Preoperative Considerations for the Patient With Charcot Neuroarthropathy

Although it may seem to be quite low, the incidence and prevalence of developing Charcot with diabetes varies between 0.1 and 0.4%.¹ The risk of development of Charcot increases up to a 35% likelihood when the onset of peripheral neuropathy begins.¹ With the expectation that up to 642 million people, or one out of every 3 people, in the U.S. will be affected by diabetes by 2040, there may be a need to be concerned with the management of the diabetic Charcot foot.² Charcot reconstruction surgery is challenging, but there are significant preoperative considerations that need to be evaluated before the patient is brought into the operating room.
 
While the timing of surgical intervention for Charcot foot remains unclear (late stage 1 versus stage 2 intervention), the complications from a reconstruction can be insurmountable. A study by Cates et al showed patients with Charcot and peripheral vascular disease had a rate of 24% for delayed healing, almost a 10% risk of wound dehiscence, and 12.4% of the population having a major lower extremity amputation (above- or below-the-knee).³ With these complication risks, a lengthy conversation must occur between patients and their health care team centering on how to optimize a Charcot reconstruction.
 
Before considering Charcot reconstruction, the surgeon must determine if the patient actually requires such a reconstruction. The type of reconstruction should depend on the need and physical capabilities of the patient. A patient may have a Charcot midfoot collapse, but not every deformity needs to have major realignment. The surgeon must determine if the deformity is causing an ulceration, pain, or is impacting the patient’s function. One must also determine if conservative measures can be utilized to properly offload the foot with diabetic shoes or bracing. The extended medical team needs to determine if the patient is healthy enough to undergo a procedure that may last several hours. After passing this test, then the patient’s social parameters need to be evaluated.
 
Social factors need to be factored in to determine if the patient has the capacity to undergo the requisite postoperative recovery process. Patients often need to be non-weight-bearing postoperatively and may not have sufficient strength or a support network to assist in protecting the surgical reconstruction. Strong social support is essential to help guide the patient through the long postoperative process, which, in our experience, may take from months to years. In situations when the support network is inadequate, placement in a subacute rehabilitation or skilled nursing facility can be helpful to bridge the time from immediate postoperative concerns to the time when the patient does not have a high need for assistance.
 
Patients with Charcot neuroarthropathy, especially those with concurrent ulcerations, often have been plagued by chronic difficulty or disability and may already be suffering from anxiety and/or depression regarding fear of limb loss. Sohn and associates showed that once a patient was diagnosed with an ulcer in addition to Charcot, the risk of lower extremity amputation was 12 times higher than a patient without Charcot.⁴ The fear of a lower extremity amputation is difficult for a patient and can be overwhelming to the point they do not want to risk a surgery.
 
The use of tobacco products, either in smoking or vaping form, can have deleterious effect on wound and bone healing. Simply stopping smoking immediately before surgery may not be sufficient in countering the negative impact on healing. Myers and associates performed a meta-analysis on individuals quitting smoking fewer than 8 weeks before surgery that showed an increase in postoperative complications.⁵ Taking this finding into account, when planning a more urgent Charcot reconstruction, like an open ulceration with osteomyelitis, severe deformity, or a case with systemic inflammatory response syndrome (SIRS) criteria, it may be best to keep the smoking cessation conversation for the postoperative period, as opposed to the preoperative period. However, in cases where the Charcot reconstruction may take place in the future, for surgical clearance, it could be beneficial to start the smoking cessation  in advance of the reconstruction process.
 
After addressing the psychosocial aspects of your patient’s case, medical optimization is the final step in preoperative management. Non-invasive vascular studies are wise even in the presence of palpable pedal pulses clinically to obtain baseline ankle-brachial and toe-brachial indices. Wukich and associates reported 40% of the time, a patient with Charcot would have peripheral arterial disease when compared to a patient with diabetes and a foot ulcer.⁶ If there is any arterial insufficiency that can be addressed preoperatively, then revascularization is paramount to ensure optimal vascular perfusion prior to Charcot reconstruction.
 
Coordinating glycemic control and optimizing vitamin D3 levels will aid in improving outcome in Charcot reconstruction. Tight glycemic control is also essential to optimize healing and hindering postoperative infection. A study of 2060 foot and ankle diabetic cases showed a higher association of surgical site infections in patients with a hemoglobin A1c greater than 8%.⁷ Unfortunately, waiting 3 months to improve glycemic control may not always be possible in certain Charcot reconstruction cases. Sadoskas and associates also evaluated postoperative glucose control and the rate of surgical site healing and showed patients with random glucose greater than 200mg/dL in the postoperative period were approximately twice as likely to develop a postoperative infection when compared to the group who did not have random glucose levels less than 200mg/dL.⁸ Yoho and associates showed patients with diabetes, regardless of Charcot status, have lower vitamin D3 levels compared to those without diabetes at baseline.⁹ Furthermore, Moore and associates showed patients with vitamin D3 deficiency were 8.1 times more likely to develop a non-union when compared to patients without vitamin D3 deficiency.¹⁰
 
Ultimately, successful Charcot reconstruction is dependent on social, psychological, and medical factors that must be addressed preoperatively. In fact, the surgical procedure may be the easiest part of the entire treatment because the surgeon can control the realignment. However, the surgical outcome is significantly tied to these non-surgical parameters.
        
Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, MI. He is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.
 
Dr. Behme is a third-year podiatric resident at McLaren Oakland Hospital in Pontiac, MI.
 
References
1. Dardari D. An overview of charcot's neuroarthropathy. J Clin Transl Endocrinol. 2020;22:100239.
2. Ogurtsova K, da Rocha Fernandes JD, Huang Y, et al. IDF diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017; 128:40-50.
3. Cates NK, Elmarsafi T, Akbari CM, et al. Complications of charcot reconstruction in patients with peripheral arterial disease. J Foot Ankle Surg. 2021; 60(5):941-5.
4. Sohn MW, Stuck RM, Pinzur M, Lee TA, Budiman-Mak E. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care. 2010; 33(1):98-100.
5. Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med. 2011;171(11):983–9.
6. Wukich DK, Sadoskas D, Vaudreuil NJ, Fourman M. Comparison of diabetic charcot patients with and without foot wounds. Foot Ankle Int. 2017; 38(2):140-8.
7. Wukich DK, Crim BE, Frykberg RG, Rosario BL. Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery. J Bone Joint Surg Am. 2014; 96(10):832-9.
8. Sadoskas D, Suder NC, Wukich DK. Perioperative glycemic control and the effect on surgical site infections in diabetic patients undergoing foot and ankle surgery. Foot Ankle Spec. 2016; 9(1):24-30.
9.  Yoho RM, Frerichs J, Dodson NB, Greenhagen R, Geletta S. A comparison of vitamin D levels in nondiabetic and diabetic patient populations. J Am Podiatr Med Assoc. 2009; 99(1):35-41.
10. Moore KR, Howell MA, Saltrick KR, Catanzariti AR. Risk factors associated with nonunion after elective foot and ankle reconstruction: a case-control study. J Foot Ankle Surg. 2017; 56(3):457-62.

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