Key Insights On Surgical Timing In Charcot Neuroarthropathy

Author(s): 
By Eric A. Barp, DPM, and W. Ashton Nickles, DPM

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.

Understanding The Goals Of Charcot Reconstruction
There are various goals with Charcot reconstruction. We attempt to create a functionally stable foot that is devoid of prominences that may lead to future ulceration and risk of amputation. Wang identified three main goals:
• correct ankle equinus and restore the calcaneal inclination angle;
• maintain the rearfoot to leg relationship; and
• correct and stabilize the degenerative joints.17
One can achieve these goals with a combination of internal and external fixation, which allows the patient early ambulation with a more rigid construct of the anticipated fusion sites. Employing external fixation along with rigid internal fixation decreases the likelihood of recurrent breakdown of the affected extremity along with the contralateral extremity. According to the literature, breakdown of the contralateral limb occurs in approximately 25 percent of the Charcot neuroarthropathy population.18

Early Arthrodesis: Should We Pursue This For Charcot Patients?
As mentioned previously, early arthrodesis in the treatment of Charcot has been reported as contraindicated.11,12 However, recent literature has challenged this thinking. Simon proposed early arthrodesis as an alternative to conservative, non-operative management.19 His study involved a series of 14 patients with Stage I Charcot, all of whom obtained stability, clinical union and anatomic reduction. Wang presented his results of 28 patients who underwent arthrodesis with external fixation.20 All were in the early development stage and all achieved radiographic consolidation.
Case studies have described successful arthrodesis of the first metatarsocuneiform joint, midfoot and rearfoot secondary to talonavicular dislocation.21-25 Though the recent literature is replete with reports of early arthrodesis, it is not a new technique as the first reported arthrodesis procedures in Charcot occurred as early as 1939.26

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