Limb Salvage And The Charcot Foot: What The Evidence Shows

Guy Pupp, DPM, FACFAS, and Robert Koivunen, DPM

Treating Charcot foot deformities can be quite challenging. Accordingly, these authors discuss the etiology and diagnostic keys with this condition, weigh in on various surgical options, and share emerging perspectives on fixation and the potential of orthobiologics in facilitating limb salvage.

Patients with diabetes can have an extensive medical and hospitalization history. This is especially the case for patients who have poor glycemic control, peripheral neuropathy and/or Charcot neuroarthopathy. It is estimated that an ulceration precedes about 84 percent of lower extremity amputations performed on patients with diabetes.1

   It may seem that once a patient has a deformed foot that requires intense supervision, a major amputation (below the knee or above the knee) may be more cost effective than reconstruction. Recent analysis demonstrates that lifelong costs for major lower extremity amputations can be about $509,275, which is about three times higher than the costs for patients undergoing reconstruction.2-4 The cost for a patient after amputation depends on three characteristics: the type of prosthetic device, the level of limb loss and the functional capability of the individual.2

   The mean costs for patients with amputations will continue to rise due to increasing life expectancy, the number of multiple prostheses an individual will utilize and the use of more technologically advanced prostheses.5 Greater health benefits with lower healthcare costs start with intensive glycemic control and optimal foot care.5

   The cost of care for a patient with diabetes with a lower extremity ulcer in comparison to one without an ulcer presents a major economic difference.6 The best and most cost-effective way of treating patients with diabetes with lower extremity ulcers and/or Charcot changes to their feet is by utilizing a team approach. This team should be composed of a podiatric surgeon as a “quarterback” along with a primary physician, vascular surgeon, endocrinologist and an infectious disease specialist.6 Numerous studies have demonstrated that a team approach to diabetic foot conditions is effective in amputation prevention as well as reducing healthcare costs.5,6

What You Should Know About The Etiology Of Charcot And Subsequent Complications

Physicians who may treat or specialize in patients with diabetes will encounter Charcot neuroarthropathy. French physician Jean-Martin Charcot first described the condition as an arthropathy associated with tabes dorsalis or progressive locomotor ataxia.7 Today, Charcot most commonly occurs in patients with diabetic neuropathy. Charcot is a progressive disabling disorder that requires early diagnosis and attention to prevent further complicating factors. Such factors include a “rocker bottom” talus, which can lead to chronic plantar wounds, subsequent infectious processes with frequent hospitalization and increasing risks for lower limb amputation.8

   Diagnosis begins with a heightened clinical suspicion of a patient with a red, hot, swollen foot.8,9 One can stage Charcot radiographically with the Eichenholtz system.10 Recently, Shibata and colleagues added a stage 0 for a foot demonstrating warmth, swelling, dull pain and joint instability in the midfoot even with normal radiographic features.11

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