Expert Insights On Treating The Wounded Charcot Foot
Stable Charcot with a non-healing ulcer will respond to an exostectomy adjacent to the ulcer, according to Dr. Habershaw. He says one would saucerize the exostosis and leave in a drain before closure. Dr. Habershaw advises leaving the wound open if sepsis is present. He recommends performing open reduction with internal fixation (ORIF) for a patient with ulceration, no osteomyelitis and unstable Charcot. Dr. Habershaw says the surgeon should attempt to restore the arch with plantar plates in midfoot Charcot or reposition the foot under the leg with nails or large compression screws in the case of subtalar or ankle Charcot.
Dr. Habershaw does not use external fixation frames in these cases. If the patient needs a frame, Dr. Habershaw says it is because the surgeon waited too long before considering exostectomy or ORIF.
Q: What are your preferred off-loading devices in these cases?
A: For Dr. Habershaw, offloading devices include crutches, walkers, wheelchairs or, in an agile patient, a Roll-About. He says canes do not qualify as offloading. While Dr. Karlock says a wheelchair is the “most prudent” offloading device when indicated, he notes that most patients refuse to use one.
Dr. Habershaw places acute Charcot patients who cannot be totally non-weightbearing in a padded cast brace and molded plastazote orthotic, which they use for three months or more. For exostosis patients who have a history of ulcers and have undergone primary closure, Dr. Habershaw says they should be non-weightbearing for four to five weeks. He subsequently transitions them to padded cast braces. Those who have undergone ORIF are non-weightbearing for three months before wearing cast braces, according to Dr. Habershaw.
Dr. Armstrong will use a TCC or instant total contact cast (iTCC) until the foot cools down.
Dr. Karlock ideally prefers to use a true or modified TCC in compliant patients and he notes that the CROW Walker has an obvious advantage of daily wound inspection.
Immobilization is often inadequate or used for too short a time period, says Dr. Lavery. For 15 years, he has assessed temperature using a handheld infrared thermometer (TempTouch, Xilas Medical) to help in the evaluation process. He uses the opposite foot to compare temperatures. Once the temperatures are about the same on the Charcot extremity, Dr. Lavery says the patient is ready to advance to the next level of “offloading.”
With such a patient population, Dr. Lavery does note a catch-22.
“They need to be active to combat obesity and heart disease and diabetes, but they need to rest and immobilize a limb that usually takes two to three times longer to ‘heal’ than a traditional fracture in a non-diabetic,” he says.
Accordingly, Dr. Lavery will normally begin with a TCC and then transition the patient to a prefabricated fracture boot like the AirCast boot or the Ossur diabetic boot. While patients are in a removable boot, he says the pedorthist can begin making shoes and insoles. Often custom shoes and insoles are required because of the severe deformity, according to Dr. Lavery.
Dr. Armstrong is a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine in Chicago. He is the founder and director of CLEAR, and is the co-Founder of the International Diabetic Foot Conference (DFCon), which is held annually in Los Angeles.
Dr. Habershaw is an Assistant Professor of Surgery at Boston University School of Medicine, and Chief of Podiatry at Boston Medical Center.