Key Insights On Surgical Timing In Charcot Neuroarthropathy
The Charcot foot and ankle is a challenging clinical entity for the qualified foot and ankle surgeon. It is a progressive disease with insidious onset. Osteoarthropathy was originally described in 1703 but it wasn’t until 1868 that it was called Charcot neuroarthropathy due to Charcot’s work in linking the disease to tabes dorsalis and neuropathy.1,2 It was Jordan who linked this destructive disease — which is associated with joint dislocation, breakdown and pathologic fracture — with diabetes mellitus.3 Osteoarthropathy has an incidence ranging from 0.16 percent to 13 percent in all patients with diabetes, and may lead to an increased risk of amputation and higher mortality rates.4,5 There have been numerous classification schemes describing Charcot neuroarthropathy. However, the most commonly used classification was described by an American orthopedist in 1966.6 Eichenholtz classified Charcot into three radiographic stages. Stage I. Usually referred to as the developmental or “hot” phase, Stage I Charcot presents with hyperemia and edema. Radiographic findings include joint subluxation, dislocation, debris formation and bony fragmentation. Stage II. Usually referred to as the coalescent phase, Stage II shows debris absorption, sclerosis of bony ends and coalescence of bone fragments. Stage III. Usually referred to as the remodeling phase, Stage III presents with marked decrease in redness and swelling. Radiographic findings include decreased sclerosis, remodeling of bony fragments and fragments fusing to the joint surfaces in an effort to recreate the architecture of the foot. Stage 0. Researchers have recently described this stage as ranging from a clinically warm, edematous and painful foot to one with mild fracture or joint space widening without debris.7-9 In addition to classification, researchers have also described the patterns of Charcot, taking the more commonly affected joints into account.10 A Review Of Key Treatment Considerations Surgical management is generally contraindicated in patients with Stage 0 Charcot or those who have active fragmentation and resorption of bone.11,12 (However, this thought process has been challenged in the recent literature. We will discuss this later in the article.) At these stages, one would utilize conservative management in the form of non-weightbearing casts or total contact casts.4,12,13 Researchers have also reported using bisphosphonates during these phases.14 Saltzman, et. al., recently found that non-operative treatment of Charcot neuroarthropathy was associated with a 2.7 percent annual rate of amputation, a 23 percent risk of requiring bracing for more than 18 months and a 49 percent risk of recurrent ulceration.15 These statistics suggest the need for improved methodology in the treatment of Charcot neuroarthropathy. One must take many factors into account prior to surgical intervention and evaluate the risk versus benefit for each individual. In addition to ensuring a complete history and physical, clinicians should keep in mind that the the vast majority of patients with Charcot neuroarthropathy have diabetes. Accordingly, one should pay special attention to metabolic control, nutrition and the vascularity of the affected extremity.16 Podiatric clinicians should also rule out osteomyelitis. Primary care physicians often mistake Stage 0 or Stage I Charcot for cellulitis with underlying osteomyelitis and will specifically request the foot and ankle surgeon to perform a deep culture with a bone biopsy. If there is no history of an ulcer, we believe clinicians should defer the bone biopsy in order to avoid the possibility of iatrogenic osteomyelitis. If doubt still remains, one should obtain a white blood cell labeled bone scan, which clinicians can correlate with gadolinium enhanced magnetic resonance imaging in order to rule out osteomyelitis. A stepwise approach to radiographic analysis is of the utmost importance. One must address the deformity in order to produce the best surgical outcome. Obtaining hindfoot alignment views along with standard foot and ankle radiographs will aid the surgeon in preoperative planning. Computerized tomography (CT) and magnetic resonance imaging (MRI) have little if any value to surgical planning other than to rule out osteomyelitis.