There is an overwhelming wealth of scientific literature available on Charcot foot. In this article, we gather and summarize some of the most interesting sources, including Charcot neuroarthropathy of the foot and ankle reviews, diabetic foot reviews, and diabetic foot care articles.
Articles on the Medical Condition
Drs. Lee C. Rogers and Robert G. Frykberg have authored many scientific articles and textbook chapters with a focus on Charcot foot and diabetic foot problems. In a paper published in 2013, titled “The Charcot Foot”1, they review the epidemiology of the condition, highlighting that although much about its pathophysiology is still unknown, most experts agree that it is the combination of existing neuropathy with trauma – even a minor one – that kindles the syndrome. The first stage is then accompanied by inflammation, releasing cytokines including tumor necrosis factor-alpha and interleukin-1-beta. These cytokines will then trigger a metabolic pathway in which osteoclasts’ maturation will be stimulated and osteoblasts’ function will be reduced, ultimately leading to bone destruction. The authors continue their article by reviewing forms of diagnosis and the classification of Charcot foot, noting that more complicated cases of Charcot foot (with deformity, ulceration, and osteomyelitis) that have a more proximal location (in the rearfoot and/or ankle) are associated with an increased risk of amputation1.
These two specialists were also part of an international task force of experts that were brought together by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize the available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for “The Charcot Foot in Diabetes”2. The scientific article that resulted from the specialists’ review of the available literature is a condensed, pertinent text with the most distinguishing features of the condition, its pathogenesis, diagnosis, and treatment recommendations. The article also includes a decision algorithm for a basic approach to a suspected Charcot foot case2. The authors call attention to the fact that osteomyelitis can be difficult to distinguish from Charcot foot on plain radiographs or nuclear imaging. In such cases, magnetic resonance imaging (MRI) can be the test of choice to evaluate the complicated foot in patients with diabetes2. Regarding treatment options, the experts agree that off-loading is the most important initial recommendation, but recognize that surgery can be helpful in early stages including acute fractures or in later stages when off-loading is no longer effective2.
Other useful resources for the clinicians who would like to have an overview of the condition include:
- The Essentials of Charcot Neuroarthropathy3, edited by Claude Pierre-Jerome, covers the epidemiology, biomechanics, pathophysiology, socioeconomic impacts, radiological findings, and differential diagnosis of Charcot foot in diabetic patients, with an emphasis on MRI.
- Diabetes Mellitus: An Overview in Relationship to Charcot Neuroarthropathy4, authored by Lindsey R. Hjelm, describes the existence of Charcot foot in the context of diabetes mellitus, both of type 1 and type 2. The author highlights that diabetic patients are particularly vulnerable to progressive disease, due to increased bone fragility, although there is also some evidence of the protective effects of insulin and metformin on bone quality4.
- Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy5, by Thomas Hester and Venu Kavarthapu, who focused on the desired outcomes of managing Charcot foot: limb salvage, structural stability of the foot and ankle, eradication of any existing infection, ulcer prevention, and restoration of a plantigrade foot.
Articles on Treatment
Many articles that provide an overview of Charcot foot also include sections on treatment, since this is an essential component to improve outcomes in the patients who suffer from it. If the condition is left untreated, its natural history is one of progressive foot deformity, often requiring amputation in later stages or when there is concomitant infection6.
