Key Insights On Surgical Timing In Charcot Neuroarthropathy
The Charcot foot and ankle is a challenging clinical entity for the qualified foot and ankle surgeon. It is a progressive disease with insidious onset. Osteoarthropathy was originally described in 1703 but it wasn’t until 1868 that it was called Charcot neuroarthropathy due to Charcot’s work in linking the disease to tabes dorsalis and neuropathy.1,2 It was Jordan who linked this destructive disease — which is associated with joint dislocation, breakdown and pathologic fracture — with diabetes mellitus.3 Osteoarthropathy has an incidence ranging from 0.16 percent to 13 percent in all patients with diabetes, and may lead to an increased risk of amputation and higher mortality rates.4,5 There have been numerous classification schemes describing Charcot neuroarthropathy. However, the most commonly used classification was described by an American orthopedist in 1966.6 Eichenholtz classified Charcot into three radiographic stages. Stage I. Usually referred to as the developmental or “hot” phase, Stage I Charcot presents with hyperemia and edema. Radiographic findings include joint subluxation, dislocation, debris formation and bony fragmentation. Stage II. Usually referred to as the coalescent phase, Stage II shows debris absorption, sclerosis of bony ends and coalescence of bone fragments. Stage III. Usually referred to as the remodeling phase, Stage III presents with marked decrease in redness and swelling. Radiographic findings include decreased sclerosis, remodeling of bony fragments and fragments fusing to the joint surfaces in an effort to recreate the architecture of the foot. Stage 0. Researchers have recently described this stage as ranging from a clinically warm, edematous and painful foot to one with mild fracture or joint space widening without debris.7-9 In addition to classification, researchers have also described the patterns of Charcot, taking the more commonly affected joints into account.10 A Review Of Key Treatment Considerations Surgical management is generally contraindicated in patients with Stage 0 Charcot or those who have active fragmentation and resorption of bone.11,12 (However, this thought process has been challenged in the recent literature. We will discuss this later in the article.) At these stages, one would utilize conservative management in the form of non-weightbearing casts or total contact casts.4,12,13 Researchers have also reported using bisphosphonates during these phases.14 Saltzman, et. al., recently found that non-operative treatment of Charcot neuroarthropathy was associated with a 2.7 percent annual rate of amputation, a 23 percent risk of requiring bracing for more than 18 months and a 49 percent risk of recurrent ulceration.15 These statistics suggest the need for improved methodology in the treatment of Charcot neuroarthropathy. One must take many factors into account prior to surgical intervention and evaluate the risk versus benefit for each individual. In addition to ensuring a complete history and physical, clinicians should keep in mind that the the vast majority of patients with Charcot neuroarthropathy have diabetes. Accordingly, one should pay special attention to metabolic control, nutrition and the vascularity of the affected extremity.16 Podiatric clinicians should also rule out osteomyelitis. Primary care physicians often mistake Stage 0 or Stage I Charcot for cellulitis with underlying osteomyelitis and will specifically request the foot and ankle surgeon to perform a deep culture with a bone biopsy. If there is no history of an ulcer, we believe clinicians should defer the bone biopsy in order to avoid the possibility of iatrogenic osteomyelitis. If doubt still remains, one should obtain a white blood cell labeled bone scan, which clinicians can correlate with gadolinium enhanced magnetic resonance imaging in order to rule out osteomyelitis. A stepwise approach to radiographic analysis is of the utmost importance. One must address the deformity in order to produce the best surgical outcome. Obtaining hindfoot alignment views along with standard foot and ankle radiographs will aid the surgeon in preoperative planning. Computerized tomography (CT) and