Can The Ostectomy Facilitate Optimal Outcomes With The Charcot Foot?
When conservative care fails for the Charcot foot, the ostectomy can be a viable surgical alternative. Accordingly, these authors offer a closer look at factors to consider before proceeding with an ostectomy, pertinent insights on the procedure and keys to minimizing the risk of post-op complications.
Diabetes mellitus is the most common cause of neuroarthropathy involving the foot and ankle. The literature estimates that Charcot neuroarthropathy affects between 0.1 percent and 2.5 percent of the 16 million patients with diabetes mellitus in the United States.1 However, more recent studies report the incidence of Charcot neuroarthropathy is in the range of 0.1 percent to 29 percent.2
Lavery and colleagues, in a population-based assessment of diabetic Charcot neuroarthropathy, reported an incidence of 8.5 per 1,000 people with diabetes per year.3 Although prevalence of this complex clinical entity is often reported to be less than 1 percent of the overall diabetes population, there is a trend for higher incidence of Charcot neuroarthropathy in patients with peripheral neuropathy and in those patients who present to specialty clinics. Armstrong and Peters reported a prevalence of 0.16 percent in a general population of patients with diabetes and 13 percent prevalence in high-risk patients with diabetes presenting to a specialty foot clinic.4
Unfortunately, the ideal protocol for managing Charcot neuroarthropathy remains nebulous. Non-surgical treatment remains the standard of care for most patients who have developed diabetic Charcot neuroarthropathy although some literature has questioned this approach.5 Since Charcot neuroarthropathy is a progressive process, many patients who fail non-operative therapy may ultimately develop a severe rocker bottom deformity. This ultimately leads to plantar ulceration secondary to the increased pressures in an insensate foot and places these patients at risk for limb loss.
One of the major problems with Charcot neuroarthropathy has been the lack of evidence-based standards. These patients are often high-risk surgical candidates because of morbid obesity, localized osteopenia, deficiency of endogenous growth factors and an impaired immune system. Treatment is often dictated by the patient’s unique set of circumstances and the goals for surgical outcome often vary from patient to patient.
The ultimate question is “What constitutes a successful outcome?” This question is often answered by very strong opinions within the medical community by those treating Charcot neuroarthropathy. Unfortunately, these opinions are often based on inferences rather than evidence-based medicine.
Determining Why Non-Operative Therapy Fails
Charcot neuroarthropathy most commonly affects the midfoot. The primary indications for ostectomy include a midfoot deformity with secondary ulceration, which has failed to heal despite an extensive course of non-operative care. The other indication is for wounds that have healed but have broken down afterward in spite of appropriate shoe therapy, bracing, etc.
One should consider an ostectomy for diabetic Charcot neuroarthropathy when non-operative therapy fails. However, before proceeding with any type of surgical intervention, one should ascertain why non-operative therapy has failed. Typical reasons for failure of non-operative therapy include:
• a lack of patience to allow the temporal Charcot neuroarthropathy process to resolve fully;
• inappropriate bracing;
• a lack of follow-up to evaluate the effectiveness of bracing;
• a lack of finances to purchase these devices; and/or
• an unwillingness of many patients to accept offloading devices.
Many of the reasons for failed non-operative care will also adversely affect the outcome in patients undergoing surgical management.