Can Bracing Have An Impact For The Charcot Foot?

Author(s): 
Alan Banks, DPM, FACFAS

Although surgical reconstruction can be effective for patients with Charcot, not every patient is an appropriate candidate for surgery. Accordingly, this author explores the potential of employing various forms of bracing, including ankle foot orthoses and patellar tendon bracing, in patients with Charcot foot.

Many years ago, I was an early advocate for surgical reconstruction of Charcot foot deformities as a means of reducing the risk for ulceration and possible amputation of the lower extremity. It would appear that surgeons have widely employed Charcot reconstruction and many favor it for this condition.

   However, each physician will at some point face patients with Charcot deformities who might otherwise benefit from surgery but physiologically may prove to be poorly suited to this type of intervention. There may be many reasons such patients are not suited to reconstruction. For patients with Charcot deformity, there is often no shortage of medical comorbidities that may create hazards, whether they occur during the procedure or postoperatively. In some patients with Charcot foot deformity, braces may prove to be the mechanism through which patients maintain some level of mobility without surgical intervention despite possessing significant deformity.

   Over 20 years ago, I watched as Gary Bauer, DPM, delivered a lecture on salvage of the limb after severe lower extremity infections. Many of the patients in his presentation had received multiple ray resections for infection yet functioned reasonably well despite the fact that they were left with a significantly compromised foot or a foot that many surgeons could consider to be beyond salvage and requiring proximal amputations. The key element between success and failure appeared to be the fact that Bauer employed postoperative bracing whereas to that point, I had not done so.

   It was not long thereafter before patients with more tenuous medical conditions began to present to our practice with significant Charcot foot deformities. The question was: how could we best treat these patients and maintain some degree of function without surgery?

   The answer appeared to be bracing. Many of us received little if any formal training relative to the use of braces, their indications and the available options. However, I found that many patients were able to achieve enhanced function and mobility without surgery. Success bred confidence with this technique. Accordingly, I would like to share a general philosophy I have employed relative to the use of braces in this patient population.

Essential Considerations Before Proceeding With Bracing For Charcot

There are a number of factors that one must consider in assessing a patient for potential conservative management of the Charcot foot. First, is the foot quiescent? If not, then the patient will need to be immobile and non-weightbearing until the active inflammatory process has resolved.

   The next issue involves the overall stability of the foot. One may encounter three potential scenarios: a stable foot; a foot that retains mobility but has a fairly stable end range of motion; or a foot that is completely unstable. The latter foot type may prove very difficult to control with bracing but patients with a stable foot or those with stable end range of motion may be reasonable candidates for a conservative approach with braces.

Comments

Great article by Dr. Banks. I've been practicing orthotics and prosthetics over 30 years. I work with many Charcot patients. I currently work at wound care center clinics in my existing practice in Tennessee.

The CROW has its disadvantages. I have been using a device known as TORCH, which is a true problem solver and patients and docs appreciate the results. TORCH is made by American Orthopedics (Mount Vernon, NY) with a cast and a completed detailed instruction form. It is a type of boot made out of any leather color with an AFO built into it. Different types of closures may be used so you don't have constant repadding issues for adjustments. You can have all your buildups and partial foot and/or custom orthotics built right into the TORCH. Patients can have a matching shoe for the opposite side. Patient compliance is better.

I've also been using American's new patented dynamic suspension AFO known as the Revolution for some Charcot and other foot and ankle conditions. I have gotten excellent results and can share patient videos for both Revolution and TORCH. The controlled motion in the Revolution brace allows improved functional outcomes and addresses gait in all three planes unlike traditional AFOs. Leather gauntlets lock the calcaneus.

I recommend that podiatry, orthopedics and therapy offices try some of the new innovations in bracing to include in their care and treatment plan. I do a lot of teaching and courses across the country. I spoke in Orlando to a podiatry group just a couple of weeks ago. The doctors in attendance were very impressed with the bracing and techniques I use in my clinical practice. I would be more than happy to offer advice to any one to help improve lives and cost of healthcare. fbcaru1@comcast.net

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