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[Surgical treatment of the Charcot foot : long-term results and systematic review]
1Abteilung für Kinderorthopädie und Fußchirurgie, Orthopädisches Krankenhaus Speising, Speisingerstraße 109, 1130, Wien, Österreich, nikihartig@hotmail.com.
Insights
Surgical treatment, including tibio-calcaneal arthrodesis, can effectively heal Charcot foot ulcerations and reduce amputation risks. Early detection and optimal management of comorbidities are crucial for successful outcomes in neuroosteoarthropathy.
Area of Science:
- Orthopedics
- Podiatry
- Diabetic Foot Care
Background:
- Charcot arthropathy (neuroosteoarthropathy) presents significant challenges due to bone loss, instability, and deformity.
- Foot ulcerations in Charcot arthropathy serve as entry points for bacteria, leading to frequent and serious infections.
- Chronic plantar ulcerations, often caused by bony prominences or malalignment, are difficult to treat without surgical intervention.
Purpose of the Study:
- To reduce ulcerations and infections in Charcot foot patients.
- To minimize the risk of lower limb amputations.
- To evaluate the effectiveness of surgical treatments, with a focus on tibio-calcaneal arthrodesis.
Main Methods:
- A 12-year retrospective study (1999-2011) involving 43 patients (46 feet) with surgically treated Charcot foot.
- Surgical procedures included triple, talo-navicular, subtalar, and tibio-calcaneal arthrodesis, as well as midfoot fusion.
- Pre- and post-operative offloading with casts or walkers, and post-operative use of custom orthopedic shoes were essential.
Main Results:
- Surgical treatment of 16 ulcerated feet resulted in healing in 14 cases, with 2 experiencing complications (infections, nonunions, necrosis, wound healing issues).
- Revisions were often necessary, but most complications were manageable.
- Three amputations were ultimately unavoidable in the study cohort.
Conclusions:
- Complications, including those leading to amputation, can occur despite meticulous surgical technique in Charcot arthropathy.
- Early diagnosis of Charcot foot is paramount for reducing morbidity and preventing further complications.
- Optimal management of comorbidities like diabetes mellitus is vital for improving surgical outcomes and reducing ulceration and amputation rates.
Background:
Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.
Objectives:
The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.
Materials And Methods:
In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.
Results:
After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.
Conclusion:
Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.
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