Point-Counterpoint: Active Charcot: Should You Proceed With Surgery?

Author(s): 
By Peter M. Wilusz, DPM, Guy R. Pupp, DPM, and Molly Judge, DPM

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.

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