied fifteen lower extremities that had a deformity following a fracture in the region of the ankle or the tarsal bones, in fourteen adults who had type-I diabetes and neuropathic osteoarthropathy. The skeletal deformities associated with these fractures were either diagnosed late (two limbs) or occurred in lower extremities that had been treated by means other than non-weight-bearing and immobilization (thirteen limbs). All deformities were severe and secondary to a non-union or malunion of the fracture; all were ultimately treated with operative reconstruction. Before the reconstruction, the limbs had had either persistent ulceration associated with an uncorrectable skeletal deformity (four) or a severe deformity that was difficult to contain with a custom-made orthosis (eleven). The most recent result was considered a success when the ulceration had healed, the involved foot was plantigrade, and the involved limb was capable of bearing weight with use of a patellar tendon-bearing orthosis. Following reconstruction, ten patients had a plantigrade foot without ulceration, three had a plantigrade foot with a persistent draining ulcer, and one had a foot that was not plantigrade. In the limbs that had an ulcer at the time of the operation, there was one successful outcome and three failures. In contrast, the outcome was successful for ten of the limbs that had not had an ulcer and a failure for one. There were three complications following sixteen operative reconstructive procedures in the fourteen patients, including one infection and two instances of accelerated bone resorption and collapse. We recommend a reconstructive procedure for patients who have a deformity that cannot be contained in a load-sharing orthosis. The skin should be free of ulceration at the time of the procedure.