Long-Standing Nonhealing Charcot Foot Ulcers That Fail Conservative Care: Is Major Amputation Always the Solution?

Charcot arthropathy represents a potentially devastating complication in patients with diabetes; this is most significant when an ulcer and/or infection are present. When conservative therapies fail to relieve symptomatology, amputation usually represents the next step in the treatment algorithm.   However, in appropriate patients, reconstructive procedures performed by specially trained surgeons may change this paradigm and prevent amputation. The following case report and subsequent literature review discusses a patient with a recalcitrant ulcer mitigated by severe Charcot foot deformity who underwent surgical intervention leading to preservation of the limb. The goal of this manuscript is to heighten awareness of this surgical alternative and foster the wound healing clinician to seek out surgeons in their communities with the skills and experience to perform these limb preservation procedures and potentially forestall amputation.

  A 65-year-old black male with a longstanding history of noninsulin dependent diabetes mellitus presented to the authors’ clinic (Barry University Podiatry Clinic, Hialeah, FL) with a complaint of a nonhealing ulceration to the plantar aspect of his right foot as well as a charcot deformity of his right foot. The ulceration was located on the medial plantar midfoot area, and the severity of the deformity caused the patient to ambulate on his talus. (Figure 1).

  Physical examination revealed an ulceration measuring 4.2 cm x 4.7 cm x 0.1 cm. The wound bed was friable in nature with mixed fibrotic and granular tissue. The periwound area was macerated secondary to copious drainage. There was no evidence of erythema, purulent drainage, and only scant malodor. A second wound also was noted, located on the dorsal aspect of the right second digit. The wound was 1.0 cm x 1.0 cm x 0.1 cm in diameter. The base was 100% granular with no periwound erythema. No purulence or malodor was noted (Figure 2). Vascular exam revealed scarce hair growth, bounding pedal pulses, and slightly delayed capillary fill times. There was marked Charcot deformity to the right foot, transverse rotation of the foot, complete collapse of the medial arch, and a 90-degree rotation at the talonavicular joint (Figure 3). Contractures of the hallux, second, and third digits of the right foot are also present. The left foot revealed a history of first and second digit amputations and the beginnings of a Charcot deformity. Muscle strength was adequate with limited range of motion to the ankle and pedal joints of the right foot. The patient had absent protective and epicritic sensations to bilateral feet.

  A CT scan of the right foot with 3-dimensional reconstructions revealed a talonavicular dislocation with approximately 90 degrees of rotation, with the navicular articulating with the lateral aspect of the talus. The remaining tarsal bones were externally rotated and shifted laterally. The subtalar joint had a downward migration into the calcaneus with complete remodeling of the calcaneus and joint fragmentation. There were flexion deformities of the toes and fusion of the second metatarsal cuneiform joint.

After undergoing serial debridements and offloading for many months, it was evident conservative treatments were failing for this patient (Figure 4). Following thorough discussions on treatment modalities, the patient and medical provider decided surgical intervention was necessary. An above-the-knee amputation was originally recommended by another physician; however, the patient opted for a reconstructive approach with the understanding that amputation could still be the end result. The patient underwent surgical intervention on the right foot which consisted of partial resection of talar bone; a pantalar fusion with the application of an circular external fixator; arthroplasties of the first, second, and fourth digits; flexor tendon release of the second digit; Achilles tendon lengthening; and, finally, debridement of the plantar medial ulceration with application of an allogenic skin graft (Figure 5). Postoperatively, the patient was seen weekly for external fixator dressing changes and adjustments (Figure 6). He remained nonweight bearing to the right lower extremity for 13 weeks. The external fixator was in place for 12 weeks and, when removed, a vacuum-assisted closure therapy device was subsequently placed over the wound site. At his 22-week follow-up visit, the patient’s wound was completely healed (Figure 7). His right foot was fit and placed in a CROW (Charcot-resistant orthotic walker) boot (Figure 8). Of note, an intraoperative pathological report of talar bone revealed no sign of osteomylitis.

