Charcot Foot and Ankle is a complex, challenging and sometimes devastating inflammatory foot disease which causes loss of sensation, weakening of the bones and collapse of the weight bearing joints. Most often due to diabetes and underlying neuropathic arthropathy, it needs a multidisciplinary team approach in order to treat it properly and prevent amputation.

Charcot Foot and Ankle neuro-osteoarthropathy is a complex, multifactorial and often frustrating pathology, where the benefit of experience is somewhat of a double-edged sword that frequently leaves more questions than answers. In spite of this premise, basic principles and a golden standard approach, together with simple techniques and clear indications, are needed to help treat Charcot foot and ankle correctly, managing midfoot, hindfoot and ankle joints deformities, and preventing foot amputation.⁽¹⁾

Today there is consensus on the following points:

1) Charcot Foot and Ankle management requires more surgery than it was thought before;

2) There is a pre-diabetes condition that often is under-diagnosed;

3) Foot and ankle ulcerations which occur frequently can be challenging when addressed surgically, after conservative care has failed;

4) Soft tissue coverage has a strong impact on Charcot reconstruction;

5) Concurrent immunopathy, angiopathy and peripheral neuropathy, accompanied by morbid obesity, may complicate the treatment approach and lead to foot amputation;

6) More than 50% of the amputations due to Charcot foot and ankle could be avoided;

7) A multidisciplinary team approach is mandatory. This team approach to the Charcot foot and ankle treatment – starting from the diagnosis – works both in preventing amputation and in reducing healthcare costs.⁽²⁾

Because of nerve damage due to diabetes, patients go on walking until the foot is compromised because they do not feel any pain. Ligaments do not function in the proper way, and biomechanical problems are often observed. Primary surgical treatment can be advantageous for the patient’s well-being: offloading with external fixation to prevent the risk of not having revascularization.

Osteomyelitis, frequently present in diabetic patients with Charcot as a result of foot ulcers, may require urgent surgery, but this is septic surgery and not yet Charcot reconstruction. Bone infections must be previously treated with antibiotics: staged salvage with prolonged targeted antibiotics until infection is eradicated.⁽³⁾

Reconstruction is indicated with an increased level of instability as well as multiplanar deformities, chronic wounds, chronic pain, and osteomyelitis. After bone debridement, the first stage of reconstructing a Charcot Foot and Ankle is to obtain correction – e.g. with acute or gradual soft tissues correction and osseous realignment, and the second stage is to maintain correction – e.g. with arthrodesis, especially when affecting the hindfoot, with the use of an external monolateral and/or circular frame.⁽⁴⁾

For Charcot midfoot reconstruction, more positive outcomes can be reached with a combination of internal and external fixation. Beaming or plating, and the use of an external fixator, is the suggested treatment. Sometimes a surgeon needs to stabilize the hindfoot in order to fix the midfoot: when isolated fusion doesn’t work, one has to fuse more segments – e.g. midfoot and hindfoot together. Plating may present the disadvantage of bad soft tissue condition, with a high risk of infections and revisions, as well as beaming.^{(5) (6)}

With ankle and subtalar dislocation, a suggested treatment is tibio-talo-calcaneal fusion by intramedullary nailing to hold the foot straight and stabilize the ankle joint. It can be done through small incisions, with lower soft tissue complications.⁽⁵⁾

Internal fixation is more suitable if the patient has no infected wounds, still good bone quality, intact soft tissue envelope.

External fixation is recommended nearly always when deformity is present, and in the case of open wounds with active infection. Some advantages of this technique are that all the extraneous metal can be removed after 6-8 weeks; it is safer with open wounds; it works well in the acute Charcot foot and ankle management with dense peripheral neuropathy, and it provides stabilisation with ankle fractures and dislocations.^{(7) (8)} It may be used in combination with internal fixation, when there is the need for supplemental fixation.

References

Edmonds ME, Foster AVM, Sanders LJ 2008. A practical Manual of Diabetic Foot care, Blackwell Publishing, USA.
Wukich DK, Amstrong DG et al. 2013. Inpatient Management of Diabetic Foot Disorders: a Clinical Guide. Diabetis Care, Sept; 36(9)2862-71.
Koller A, Springfeld R et al. 2011. German-Austrian consensus on operative treatment of Charcot neuroarthropathy: a Perspective by the Charcot task force of the German Association for Foot Surgery, Diabet Foot Ankle; 2:10207.
Baravarian B, Van Gills CC 2004. Arthrodesis of the Charcot foot and ankle. Clin Podiatr Med Surg; 21(2):271-89.
Lee L, Blume PA et al. 2003. Charcot joint disease in diabetes mellitus. Ann Vasc Surg; 17(5):571-80.
Ferreira RC, Gonçalez DH et al. 2012. Midfoot Charcot Arthropathy in diabetic Patients: Complication of an epidemic disease in Rev Bras Ortop. Sep-Oct; 47(5):616-25.
Illgner U, Budny T et al. 2014. Clinical benefit and improvement of activity level after reconstruction surgery of Charcot feet using external fixation: 24-months results of 292 feet.BMC Muscoloskeletal Disorders, 15:392.
Liu G 2008. Is External Fixation Overutilized In Managing Charcot In The Diabetic Foot? Podiatry Today; 21(2):1-6

Surgical Management of the Charcot Ankle2024-01-17

Charcot neuroarthropathy of the ankle is an especially challenging condition that often leads to instability and destruction of the joint with significant morbidity requiring an amputation in many instances^1-3. According to Brodsky et al., the ankle is affected in 9% of patients with Charcot neuroarthropathy, whereas the hindfoot is involved in 30-35%³. The overall goal of Charcot ankle reconstruction is to achieve a painless, plantigrade and stable foot, and thus avoid ulceration with subsequent infection^1,2. However, this procedure is also associated with a high complication rate^1,2.

