Key Considerations In Managing The Charcot Foot
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 Despite surgical timing in regards to the stage of Charcot, internal fixation facilitates the realignment and establishment of a plantigrade foot at the level of the fracture dislocation, particularly at the tarsometatarsal level. Large-frame external fixators have been credited for affording a more comprehensive reconstruction of the Charcot joint by ultimately allowing one to re-establish the rearfoot-to-leg and forefoot-to-rearfoot relationships. Such frames have also allowed for postoperative weightbearing in patients as early as one week. Pin tract infection rates vary widely in the literature and the fixation device does need to remain intact for an average of three months. Using mini external fixation devices has been briefly discussed in the correction of Charcot joints.11 These devices, in conjunction with pinning or internal fixation, allow for an external structural frame to support the established arthrodesis and maintain stability. Although they do not facilitate early weightbearing, the mini external fixation devices are an excellent addition to internal screw fixation or percutaneous pinning with Steinmann pins.