  The destructive changes that occur in the joints of neuropathic patients was first described by Jean-Martin Charcot¹ in 1868. Charcot neuropathic osteoarthropathy, often referred to as Charcot foot, is a multifactorial condition affecting the bones and soft tissues of the foot and ankle, resulting in acute fractures, dislocations, and joint destructions. Diabetes mellitus has become the most common cause of Charcot foot ranging from 0.08% to 7.50% of patients affected.² A patient like the one described here who presents with both a diabetic foot ulcer and a Charcot foot deformity is 12 times more likely to need an amputation in the future.³ Non-surgical treatment of the Charcot foot is most common during the acute phase. Immediate immobilization is vital to prevent further breakdown of the joints during the acute phase.⁴

Total contact casts (TCCs) remain the gold standard for immobilization and redistribution of plantar forces in the presence of Charcot foot and plantar ulcers.⁵ Morona et al⁶ concluded that TCC and the instant TCC are equally effective at achieving complete healing. Once out of the acute stage, patients are then generally fitted for a CROW. It is being demonstrated, however, that immobilization may not be sufficient to prevent recurrence. Osterhoff et al⁷ showed that even with immobilization patients with a body mass index > 30 were 6.4 times more likely to experience recurrence, concluding that obesity and noncompliance were the strongest predictors of recurrence.⁷ In this particular case, conservative management was no longer sufficient to prevent recurrence and subsequent breakdown.

  When successive months of conservative management have failed, the physician should consider surgical intervention for limb salvage. A multidisciplinary approach should be taken since the majority of patients with a Charcot foot disorder have multiple co-morbidities. Panagakos et al⁸ noted several indications for Charcot midfoot arthrodesis such as rocker bottom deformity, any unstable midfoot joint for which conservative treatment has failed, recurrent ulceration from deformity, progressive preulcerative lesion, or any stable deformity with ulceration or preulcerative lesion. Performing a surgical arthrodesis when indicated resulted in a greater chance for limb salvage by decreasing the rate of ulceration.⁸

 Early and Hansen⁹ showed a Charcot foot that underwent arthrodesis with Achilles tendon lengthening and offloading experienced an 86% treatment success rate after 28 months. The patient in that study showed a near 99% decrease in ulceration size at 19 weeks follow-up, indicating that surgical intervention was the best consideration when long-term conservative management had failed.

  Diabetic foot ulcers are one of most commonly diagnosed lower extremity wounds in podiatric clinics. One of the predisposing factors of diabetic foot ulcers is peripheral neuropathy,¹⁰ the most destructive consequence of which is Charcot osteoarthropathy.⁴ Clinicians often treat diabetic Charcot deformity with conservative treatments consisting of TCC or CROW boots.¹¹ According to Morona and colleagues,⁶ the most important part of conservative treatment is offloading. Total contact cast and CROW boot treatment will help offload the patient’s plantar ulcer to facilitate the healing process.¹¹

 Unfortunately, in some cases conservative treatment options and effective offloading of diabetic ulcers don’t result in healing of wounds. When conservative options fail, patients are often relegated to amputation. Moreover, removal of primary exostosis is also an option. Reconstructive surgical intervention with well-trained foot and ankle surgeons are a viable and durable option, and the utmost step in healing these types of lower extremity wounds. The interdisciplinary approach in the treatment of patients with diabetes is vital when considering complicated Charcot foot ulcers. Early surgical interventions to correct deformity and reposition misaligned joints with the assistance of internal and external fixation have been reported to help improve the patient’s quality of life.⁵ Removal of ulcer-inducing bony prominences, fusion of misaligned joints, and repositioning of foot joints helps restore the plantigrade foot, thereby preventing recurrence of plantar ulcerations.⁵ Once the foot deformity is corrected by a foot and ankle surgeon, the wound care specialist can continue with treatment to heal the ulcers adequately. Early detection of misaligned pedal joints by wound specialists combined with a surgeon’s opinion about a reconstructive surgical approach will help prevent amputation. The authors strongly believe that wound care specialists should reach out to lower extremity surgical specialists in their communities for their expertise in treating Charcot foot deformity ulcerations in appropriate patients. In the present case, the major cause of deformity was disarticulation of talonavicular joint and midtarsal joints. Once the talus bone had shifted plantar and medially, it created the pressure point at the medial aspect of the midfoot, ultimately creating a pressure ulcer. The opinion of the foot and ankle surgeon in correcting this deformity was vital in healing this wound. Partial resection of the talus bone along with fusion of the midfoot joints and adjunct digital arthroplasties helped restore a plantigrade foot for this patient and offload the pressure ulcer, with the ultimate result of a completely healed wound (Figure 9).

  Diabetic foot ulcers can become complicated with associated comorbidities, and a multidisciplinary approach is vital in the management and treatment of complicated wounds. Wound care specialists should seek out the expertise of foot and ankle specialists when treating lower extremity diabetic foot ulcers with deformity. In appropriate patients, quality of life can be significantly improved by early surgical intervention to correct the deformity and realign the malformed pedal joints, ultimately leading to healing of the diabetic ulcer.

Affiliations: The authors are from the Barry University Foot and Ankle Institute, Hialeah, FL.

Address correspondence to:
Masoud Moradi, DPM
Barry University Foot and Ankle Institute
777 East 25th Street suite 316
Hialeah, FL 33013
moradi.18@gmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.