How To Manage The Charcot Midfoot Deformity
Given the challenges of Charcot neuroarthropathy and the lack of guidelines for surgical treatment, this author offers a closer look at Charcot midfoot deformities as well as insights on addressing concomitant soft tissue infection and joint instability.
Charcot neuroarthropathy most commonly affects the foot and ankle, and is unfortunately becoming more prevalent over the last decade as the incidence of diabetes and its related complications continue to rise.1 The scientific literature is limited in regard to treatment protocols and guidelines for the overall surgical management of Charcot foot and ankle deformities.1-3 Some of the reasons for the lack of specific treatment recommendations may be largely due to the presence of the unique clinical scenario that is usually associated with each Charcot of the foot and ankle.
Accordingly, let us consider pertinent keys to the thorough evaluation of a Charcot midfoot deformity among various presentations and the surgical rationale for addressing the vast majority of Charcot midfoot deformities.
The initial examination of the Charcot midfoot deformity begins with evaluation of the multiple associated factors that usually determine the patient’s overall treatment. The inherent factors that are often associated with a Charcot midfoot deformity include but are not limited to the following: acute Charcot process; presence of an ulceration; pre-ulcerative lesion with a Charcot bursa formation; concomitant osteomyelitis; Charcot joint instability; and coexistent rearfoot and/or ankle deformity.
In regard to the overall management of the Charcot midfoot deformity, one must address any of the aforementioned factors in conjunction with a thorough evaluation of the patients’ comorbidities. Since operative intervention may involve multiple complicating issues, a stepwise rational approach with appropriate procedure and patient selection that is based on these inherent factors is essential for the patient’s successful outcome.
As with any Charcot reconstructive case, a thorough history and physical examination, vascular assessment, review of precipitating events, pertinent radiographs, laboratory testing and medical imaging studies serve as the foundation in surgical preparation or for establishing the criteria of which patients would not be suitable for reconstruction. Careful preoperative evaluation and patient selection are fundamental to reduce the risks associated with reconstructive surgery. Neglecting issues such as patient adherence, overall medical health status, cardiac disease, renal dialysis, uncontrolled blood sugars, smoking, ambulatory ability and lack of social or family support will only lead to further complications regardless of the surgical plan.4 Awareness of patient-related variables that may increase the risks of complications would allow for better preoperative planning and overall management of the patient.
Surgical consideration for the management of a Charcot midfoot deformity mostly depends on the underlying pathology. The following recommendations emphasize the fact that not every Charcot midfoot deformity or patient presentation is the same, and physicians need to consider many factors prior to surgical intervention for the patient.