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When Should You Operate On The Charcot Foot?
Following a delayed diagnosis of Charcot foot, physicians may turn to surgery to salvage the limb although there are debates surrounding the timing of surgery. In a thorough review of the literature, this author reviews the impact of Eichenholtz staging upon treatment interventions and weighs the pros and cons of arthrodesis and exostectomy procedures.
The ultimate goal in treatment of a Charcot foot is maintenance of a stable, plantigrade foot, which can be easily shod, minimizing the risk of callus, ulceration, infection and amputation. The gold standard of treatment remains immobilization in a total contact cast (TCC).1-4 Given that the diagnosis of a Charcot foot is often delayed, rigid foot deformities develop, increasing the risk of major lower extremity amputation by 15-40 fold and causing podiatric surgeons to consider surgical intervention for limb salvage.5-19
The proper timing of surgical intervention, specifically the optimal Eichenholtz stage in which surgical intervention occurs, remains controversial. Surgery during the acute phase of Charcot has historically been a relative contraindication. There is a paucity of literature regarding surgical intervention for stage 0 Charcot.7,20 It is best to treat patients diagnosed in stage 0 with cast immobilization with or without weightbearing restrictions. The majority of literature involving surgical treatment of acute Charcot involves outcomes of procedures performed in stage 1 when some form of osseous collapse has already occurred.3,14,21-23
The concern with surgery on an acute Charcot foot lies with the potential complications (wound healing complications and infection) that could occur from operating on an edematous limb.2,4,7,10,14,21,24-26 The primary concern, however, is with the quality of the bone. As the bone is undergoing a pathogenic process of osteoclastic resorption and fragmentation, there is concern about its ability to maintain optimal fixation purchase. This could lead to complications such as hardware failure, pseudarthrosis, delayed union or non-union.4,7,21,25
What Studies Say About Surgical Results
Shibata and colleagues reported on four patients who had ankle arthrodesis due to acute ankle Charcot secondary to leprosy.20 They utilized intramedullary nails, Kirschner wires and staples for fixation due to the poor quality of the bone. The average patient age was 48 years and the average follow-up time was 61 months. Complete arthrodesis occurred in all patients at an average of six months. Two patients developed a transient ulcer. The authors felt that if plantigrade weightbearing was possible in the early stages, bracing or immobilization was all that was necessary for treatment. The authors felt repeated infection and deep ulcerations of the ankle or forefoot are the only indications for surgical intervention.20
Myerson and coworkers reported on nine patients with stage 1 Charcot foot who had surgical intervention.23 The mean duration of postoperative immobilization was five months with the initial eight to 10 weeks of non-weightbearing followed by weightbearing as tolerated. Eight (88.9 percent) patients had a stable, plantigrade foot at 28 months postoperative. Authors reported no complications. The authors only performed surgery in patients with a severe, unstable and reducible deformity. The authors felt surgery is contraindicated if radiographs revealed bone resorption or fragmentation due to concern with the lack of adequate bone stock for secure purchase of internal fixation.
Armstrong and colleagues reported on 14 patients with acute Charcot who had surgical intervention (nine exostectomies, five arthrodesis procedures).13 Surgery occurred only after patients reached stage 3 and only if they had a deformity that had the potential to result in ulceration. Patients who had an arthrodesis procedure had significantly longer times of postoperative cast immobilization and return to shoe gear in comparison to patients who had an exostectomy or had an early diagnosis and conservative management. The only complication the authors reported was one patient who developed pseudarthrosis of the ankle after an attempted arthrodesis. This patient subsequently had conservative treatment with an ankle-foot orthosis.
Simon and colleagues wrote the article most cited for advocating early surgical intervention in the management of acute Charcot.21 Fourteen patients with diabetes and stage 1 Charcot elected for early surgical intervention for various reasons. These reasons included one or more of the following: concern for potential complications if a foot deformity developed; the need for a kidney transplant and the effect of this on casting; and the functional and occupational difficulties associated with prolonged immobilization with conservative treatment. The study authors performed an arthrodesis for all patients and instructed them to remain non-weightbearing until radiographic evidence of consolidation was visible. They then transitioned patients to assisted weightbearing in a short leg cast for a mean of 10 ± 3.3 weeks, which was followed by unassisted weightbearing in a short leg cast for a mean of 15 ± 8.8 weeks. The follow-up time was 41 months. The mean time to return to normal shoe gear was 27 ± 14.4 weeks. The study authors reported no complications.
