Key Considerations In Managing The Charcot Foot

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A 58-year-old patient with longstanding diabetes and a previous history of ulceration and neuropathy presented with increasing redness and swelling to his right foot (as shown above).
Radiographs (like the one shown above) revealed dorsal dislocation at the tarsometatarsal joint, resulting in a divergence of the joint complex.
Here one can see a plantigrade foot five weeks after the patient underwent surgical arthrodesis.
Key Considerations In Managing The Charcot Foot
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Author(s): 
By Suhad A. Hadi, DPM

   After making a diagnosis, appropriate offloading (i.e., total contact casting or TCC) will often allow for resolution of the active Charcot event.4 When a TCC is not available, employing removable cast boot walkers may be equally effective for offloading the foot. Appropriate radiographic and clinical follow-up will determine full healing. Researchers have also shown that medical management via the use of bisphosphonates is effective in the early arrest of active Charcot joints, and serves as a viable adjunctive therapy in this population.5

   Although the resulting deformities of Charcot can be destructive, only 5 to 25 percent of patients with Charcot require surgical intervention.4,6 When anticipating surgical management of the Charcot foot, it is important to allow an appropriate period of patient education, planning, offloading and edema control. One must establish and confirm vascular integrity in patients prior to surgical correction. Confirming an external support structure is also important in order to optimize a patient’s ability to comply with postoperative needs and demands, and increase the possibility of a successful surgical outcome.

Exploring A Variety Of Surgical Options

   Researchers have proposed many surgical alternatives in treating Charcot deformities. Salvage attempts range from exostectomy to arthrodesis of the affected joints, and authors have also described both internal and external fixation. Regardless of the procedure or technique one employs, the goal of surgery is to establish and maintain a plantigrade foot. Accordingly, this would facilitate long-term offloading in custom-molded, extra-depth shoes and ultimately reduce recurrent breakdown and the risk of amputation.7

   Authors have described planing procedures in which adequate resection of plantar prominences is a favorable option in the presence of recurrent ulcerations that have been non-responsive to offloading attempts. Plantar, lateral and medial approaches have been described based on the location of the prominence and ulceration, with the ultimate goal being to resect an adequate amount of bone to allow for a wide and level surface. Achieving this also requires adequate soft tissue dissection as well as resection of inflamed, indurated soft tissues.

   Although saucerization is a viable surgical alternative, if the coalescence or remodeling stages have not resulted in ankylosis of the affected joint, one must take care to avoid creating further instability of a joint which is already structurally unstable, predisposing the foot to further breakdown and collapse.8

   When both joint deformity and instability are predominant and the risks of progressive deformity and recurrent ulceration prevail, one must consider more aggressive surgical management. Often, the remodeling phase of Charcot leads to ankylosis of the affected joints. In light of an unstable joint that has not achieved fusion, surgical arthrodesis becomes a viable option for re-establishing joint stability and ultimately maintaining joint integrity. Successful fusion and reduction of the deformity has shown promising results with average outcomes as high as 90 percent although controversy persists in regards to the timing of surgical arthrodesis in the earlier stages of Charcot.9

   There have been a variety of fixation techniques for Charcot joint arthrodesis. Researchers have described internal and external fixation techniques, and the addition of adjunctive procedures and therapies have also added to the successful outcomes in the long-term surgical management of the Charcot foot.10-12

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