• T Mittlmeier and A Eschler.
• Chirurgische Klinik und Poliklinik, Abt. für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18055, Rostock, Deutschland, thomas.mittlmeier@med.uni-rostock.de.
• Oper Orthop Traumatol. 2015 Apr 1; 27 (2): 139-53.

ObjectiveThe goal of treatment is a plantigrade, stable, ulcer-free foot which can be addressed with diabetes-adapted insoles and/or DNOAP shoes.IndicationsCharcot foot of the midfoot with/without infection-free ulcers.ContraindicationsInacceptable anesthesiological risk in polymorbidity. Severe anesthesiological risks in multimorbid patients; symptomatic peripheral arterial occlusive disease not suitable for reconstruction; infections PEDIS/IWGDF grade 3 or 4, nonreconstructable osseous defects.Surgical TechniqueCorrective arthrodesis with segmental resection or bone grafting of the midfoot to achieve a plantigrade foot position. Plantar plate application or intramedullary (e.g., midfoot fusion bolt) and extramedullary (preferably: angular stable locking plates) implant combinations to create the highest possible degree of primary stability of the medial and/or lateral foot columns (superconstruct). In case of higher degrees of instability, the hindfoot should also be included into the arthrodesis.Postoperative ManagementPartial weight-bearing (20 kg) with forearm crutches for 3-5 months postoperatively in special orthosis or total contact cast. Therapeutic shoes with diabetes-adapted insoles with full weight-bearing.ResultsUsing any of these stabilization variants, a plantigrade, stable, and long-lasting ulcer-free foot may be obtained that is suitable for custom-made footwear. The outcome does not depend on definite osseous healing of the arthrodesis and allows for the patient to have a self-determined lifestyle. The consecutive rate of amputation is low.ComplicationsHigh rate of surgical complications (e.g., infection, implant failure, non-union, loss of correction, reulceration), in particular, in cases of inadequate indication or insufficient primary stability.

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