Some articles, like the one authored by Felix W.A. Waibel and Thomas Böni, have a specific focus on conservative management. In their article, titled “Nonoperative Treatment of Charcot Neuro-osteoarthropathy,” the authors state that whenever there is a suspicion of active Charcot foot, there should be immediate off-loading and a decrease in physical activity to prevent progression7. If the patient is unable to cope with the off-loading device, short hospitalization and instruction physiotherapy can be considered to ensure adherence to treatment. After the active phase of Charcot foot, when off-loading with either irremovable or removable total contact casts are recommended, patients are advised to wear orthopedic footwear to reduce pressure while walking, thus preventing ulcer formation and bone injury, which would lead to Charcot foot reactivation7. Although the focus of the article is nonoperative treatment, the authors note that surgical treatment is indicated whenever there is:
- A severe deformity with an open wound and osteomyelitis
- A severe deformity with an open wound refractory to off-loading
- A severe midfoot or hindfoot deformity with instability
- A severe deformity with recurrent ulcers despite initial healing with off-loading7
The topic of “Surgical Optimization for Charcot Patients” is addressed by Kelsey J. Millonig, DPM and Rachel Gerber, DPM in a recent article. There is no clear consensus on the best treatment approach. Although there is a significant risk for amputation with or without reconstructive treatment for Charcot foot, there are modifiable risk factors associated with Charcot reconstruction in the preoperative stage. The authors provide a few pre-surgical instructions to address these risk factors, including:
- Encourage well-controlled glucose levels in patients with diabetes
- Evaluate the existence of peripheral vascular disease beyond clinical examination findings
- Promote tobacco cessation no later than 8 weeks before surgery
- Evaluate renal function, paying particular attention to patients with end-stage renal disease and chronic kidney disease
- Assess the presence of obesity, hypertension, edema, the patient’s metabolic profile, and the presence of infection8
These factors can impact the success of surgical reconstruction in Charcot foot beyond the surgical technique or devices used, and it is therefore essential that surgeons consider them carefully8.
Surgical procedures are chosen according to the clinical scenario, say Alan C. Stuto and John J. Stapleton in their article, “Surgical Considerations for the Acute and Chronic Charcot Neuroarthropathy of the Foot and Ankle.” The authors note that the goals of surgery will depend on the characteristics and stage of the disease9:
- In the acute stage, the goal is to provide stabilization. This can be achieved with gradual deformity correction and delayed osseous reconstruction or with a one-stage procedure where both correction and reconstruction are addressed. It is worth noting that surgical treatment in the acute stage is the exception and not the rule, due to the high failure rate.
- After the acute phase subsides, the focus of surgical management is on deformity correction.
Depending on the specific goals of the surgery, the deformity correction can be done through osteotomies and/or joint arthrodesis with internal and/or external fixation9.
Although the outcomes of a surgically repaired Charcot foot are not always easy to predict, surgical reconstruction has been associated with better quality of life in patients, compared with life-long bracing or amputation10.
Articles on Fixation Devices
The renewed interest in the surgical reconstruction of the deformed Charcot foot has led to the publication of several scientific articles on the subject. In a recent systematic review by Joon Ha and colleagues, the authors analyzed the outcomes of Charcot foot reconstruction, concluding that surgical management can offer limb salvage to a select population11.
Both internal and external fixation devices can be used for the surgical reconstruction of the Charcot foot. Circular or hexapod external fixation is preferred when there is infection, poor bone stock, or the soft tissue envelope is already compromised (e.g., from ulceration)9,12. Internal fixation devices can be:
- Plates and screws
- Beams, screws, or bolts
- Intramedullary nails
Many times, the reconstruction of a Charcot foot will require several different internal fixation devices, or even a combination of external and internal devices, according to the level and location of the deformity12.
External fixation can be a powerful and versatile tool in the management of Charcot foot, states Dr. Byron Hutchinson in his article “Circular Fixation in Charcot,” where he also discusses aspects of frame application and biomechanics13.
In a comprehensive article titled “The Use of Hexapod External Fixation in the Management of Charcot Foot and Ankle Deformities,” Dr. Guido LaPorta and colleagues provide useful advice for the use of a 2-stage computer hexapod-assisted technique to address midfoot Charcot and ankle-hindfoot deformities with the goal of restoring function and decreasing the risk of amputation secondary to ulceration and infection.
In a systematic review of outcomes following intramedullary fixation for midfoot Charcot foot, Wukich and colleagues found that the use of screws, beams, and bolts that are inserted into cancellous Charcot bone or that cross large bone voids can delay osseous incorporation14. They also note that in the cases where bolts were used, migration was more common than breakage, which may be a result of implant design, particularly due to the lack of medial column stability. In an effort to assess the construct rigidity and strength of beaming and plantar plating of the medial column, Simonik et al performed a biomechanical study to compare the construct rigidity and strength of beaming and plantar plating, concluding that while both implant types were similar in terms of stiffness, beams were able to withstand significantly more load before failure occurred15. Another aspect to consider is that the use of plates and screws to reconstruct midfoot deformities requires an adequate soft tissue envelope and is associated with a high failure rate9,16.
