Point-Counterpoint: Active Charcot: Should You Proceed With Surgery?
Yes, these authors say early identification of the Charcot process and prompt surgical intervention can prevent progression of the deformity and related complications.
By Peter M. Wilusz, DPM and Guy R. Pupp, DPM
The presentation of Charcot neuroarthropathy has been historically problematic for the foot and ankle surgeon. Acute Charcot has traditionally been treated with conservative therapy as most attempts at treatment involve immobilization and removal of weightbearing forces from the involved foot. Many surgeons do not surgically address the acute Charcot foot due to the immunocompromised status of the patient, non-compliance issues and the progressive nature of the deformity.
In the past, most surgical approaches have consisted of “lump and bump” exostectomies, which are performed after the gross deformity has occurred, in an attempt to prevent ulceration from osseous deformities producing pressure points. To achieve success in treating the acute Charcot foot, early recognition and aggressive treatment of deforming contractures is essential. Such contractures would otherwise lead to limb threatening complications with deformation, the potential for ulcer formation and an eventual battle with infection.
Voicing Concerns Over Conservative Care
The goals of resolving the acute Charcot foot have traditionally been immobilization and offloading of the involved foot. Immobilization in a nonweightbearing cast or a total contact cast in our clinic has averaged between seven and 16 weeks. However, when one looks back and reevaluates casting for acute Charcot treatment, there is the concern of cast disease and the potential development of osteopenia in an already threatened osseous integrity of a limb. Keep in mind that making the transition from the cast to shoes, with or without bracing, often frustrates both the patient and physician with recurrence of an acute Charcot foot.
It is our belief that patient education, strict glycemic control and aggressively treating the deforming forces causing the Charcot arthropathy are key for successful salvage of the at-risk limb. Early surgical treatment of the Charcot foot can avoid the progression of major deforming forces and limb threatening complications.
What The Literature Reveals About Early Surgical Intervention
In order to consider whether surgical intervention is appropriate, one should review the classification of the stages of Charcot neuroarthropathy. In 1966, Eichenholtz described Charcot in three stages.1 Stage 1, often described as the “hot phase,” usually presents with edema, hyperemia and often pain. Stage 2, which is referred to as the coalescence phase, radiographically demonstrates the absorption of cartilaginous and osseous debris with larger fragments fusing to the joint surfaces. Stage 3 is the remodeling phase and displays a fusion of bone and joint. With their respective articles in 1990 and 1999, Shibata and Sella added stage 0, which does not display radiographic changes but presents clinically with warmth, edema and pain in an often otherwise anesthetic foot.2,3
A few reports have supported early surgical correction during the acute developmental phase of Charcot when there are structural changes. In 2000, Simon reported success in restoring the anatomic alignment and improving function in acute Charcot with open reduction and internal fixation.4 As early as 1966, Harris and Brand suggested performing arthrodesis early in the disease process.5 A paper by Newman in 1981 suggested that early arthrodesis and a period of immobilization of the involved joint(s) can prevent further deformity.6 In 2003, Wang presented surgical goals to achieve a stable, reliable foot early in the Charcot process with external fixation and closed reduction of the deformity.7 We have had similar experiences utilizing open reduction and external fixation.
No published papers specifically address surgical intervention of the Charcot foot in Stage 0 or early Stage 1 before deformation exists. Many Charcot feet present in the category of stage 1, 2 or 3. However, critical evaluation of a stage 0 foot should include surgical intervention.