Is Rocker Bottom Reconstruction A Viable Option For Limb Preservation?

By Scott Neville, DPM, Peter Blume, DPM, and Jonathan Key, DPM

Key Treatment Considerations

   The profound neuropathy coupled with hyperemia, which is idiopathic in the Charcot patient, plays havoc on the osseous structures of the foot. As the hyperemia washes out the bone, the profound neuropathy allows the patient to ambulate free of pain while the osseous structure of the foot is destroyed.    Eichenholtz described a radiological staging system whereby patients with Charcot could be classified into three stages. The hallmark of the first stage is hyperemia with rapid fragmentation of joints and multiple fractures. The second stage is marked by coalescence of the fragmented osseous structures. In Stage II, the healing process begins and the inflammation starts to subside. Stage III is marked by resolution of inflammation with mature fracture healing. This healing process may result in significant deformity of the affected limb. If this natural disease course can be interrupted, one may minimize catastrophic osseous destruction if not prevent it entirely.2    The most common deformity resulting from Charcot related osseous destruction is a midfoot collapse, which may result in a rocker bottom deformity.3,4 The midfoot ulcerations that occur secondary to the rocker bottom foot are especially difficult to treat. When conservative care fails to provide closure, the foot is at significant risk for infection and subsequent amputation.    Although amputations have their place in the treatment of the Charcot foot, reconstruction is an attractive alternative for limb salvage. Rocker bottom feet can be classified into two groups based on the motion available at the midtarsal joint: stable or unstable. Stable forefeet that have failed conservative care may be candidates for exostectomy with plastic surgery closure. As a rule, lateral rocker bottom ulcerations are the result of a stable deformity. In the event that an exostectomy will allow for relief of the deforming forces, one should consider this the treatment of choice.    One must also address the associated biomechanical flaws if long-term closure is to be successful. The unstable rocker bottom foot will not allow the forefoot to function as a rigid lever during the propulsive phase of gait. The rocker bottom collapse allows excess force to be distributed to the midfoot, leading to progressive midtarsal joint destruction.    When it comes to ulcerations that result from an unstable forefoot, clinicians will often locate these at the medial midfoot. If one performs a simple exostectomy on this unstable foot, further forefoot collapse will result in reulceration. Although we must evaluate every surgical candidate individually, a reconstructive midfoot osteotomy is often indicated for the unstable rocker bottom foot.

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