When Charcot Arises After Surgery
Charcot arthropathy is a devastating condition of the foot and ankle that causes severe instability and resultant deformity. Any patient who has peripheral neuropathy, regardless of the etiology, is susceptible to this condition.
Acute Charcot arthropathy may be characterized by profound redness, heat and swelling of the foot and leg. Differential diagnoses may include cellulitis, deep venous thrombosis and gout. In a patient who has peripheral neuropathy, in the absence of a wound, Charcot arthropathy should be your diagnosis until proven otherwise. The most important treatments at this point are compression and non-weightbearing of the extremity.
One of the most frustrating and serious complications following surgery in a patient with neuropathy is the development of acute Charcot. I published a paper years ago describing multiple cases of surgically induced Charcot and unfortunately, I have quite a collection of cases.1
I have learned that surgically induced Charcot can occur after major reconstructive surgery just as easily as after something fairly benign such as removal of a sesamoid bone for a chronic ulcer under the first metatarsal head. I have seen Charcot develop after a patient came out of a total contact cast for healing a plantar ulcer.
When I look back at the cases that turned into Charcot after surgery, I believe there are two types of events. The first event is localized wherein Charcot develops at the surgical site. A perfect example is the development of profound ectopic bone and eventual breakdown at an osteotomy site, such as in a bunionectomy type of procedure.
The second type of event is remote wherein Charcot develops in an area other than the surgical site. I believe this has to do with “altering” of the biomechanics of the foot. An example includes removal of a fifth metatarsal head for osteomyelitis and ultimately the midfoot breaks down at the level of the Lisfranc joints or midtarsal joints.
When I look at the cases of Charcot following surgery that affect joints other than the surgical site, there seems to be a common denominator. In the higher arch or metatarsus adductus foot type, there is a greater chance of the development of Charcot. Maybe it has to do with lateral column overloading in which the lateral column is not as flexible and adaptable to the ground reactive forces. Maybe it is a function of less flexibility of the foot. Whatever the reason is, I encourage you to make a mental note of the foot type that you are doing surgery on when there is a history of underlying peripheral neuropathy.
When I have to perform surgery on patients with a history of neuropathy, I take extra precautions with shoe modifications, bracing, orthotics, etc., before patients are “returning to shoes.” You need to watch these patients like a hawk.
In summary, when a postoperative patient with neuropathy develops a sudden onset of redness, heat and swelling in the foot and ankle after initiation of ambulation in a shoe, be suspicious of Charcot. The quicker you recognize the problem and initiate treatment, the better the outcome. Neglected Charcot becomes a serious problem that you cannot easily treat.
1. Fishco WD. Surgically induced Charcot’s foot. J Am Podiatr Med Assoc. 2001; 91(8):388-393.