To address these limitations, surgeons developed ‘super constructs,’ a method where some of the normal principles of orthopedic techniques are abandoned to improve stability and reduce the likelihood of failure of the procedure17. A ‘super construct’ is defined by four factors:
- Application of hardware beyond the injury area, including nearby joints
- Bone resection to allow for adequate reduction without compromise of the soft tissue envelope
- Use of the strongest device(s) that can be tolerated by the soft tissue envelope
- Application of the devices in a position that maximizes mechanical function
‘Super constructs’ can be achieved with the use of large intramedullary screws (solid or cannulated), also called bolts or beams, or with other devices16. The mechanics, technique and hardware considerations are addressed in the article “Beaming the Charcot Foot” by Drs. William Grant and Lisa Grant-McDonald16.
Charcot neuroarthropathy in both the hindfoot and the midfoot results in complex deformities, which have a high risk of ulceration, infection, and limb amputation if uncorrected18. Although technically demanding, reconstruction of hindfoot and midfoot Charcot deformities can be carried out with the use of internal fixation. In a recent article titled “Combined Charcot hindfoot and midfoot reconstruction using internal fixation method – surgical technique and single surgeon series,” Kavarthapu and colleagues (Kavarthapu, 2023) present the surgical technique and outcomes of deformity correction and stabilization using a hindfoot nail, midfoot beams, and locking plates18. The authors performed 35 reconstruction procedures in 34 patients with limb-threatening deformity due to Charcot neuroarthropathy, showing that the proposed technique provided functional limb salvage in most cases, with an acceptable level of complications.
Patients with a hindfoot or ankle Charcot neuroarthropathy deformity can be managed with arthrodesis19. In a thorough review titled “Tibial Lengthening and Intramedullary Nail Fixation for Hindfoot Charcot Neuroarthropathy,” Drs. Kelsey J. Millonig and Noman A. Siddiqui explore the outcomes of tibiocalcaneal arthrodesis with distal tibial lengthening in patients with neuropathy and provide some guiding principles of external and internal fixation in this patient population. They highlight that intramedullary nailing reduces the duration of external fixation and protects the regenerate during fixation, which is relevant for neuropathic patients.
In the article “Charcot foot reconstruction outcomes: A systematic review,” a total of 1116 feet in 1089 patients were included, which were managed with external fixation in 346 cases, internal fixation in 726, and with combined internal plus external fixation in 44 cases. The authors could not find a preferential method of fixation, since all methods resulted in high fusion and low amputation rates, but also high complication rates11. This is a reflection not only of the complexity involved in Charcot foot reconstruction, but also of the challenges of managing such condition in highly morbid patients.
Charcot foot is a complex problem, which arises from peripheral neuropathy and is today more prevalent among patients with diabetes2. Surgical reconstruction is a challenging procedure, with a high complication rate. Nonetheless, it is indicated for some patients or in cases of advanced disease, for whom it can be an alternative to limb amputation and provide better quality of life11.
There are several fixation devices available, both internal and external, and it is up to the surgeon to take into consideration the patient characteristics and condition features before deciding on the best approach for each Charcot foot case.
To help you prepare the best surgical approach for your Charcot cases we have compiled several Charcot Reconstruction Case Reports, which are available to subscribers/registered users.
1. Rogers LC, Frykberg RG. The Charcot Foot. Medical Clinics of North America. 2013/09/01/ 2013;97(5):847-856. doi:https://doi.org/10.1016/j.mcna.2013.04.003
2. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot Foot in Diabetes. Journal of the American Podiatric Medical Association. 01 Sep. 2011 2011;101(5):437-446. doi:10.7547/1010437
3. Pierre-Jerome C. The essentials of charcot neuroarthropathy: biomechanics, pathophysiology, and MRI findings. Elsevier; 2022.