Despite concern with the prolonged immobilization time associated with conservative management of acute Charcot being one of the reasons for electing surgical intervention, the mean return to shoe gear time following surgical intervention in the study was 27 weeks.21 This is not significantly different from the 26 weeks that Armstrong and colleagues reported for conservative treatment of acute Charcot.13 One should only perform surgery in stage 0 and stage 1 Charcot if there is infection, concern for skin breakdown, severe dislocation or instability, or if conservative treatment has failed to obtain a stable, plantigrade foot.2-4,7,9,10,14,25
When To Perform Arthrodesis For Charcot
Eichenholtz stage 2 is reportedly the optimal stage for open reduction and internal fixation, or arthrodesis as any present deformity is often still reducible.16 The current trend is realignment arthrodesis utilizing the “superconstruct” concept as Sammarco described.27 The four tenets of a “superconstruct” are: 1) osseous resection for deformity correction and reduction of tension on the soft tissue envelope; 2) arthrodesis extending beyond the affected joints; 3) utilization of hardware deemed to be the strongest that the soft tissues will allow; and 4) use of this hardware in a novel position that maximizes mechanical function.27
Indications for arthrodesis utilizing a “superconstruct” are a grossly unstable foot, recurrent ulceration, failed conservative treatment or prior failure of surgical treatment consisting of an exostectomy. Early and Hansen reported on surgical reconstruction in 10 patients with midfoot Charcot and recurrent ulceration.28 The follow-up time was 28 months. Major complications included osteomyelitis requiring below-knee amputation (BKA) (two patients) and death in the immediate postoperative period secondary to myocardial infarction.1 The remaining seven patients healed with minor complications occurring in four patients (wound dehiscence in three patients and one hardware failure without loss of correction).1,28
The primary disadvantages associated with realignment arthrodesis are the longer operative times; the greater potential for hardware-related complications; the greater potential for delayed unions, non-unions and pseudarthrosis; infection; and prolonged restrictions on weightbearing. The most commonly reported complications are hardware failure or migration, non-union, infection, wound dehiscence, osteomyelitis and recurrent ulceration. Researchers have also reported major complications consisting of continued fracture and deformity, osteonecrosis, deep venous thrombosis and major lower extremity amputation.27,29-34
What You Should Know About The Exostectomy Procedure
Once patients have reached stage 3 Charcot, open reduction and internal fixation or arthrodesis may be more difficult due to the amount of bone that one may need to resect to allow for deformity correction. Authors have recommended exostectomy/ostectomy for this stage as these procedures require minimal dissection and result in the removal of the osseous prominences that could cause ulceration.13,16
One can perform this procedure utilizing a direct or indirect approach. In a direct approach, bone resection occurs directly through the ulceration. An indirect approach involves making an incision on the medial or lateral aspect of the foot above and adjacent to the site of the ulceration. Then one would use an osteotome or sagittal saw to resect the osseous prominence. The advantages of an indirect approach are avoidance of a plantar incision and reduced risk of contamination as surgeons do not resect bone directly through the ulceration.36 Reported complications following exostectomy are: delayed healing, a non-healing wound, instability and need to convert to an arthrodesis, skin/soft tissue infection, osteomyelitis, and amputation.35-40
The difficulty with exostectomy lies in ensuring that one resects an adequate amount of bone to minimize the potential for recurrent ulceration while avoiding excessive resection, which could potentially destabilize the foot.36,37 There is currently no widely accepted protocol to quantify how much bone to resect. Wieman and colleagues describe a method in which one performs osseous resection in such a way as to “recreate” the arch of the foot.34 They emphasize a curvilinear approach to osseous resection, extending from the inferior aspect of the first metatarsal to the inferior aspect of the calcaneus and approximately one-third superiorly into the arch of the foot.
Wieman and colleagues reported the results of this technique in 40 patients (54 diabetic midfoot ulcers).34 The mean patient age was 60 years, the mean duration of ulceration was 212 days and the mean follow-up time was 38 months. Surgeons used an indirect approach in all cases. Minor complications consisted of wound dehiscence (one patient) and recurrent ulceration (two patients). A total of 29 amputations occurred secondary to combined infection and peripheral vascular disease. The 25 remaining ulcerations took a mean of 129 days to heal.
