When Charcot Reconstructions Fail
When a reconstructed Charcot foot becomes unstable, physicians face a dilemma for salvaging the foot, given the complexity of the condition. Accordingly, these authors discuss key considerations and offer pertinent pearls for revisional and failed Charcot repair.
As the need for reconstruction of the Charcot foot increases across the population, surgeons are successfully and dramatically improving useless limbs via increasingly sophisticated techniques of foot and ankle surgery. The purpose of this article is not to describe primary Charcot repair but we will instead focus on the revisional and failed Charcot repair.
Before we discuss a treatment algorithm, it is essential to describe the distinction between a revisional procedure versus a failed Charcot reconstruction. We can define the failure of Charcot reconstruction as the inability to reconstruct a Charcot deformity adequately due to major overriding complications, including extensive osteomyelitis, hardware failure and a dysvascular foot.1 Charcot failure is a distinct entity from revisional Charcot reconstruction, which may encompass the same complications but to a lesser severity, enabling surgeons to undertake a revisional procedure.
The nature of Charcot arthropathy alters one’s definition of a successful outcome in Charcot reconstruction. A post-op pseudarthrosis is a failed surgical outcome in a healthy patient but that same pseudarthrosis may not be a failure in the Charcot patient as long as it is stable and non-edematous. A diagnosis of failure is therefore different for this population of patients just as a diagnosis of success is different.
For a successful outcome in diabetic Charcot reconstruction, the surgery typically requires the surgeon to achieve the following:
1. A foot with no open ulcers or any tendency to develop open ulcers during gait
2. A foot that fits into at least diabetic foot gear
3. A foot that permits the patient to be ambulatory
4. A foot that is not prone to collapse or recurrent instability
5. A foot that is least plantigrade and optimally has a medial longitudinal arch, and no bulging cuboid or medial cuneiform
6. A limb that can have its edema controlled with standard support hose or other simple means
7. A limb that is not painful or a burden to the patient
What To Consider When Beginning Surgical Re-Intervention
The management of a failed Charcot reconstruction parallels that of other revisional reconstructive foot and ankle surgeries. The most demonstrable difference is the extremely compromised state of these patients. These patients are significantly immunocompromised with advanced neuropathy and in many cases, they present with arterial insufficiency and some degree of renal insufficiency. It is obvious that this population has limited reserves for healing. Accordingly, it is incumbent upon the surgeon to evaluate all potential comorbidities prior to proceeding with further management of a revisional Charcot reconstruction.
Evaluation of the patient’s general medical status is absolutely essential to begin the workup for surgical re-intervention. Optimization of blood panels is paramount. We see many patients with HbgA1c far greater than 10%. Such poor control makes it very difficult for antibiotics or the patient’s own white blood cells for that matter to work in this population. The hospitalist or internist needs to take an active role in the management of these patients. Optimization of blood glucose, vitamin D, calcium, phosphate, control of hypertension and, in many instances, cardiac workup, are necessary.2