Charcot Arthropathy: When Mechanical Treatment Can Help
A: Drs. Ribotsky and Sol say it’s important to assess the level of deformity as well as the level of impairment. For example, if you’re treating a patient who has developed a significant Charcot arthropathy with a contracted Achilles tendon and a dysfunctional posterior tibial tendon, Dr. Ribotsky says it’s essential to ensure control above the ankle joint. Therefore, in this situation, he recommends using a device that will give you control of more proximal joints.
In providing long-term therapy for Charcot arthropathy, Dr. Phillips says employing a rigid custom foot orthosis works “extremely well” for a Lisfranc’s joint arthrosis. However, he says you must provide a very precise fit to the plantar foot (ensuring that the device fully pronates the midtarsal joint) and an accurate posting prescription. Dr. Phillips says he doesn’t worry about using a rigid orthosis as long as it has appropriate padding on top and that the pedobraograph readings are not registering excessive peak pressures.
Dr. Phillips adds that it may be necessary to use a custom-made shoe if your patient has developed a true rocker bottom foot or if the foot has become severely displaced medially or laterally relative to the leg. He says he always makes sure that he uses a rigid orthosis concept inside the shoe.
Shoe modifications are a “remarkably underutilized service” that DPMs should be providing to patients, explains Dr. Levine. For example, if you’re looking at a severe Charcot foot with complete collapse, Dr. Levine says a functional leg length discrepancy may occur and a custom orthotic device would be “woefully insufficient” in this situation. You may need a lift on the shoe in addition to the orthoses, according to Dr. Levine.
What about a patient who has unilateral collapse of the foot? Even with surgical reconstruction, significant asymmetry may persist, according to Dr. Levine. He says using an off-the-shelf shoe may not provide a proper fit for the affected foot. In this scenario, Dr. Levine notes that relasting the shoe in order to make the midfoot of the shoe wider may be an excellent, cost-effective alternative for the patient.
If you’re treating a patient who has minimal localized Charcot arthropathy, Dr. Ribotsky says employing a local weight distribution device would be appropriate. You may also consider using this device to treat patients who are still propulsive during gait, according to Dr. Ribotsky.
Dr. Levine strongly emphasizes the value of performing gait analysis. Using video cameras from four different angles and integrating pressure sensing computer software, you can gain a comprehensive understanding of the patient’s gait.
Q: In patients with Charcot arthropathy, what are the effects of occupational demands, including cumulative weightbearing time, surface characteristics, climbing and load carrying?
A: Generally, the risk of complication is proportionate to the number of repetitive loads applied to the feet and/or cumulative weightbearing time, according to Dr. Sol. He notes that harder or irregular surfaces, climbing and load carrying can create additional stress. Dr. Phillips adds that considering the load the feet have to carry is important in dictating how strong or rigid you should make the device or shoe.
While Dr. Phillips notes that every case is different, he is most concerned about irregular surfaces, which distort the foot position from what you’re trying to accomplish. Ideally, Dr. Phillips notes, you want to have the patient walking on a flat surface, so you can plan better how the foot relates to the ground.
Occupational shoewear can also pose problems, according to Dr. Levine. For example, he points out that the combination of steel toe safety shoes with insensate feet can be disastrous. Dr. Levine adds that occupational demands, like climbing ladders or standing eight hours a day, can also be problematic. He emphasizes educating these patients to do routine inspections of their feet in order to help facilitate biomechanical control.
Q: Do you recommend continued mechanical management following a surgical fusion to correct Charcot arthropathy?