Key Insights On Surgical Timing In Charcot Neuroarthropathy
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 A recent review article evaluated 14 published clinical series of midfoot, rearfoot and ankle arthrodesis procedures.27 These series comprised a total of 254 total procedures with 80.7 percent achieving radiographic fusion in approximately five months on average. Clinical stability, defined as “a stable foot on which a brace, shoe or both could be worn,” was obtained in 92.1 percent of these same subjects. In addition, the researchers reported a 26 percent rate of complications, which included infection, nonunion, malunion, amputation, stress fracture, fixation failure and recurrence of deformity. A history of ulceration and concurrent ulceration increase the risks associated with surgical intervention but they are not an absolute contraindication. It has been reported that patients with Charcot neuroarthropathy and ulceration who undergo reconstruction have a 25 percent infection rate.28 The risk of non-healing ulceration also exists with one report citing that three out of 10 patients with ulceration at the time of reconstruction did not heal normally in the postoperative phase.29 Final Thoughts Surgical intervention in the Charcot foot and ankle is becoming more common and much less restrictive. With the improvements in external fixation as well as the training of foot and ankle surgeons in these techniques, there are few limits when it comes to Charcot reconstruction. Charcot neuroarthropathy remains a challenging clinical entity to treat not only due to its complexity but due to the associated diseases as well. In all cases, one must take proper patient selection and preoperative considerations into account. While difficult, these cases can be satisfying for the patient and surgeon alike. Dr. Barp is a Fellow of the American College of Foot and Ankle Surgeons. He practices at the Iowa Clinic at Iowa Methodist Medical Center in Des Moines. Dr. Nickles is the Chief Resident at Broadlawns Medical Center in Des Moines, Iowa. Dr. Steinberg (pictured) is an Assistant Professor in the Department of Surgery at the Georgetown University School of Medicine inWashington, D.C. Editor’s note: For related articles, visit the archives at www.podiatrytoday.com.