Brodsky and Rouse reported on 12 patients (eight plantar medial ulcerations and four plantar lateral ulcerations) who had an exostectomy with an indirect approach.35 The average patient age was 56 and the follow-up time was 25 months. Nine (75 percent) patients went on to successful healing of their ulcerations. Complications consisted of serous drainage (four), delayed healing (three) and one recurrent wound. Two patients died of complications unrelated to the foot. One patient with a recurrent wound required a Syme’s amputation, which the authors felt was due to the tenuous nature of the plantar skin secondary to the four previous procedures performed, including a split-thickness skin graft to the plantar foot.
Myerson and colleagues reported on 12 patients who had an exostectomy.39 Eight of the patients remained with a stable foot free of ulceration at 32 months postoperative. Reported complications were three conversions to arthrodesis (two secondary to instability) and one amputation secondary to infection at three months postoperative.
Catanzariti and colleagues reported on 20 patients (27 midfoot ulcerations) who had an ostectomy.38 Surgeons used a direct approach for 21 ulcerations (13 medial, eight lateral) and an indirect approach for six ulcerations (five medial, one lateral). Twelve (60 percent) patients had successful healing of their ulceration. Complications consisted of one midfoot instability, one hindfoot/ankle Charcot, one recurrent ulceration requiring medial plantar artery flap coverage, one soft tissue infection, osteomyelitis in two patients, one non-healing wound and one BKA. Complications occurred more often with plantar lateral ulcerations. The only complication to occur with a plantar medial ulceration was the one BKA.
Laurinaviciene and coworkers also found a higher incidence of complications related to plantar lateral midfoot ulcerations following an exostectomy.36 In their study of 20 patients with 27 ulcerations (18 medial and nine lateral) with an average follow-up time of 22 months, 17 medial ulcerations went on to complete healing in comparison to three lateral ulcerations.
Rosenblum and coworkers reported on 31 patients (32 ulcerations) who had an exostectomy.37 The average patient age was 51 years. The mean duration of the ulceration was 13 months. Ulceration depth ranged from superficial to deep but not probing to bone and probing to bone. Surgeons ellipsed ulcerations < 3 cm in diameter and performed primary closure. Surgeons ellipsed ulcerations >3 cm in diameter and closed them with a local fasciocutaneous flap overlying a flexor digitorum brevis muscle flap. The follow-up time was 21 months. Twenty-one ulcerations remained healed. Eleven ulcerations had subsequent wound dehiscence and recurrence, which the authors attributed to inadequate bone resection.
What To Discuss With The Patient About Charcot Surgery
When it comes to the consideration of surgical intervention in a patient with Charcot foot, there should be a frank discussion as to the potential complications. One should discuss the following points with each patient.
• The potential for postoperative infection and skin, soft tissue and bone healing complications are high.
• Attempts at limb salvage and reconstruction will take a minimum commitment from the patient of 12 months of postoperative recovery, which will include a significant portion of time in which weightbearing restrictions will be in place.
• Future surgical intervention may be required and the potential for major lower extremity amputation continues to exist.
If the patient does not desire attempts at limb salvage, partial amputation of the foot to eradicate the area of deformity is an option. This would require a minimum of six to 12 weeks of some form of weightbearing restriction. Following surgical intervention, there must be strict adherence to a lifelong routine dedicated to lower extremity hygiene, foot care and the use of proper orthotics, shoe gear and bracing. A primary BKA is also an option.
The treating physician should involve the patient’s family and support network in these discussions so they are aware of what treatment entails. One should also discuss the accessibility of the patient’s home to use of a wheelchair, walker, crutches, etc. Does the patient need to use any stairs? Are all the areas where the patient must go accessible? A consult to physical therapy can be beneficial in having patients trained in the proper use of ambulation assistive devices to maintain their weightbearing restrictions safely.
Also consider requiring a short period of postoperative hospitalization to ensure patient safety, minimize complications in the acute postoperative recovery phase and reinforce proper ways for patients to safely maintain their weightbearing restrictions. One should also educate the patient and family on how they should be maintaining themselves upon discharge to the home, and aid in discussing antithrombotic prophylaxis use when required in these patients.
Dr. Schade is a Fellow of the American College of Foot and Ankle Surgeons and the American College of Foot and Ankle Orthopedics and Medicine.
The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. government.
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