Talonavicular dislocations and midfoot arthropathy in neuropathic diabetic feet. Natural course and principles of treatment.

Talonavicular dislocations, sometimes associated with other midtarsal arthropathy, occasionally occur in patients with diabetic neuropathy. The natural course and rationale of treating this diabetic arthropathy is presented, based on the literature and the authors' experience with eight cases. Appropriate management depends on the acuteness of the injury, the degree of deformity, and the degree of bone fragmentation. If the injury is acute and alignment is acceptable, immobilization and protective weight bearing may prevent progression of the neuropathic joint destruction. If dislocation is acute with marked deformity but there is little fragmentation and the foot has intact circulation, reduction and surgical arthrodesis may be indicated. If dislocation is chronic, with bone fragmentation and severe deformity, proper management consists of wearing custom-molded shoes with stiff rocker-bottom soles. Patellar tendon weight-bearing braces may be added if needed. For patients in this last category, surgical treatment is recommended as a last resort only if soft-tissue breakdown cannot be prevented by appropriate footwear and bracing alone.