4. Hjelm LR. Diabetes Mellitus: An Overview in Relationship to Charcot Neuroarthropathy. Clinics in Podiatric Medicine and Surgery. 2022/10/01/ 2022;39(4):535-542. doi:https://doi.org/10.1016/j.cpm.2022.05.001
5. Hester T, Kavarthapu V. Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy. Foot and Ankle Clinics. 2022/09/01/ 2022;27(3):583-594. doi:https://doi.org/10.1016/j.fcl.2022.03.002
6. Dardari D. An overview of Charcot’s neuroarthropathy. J Clin Transl Endocrinol. Dec 2020;22:100239. doi:10.1016/j.jcte.2020.100239
7. Waibel FWA, Böni T. Nonoperative Treatment of Charcot Neuro-osteoarthropathy. Foot and Ankle Clinics. 2022/09/01/ 2022;27(3):595-616. doi:https://doi.org/10.1016/j.fcl.2022.05.002
8. Millonig KJ, Gerber R. Surgical Optimization for Charcot Patients. Clinics in Podiatric Medicine and Surgery. 2022/10/01/ 2022;39(4):595-604. doi:https://doi.org/10.1016/j.cpm.2022.05.006
9. Stuto AC, Stapleton JJ. Surgical Considerations for the Acute and Chronic Charcot Neuroarthropathy of the Foot and Ankle. Clinics in Podiatric Medicine and Surgery. 2022/04/01/ 2022;39(2):331-341. doi:https://doi.org/10.1016/j.cpm.2021.11.005
10. Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer’s Perspective? Clinical Orthopaedics and Related Research®. 2020;478(12)
11. Ha J, Hester T, Foley R, et al. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma. May-Jun 2020;11(3):357-368. doi:10.1016/j.jcot.2020.03.025
12. Abyar E, McKissack H, Johnson MD. Chapter 19 – The surgical management of the Charcot foot: physical examination of the foot prior to surgery, indications and criteria for amputation, and surgical techniques. In: Pierre-Jerome C, ed. The Essentials of Charcot Neuroarthropathy. Elsevier; 2022:441-448.
13. Hutchinson B. Circular Fixation in Charcot. Clinics in Podiatric Medicine and Surgery. 2022/10/01/ 2022;39(4):643-658. doi:https://doi.org/10.1016/j.cpm.2022.05.008
14. Wukich DK, Liu GT, Johnson MJ, et al. A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy. The Journal of Foot and Ankle Surgery. 2022/11/01/ 2022;61(6):1334-1340. doi:https://doi.org/10.1053/j.jfas.2022.04.009
15. Simonik MM, Wilczek J, LaPorta G, Willing R. Biomechanical Comparison of Intramedullary Beaming and Plantar Plating Methods for Stabilizing the Medial Column of the Foot: An In Vitro Study. The Journal of Foot and Ankle Surgery. 2018/11/01/ 2018;57(6):1073-1079. doi:https://doi.org/10.1053/j.jfas.2018.03.043
16. Grant W, Grant-McDonald L. Beaming the Charcot Foot. Clinics in Podiatric Medicine and Surgery. 2022/10/01/ 2022;39(4):605-627. doi:https://doi.org/10.1016/j.cpm.2022.05.007
17. Sammarco VJ. Superconstructs in the Treatment of Charcot Foot Deformity: Plantar Plating, Locked Plating, and Axial Screw Fixation. Foot and Ankle Clinics. 2009/09/01/ 2009;14(3):393-407. doi:https://doi.org/10.1016/j.fcl.2009.04.004
18. Kavarthapu V, Guduri V, Hester T. Combined Charcot hindfoot and midfoot reconstruction using internal fixation method—surgical technique and single surgeon series. Annals of Joint. 2023;8
19. Millonig KJ, Siddiqui NA. Tibial Lengthening and Intramedullary Nail Fixation for Hindfoot Charcot Neuroarthropathy. Clinics in Podiatric Medicine and Surgery. 2022/10/01/ 2022;39(4):659-673. doi:https://doi.org/10.1016/j.cpm.2022.05.011