Patients with Charcot foot have a risk of developing contralateral Charcot and ulcers, noted Jake Wynes, DPM. He said Waibel and colleagues reviewed the medical records of 130 patients with unilateral midfoot Charcot neuroarthropathy, finding almost 20% developed contralateral Charcot.¹ In addition, the authors noted 46.2% of patients developed a contralateral ulcer, while the incidence of an ulcer in those with contralateral Charcot was 60%.

Dr. Wynes noted decreased ankle accommodation results from intramedullary fixation. In a study of seven amputated limbs, Pope and colleagues studied the efficacy of plantar plates compared with intramedullary screw fixation in the contralateral limb.² The authors noted 7 of the 7 plantar plate fixations failed by separation of the fifth to third metatarsal bases originating at the fifth, and 3 showed fracture of the fifth metatarsal base. The authors noted no significant biomechanical difference between the 2 techniques. Manchanda and colleagues reviewed medical records of 30 patients who had midfoot Charcot reconstruction with intramedullary beaming superconstructs.³ The authors found including the subtalar joint as part of a superconstruct to reconstruct Sanders-Frykberg II/III Charcot showed an 80% lower complication rate compared to intramedullary beaming alone. 

Mateen and colleagues reviewed 72 patients who had reconstructive surgery for midfoot Charcot, with or without accompanying subtalar joint arthrodesis.⁴ The authors found a subtalar arthrodesis with midfoot Charcot reconstructive surgery may benefit hindfoot stability, establishing a plantigrade foot, and provide further insight into managing midfoot Charcot. 

A study by Pinzur and colleagues focused on surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a circular external fixator.⁵ The authors noted 5 patients developed a neuropathic deformity of the ipsilateral ankle after removal of ex fix and the subsequent weight-bearing total contact cast, with 3 of the 5 progressing to successful healing of the neuropathic Charcot ankle arthropathy following treatment with a series of weight-bearing total contact casts, while 2 underwent successful ankle fusion with retrograde locked intramedullary nailing. 

Hindfoot varus predisposes patients to ankle instability and may be a plausible factor in ankle Charcot, noted Dr. Wynes. DuBois and colleagues reviewed 48 limbs in 43 patients with midfoot Charcot neuroarthropathy.⁶ The authors found patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints, and that patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint.  

Trauma can create ligamentous disruption leading to Charcot neuroarthropathy, noted Dr. Wynes. He said ankle Charcot after midfoot reconstruction may be underreported, and lateral ankle stabilization could have an effect in preventing ankle Charcot development. Adjunctive soft tissue procedures and osteotomies may be necessary in preventing ankle Charcot breakdown, according to Dr. Wynes. Talar height may play a role in Charcot. He added that protection in an off-loading device is critical, as is routine follow-up.

Dr. Wynes discloses a relationship with Paragon 28.

References

1. Waibel FWA, Berli MC, Gratwohl V, et al. Midterm fate of the contralateral foot in Charcot arthropathy. Foot Ankle Int. 2020;41(10):1181-1189. 

2. Pope EJ, Takemoto RC, Kummer FJ, Mroczek KJ. Midfoot fusion: a biomechanical comparison of plantar planting vs intramedullary screws. Foot Ankle Int. 2013;34(3):409-13. 

3. Manchanda K, Wallace SB, Ahn J, et al. Charcot Midfoot reconstruction: does subtalar arthrodesis or medial column fixation improve outcomes? J Foot Ankle Surg. 2020;59(6):1219-1223. 

4. Mateen S, Thomas MA, Jappar A, Wu S, Meyr AJ, Siddiqui NA. Progression to hindfoot Charcot neuroarthropathy after midfoot Charcot correction in patients with and without subtalar joint arthrodesis. J Foot Ankle Surg. 2023;62(4):731-736. 

5. Pinzur MS. The development of a neuropathic ankle following successful correction of non-plantigrade charcot foot deformity. Foot Ankle Int. 2012;33(8):644-6. 

6. DuBois KS, Cates NK, O’Hara NN, Lamm BM, Wynes J. Coronal hindfoot alignment in midfoot Charcot neuroarthropathy. J Foot Ankle Surg. 2022;61(5):1039-1045.