magnetic resonance imaging (MRI) have little if any value to surgical planning other than to rule out osteomyelitis. Understanding The Goals Of Charcot Reconstruction There are various goals with Charcot reconstruction. We attempt to create a functionally stable foot that is devoid of prominences that may lead to future ulceration and risk of amputation. Wang identified three main goals: • correct ankle equinus and restore the calcaneal inclination angle; • maintain the rearfoot to leg relationship; and • correct and stabilize the degenerative joints.17 One can achieve these goals with a combination of internal and external fixation, which allows the patient early ambulation with a more rigid construct of the anticipated fusion sites. Employing external fixation along with rigid internal fixation decreases the likelihood of recurrent breakdown of the affected extremity along with the contralateral extremity. According to the literature, breakdown of the contralateral limb occurs in approximately 25 percent of the Charcot neuroarthropathy population.18 Early Arthrodesis: Should We Pursue This For Charcot Patients? As mentioned previously, early arthrodesis in the treatment of Charcot has been reported as contraindicated.11,12 However, recent literature has challenged this thinking. Simon proposed early arthrodesis as an alternative to conservative, non-operative management.19 His study involved a series of 14 patients with Stage I Charcot, all of whom obtained stability, clinical union and anatomic reduction. Wang presented his results of 28 patients who underwent arthrodesis with external fixation.20 All were in the early development stage and all achieved radiographic consolidation. Case studies have described successful arthrodesis of the first metatarsocuneiform joint, midfoot and rearfoot secondary to talonavicular dislocation.21-25 Though the recent literature is replete with reports of early arthrodesis, it is not a new technique as the first reported arthrodesis procedures in Charcot occurred as early as 1939.26 A recent review article evaluated 14 published clinical series of midfoot, rearfoot and ankle arthrodesis procedures.27 These series comprised a total of 254 total procedures with 80.7 percent achieving radiographic fusion in approximately five months on average. Clinical stability, defined as “a stable foot on which a brace, shoe or both could be worn,” was obtained in 92.1 percent of these same subjects. In addition, the researchers reported a 26 percent rate of complications, which included infection, nonunion, malunion, amputation, stress fracture, fixation failure and recurrence of deformity. A history of ulceration and concurrent ulceration increase the risks associated with surgical intervention but they are not an absolute contraindication. It has been reported that patients with Charcot neuroarthropathy and ulceration who undergo reconstruction have a 25 percent infection rate.28 The risk of non-healing ulceration also exists with one report citing that three out of 10 patients with ulceration at the time of reconstruction did not heal normally in the postoperative phase.29 Final Thoughts Surgical intervention in the Charcot foot and ankle is becoming more common and much less restrictive. With the improvements in external fixation as well as the training of foot and ankle surgeons in these techniques, there are few limits when it comes to Charcot reconstruction. Charcot neuroarthropathy remains a challenging clinical entity to treat not only due to its complexity but due to the associated diseases as well. In all cases, one must take proper patient selection and preoperative considerations into account. While difficult, these cases can be satisfying for the patient and surgeon alike. Dr. Barp is a Fellow of the American College of Foot and Ankle Surgeons. He practices at the Iowa Clinic at Iowa Methodist Medical Center in Des Moines. Dr. Nickles is the Chief Resident at Broadlawns Medical Center in Des Moines, Iowa. Dr. Steinberg (pictured) is an Assistant Professor in the Department of Surgery at the Georgetown University School of Medicine inWashington, D.C. Editor’s note: For related articles, visit the archives at www.podiatrytoday.com.
References 1. Kelly M. De arthritide symptomatica of Willima Musgrave (1657-1721): his description of neuropathic arthritis. Bull Hist Med 1963;37:372-7. 2. Charcot JM. Sur quelques arthropathis. Qui paraissent dependre d’une lesion. Du cerveau ou de la moelle epiniere. Arch Physiol Norm Pathol 1868;1:161-78 [in French] 3. Jordan WR. Neuritic manifestations in diabetes mellitus. Arch Intern Med 1936;57:307-66. 4. Armstrong DG, Lavery LA. Elevated peak plantar pressures in patients who have Charcot arthropathy. J Bone Joint Surg Am 1998;80(3):365-9. 5. Schon LC, Easley ME, Windield SB. Charcot neuro-arthropathy of the foot and ankle. Clin Orthop 1998;349:116-31. 6. Eichenholz SN. Charcot joints. Springfield (IL): Charles C. Thomas;1966 7. Shibata T, Tada K, Hashizume C. The result of arthrodesis of the ankle for leprotic neuro-arthropathy. J Bone Joint Surg Am 1990;72:749-56. 8. Sella EJ, Barrette C. Staging of Charcot neuroarthropathy along the medial column of the foot in the diabetic patient. J Foot Ankle Surg 1999;38(1):34-40. 9. Schon LC, Marks RM. The management of neuroarthropathic fracture-dislocation in the diabetic patient. Orthop Clin North Am 1995;26(2):375-92. 10. Brodsky JW, Wagner FW, Kwong PK, et al. Patterns of breakdown. I. The Charcot tarsus of diabetes and relation of treatment. Presented at the American Orthopedic Foot and Ankle Society (AOFAS) 16th Annual Meeting. New Orleans, February, 1986. 11. Pinzur MA, Shields N, Trepman E, et al. Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 200;11(21):916-20. 12. Myerson MS, Henderson MR, Saxbt T, et al. Management of midfoot diabetic neuroarthropathy. Foot Ankle Int 1994;15(5):233-41. 13. McGill M, Molybeaux L, Boulton T, et al. Response of Charcot’s arthropathy to contact casting: assessment by quantitative techniques. Diabetolgia 2000;43:481-4. 14. Jude EB, Selby PL, Burgess J, et al. Bisphosphonates in the treatment of charcot neuroarthropathy: a double-blind randomized controlled trial. Diabetolgia 2001;44:2032-7. 15. Saltzman CL, Hagy ML, Zimmerman B, et al. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot Arthropathy of the feet? Clin Ortho Rel Research; 435:185-190, 2005. 16. Catanzariti AR, Blitch EL, Karlock LG. Elective foot and ankle surgery in the diabetic patient. J Foot Ankle Surg 1995; 34(1): 23-41. 17. Wang JC. Use of external fixation in the reconstruction of the Charcot foot and ankle. Clin Podiatr Med Surg 2003;20:97-117. 18. Frykberg RG. Charcot foot. In: Boulton AJM, Connor H, Cavanagh PRE, editors. The foot in diabetes. Chichester, United Kingdom: Wiley; 2000. p. 235-60 19. Simon SR, Tejwani SG, Wilson DL, et al. Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg 2000;82(7):939-50. 20. Wang JC, Le AW, Tsukuda RK. An new technique for charcot’s foot reconstruction. J Am Podiatr Med Assoc 2002;8(92):429-36. 21. Cohn BT, Brahms MA. Diabetic arthropathy of the first metatarsal cuneiform joint. Introduction of a new surgical fusion technique. Ortho Rev 1987;16(7):38-43. 22. Deresh GM, Cohen M. Reconstruction of the diabetic Charcot foot incorporating bone grafts. J Foot Ankle Surg 1996;5(35):474-88. 23. Sticha RS, Frascone ST, Wertheimer SJ. Major arthrodesis in patients with neuropathic arthropathy. J Foot Ankle Surg 1996;35(6):560-6. 24. Brink DS, Eickmeier KM, Levitsky DR, et al. Subtalar and talo-navicular joint dislocation as presentation of diabetic neuropathic arthropathy with salvage by triple arthrodesis. J Foot Ankle Surg 1994;33(6)583-9. 25. Tisdel CL, Marcus RE, Heiple KG. Triple arthrodesis for diabetic peritalar neuroarthropathy. Foot Ankle Int 1995;6(16):332-8. 26. Cleveland M. Surgical fusion of unstable joints due to neuropathic disturbance. Am J Surg 1939;43:580-4. 27. Baravarian B, Van Gils CC. Arthrodesis of the Charcot foot and ankle. Clin Podiatr Med Surg 2004;21:271-289. 28. Clohisy DR, Thompson RC. Fractures associated with neuropathic arthropathy in adults who have juvenile-onset diabetes. J Bone Joint Surg 1988;70A(8):1192-200. 29. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: A salvage approach for mid-foot collapse. Foot Ankle Int 1996;17(6):325-30.