Postoperative Management in Charcot Foot Reconstruction2024-01-10

The successful treatment of Charcot foot does not end with a completed surgery; success also requires a diligent postoperative care regime. This devastating condition mainly affects patients with diabetes and peripheral neuropathy, resulting in bone destruction and joint deformation¹. During the initial, inflammatory stage, the recommended treatment consists of off-loading with total contact casts or custom orthotics to prevent further damage, although surgical management is indicated in cases of severe instability or soft tissue compromise². After the acute stage, the focus of treatment is on deformity correction and foot reconstruction to prevent further damage and improve the patients’ quality of life².

Charcot Foot Reconstruction Using Internal Fixation2023-12-12

Appropriate timing for surgical intervention is a matter of controversy among specialists¹. While in the past Charcot foot surgical reconstruction was mainly reserved to salvage the limb, today surgeons also perform operative corrections to ensure patients can use commercially available footwear instead of cumbersome orthoses¹. Regardless, the main goal of Charcot foot surgery, independent of the fixation method, is to create a stable and plantigrade foot. This article will discuss different approaches for Charcot foot surgery with internal fixation, focusing on midfoot reconstruction.

Expert Tips on How to Medically Diagnose Charcot Arthropathy2023-11-30

The diagnosis of Charcot neuroarthropathy of the foot and ankle can be challenging due to a lack of information in the patient's history, clinical assessment, imaging, and laboratory findings¹. It is assumed that one in four cases of acute foot and ankle Charcot are undiagnosed or misdiagnosed¹. However, correct diagnosis and effective treatment are crucial to avoid ulceration, worsening deformity, infection, or amputation¹.

Charcot Arthropathy Symptoms and Initial Stage2023-11-21

Charcot arthropathy occurs in the presence of peripheral neuropathy and metabolic abnormalities. Today it is seen more commonly in patients with long-standing diabetes^1,2. Its pathogenesis, although still largely unknown, involves several pro-inflammatory pathways, which stimulate osteoclastic activity³.

Medical Resources for Charcot Foot & Ankle Specialists2023-11-14

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.

The Experts’ Definition of Diabetic Charcot Foot2023-11-14

Charcot foot is a progressive, devastating pathology defined by bone and joint changes that occur as a result of loss of sensation. Also called Charcot joint or neuropathic arthropathy, this condition is almost always associated with the vascular and neurological changes caused by poorly controlled diabetes¹.

Charcot Surgical Reconstruction2023-11-14

Charcot foot, also called Charcot neuropathy, is a condition caused by a combination of peripheral neuropathy and vascular disorders that results in progressive joint damage and eventually foot instability¹. If left untreated, the consequences for patients are devastating, with reduced quality of life, inability to weight-bear, and an increased risk of amputation².

Surgical Approaches for Charcot Foot2023-11-14

Charcot neuroarthropathy is a rare, but devastating complication of diabetes¹. Progressive destruction of the bones and joints of the foot cause deformities and thus alter foot biomechanics¹. If not recognized nor treated properly, the disease can result in ulcer formation, infection, and progression of the disease with joint instability and bone destruction^2,3. In the worst case, limb amputation is required^4,5.

Tips for Timely Diagnosis of Charcot Foot and Ankle2022-01-17

It is known that around 9 per cent of patients with diabetic neuropathy and foot ulcers develop a Charcot foot and ankle. This pathology often goes unrecognized, particularly during the acute phase, until severe complications occur, such as an abnormal pressure distribution on the plantar fascia with bones weakened enough to fracture, followed by a marked foot and ankle deformation and, in the worst cases, by amputation. Thus, today, one of the most crucial questions is how to timely diagnose this condition.

Magnetic Resonance for Charcot Foot and Ankle Diagnosis2021-12-21

Charcot Foot and Ankle is a significant problem caused by peripheral neuropathy, with an estimated incidence of 0.3 to 7.5% in the diabetic population. This condition, which is also known as Charcot arthropathy, Charcot joint, or neuropathic arthropathy, affects the soft tissues, joints, and bones in the foot and ankle. If left untreated, it may lead to progressive foot deformity, ulceration, or osteomyelitis. In the most advanced stages, it may be necessary to resort to limb amputation.

Tips for the Prevention of Charcot Foot and Ankle2021-12-17

Charcot Foot and Ankle is a severe condition that, if left untreated, may lead to deformity, permanent disability, amputation or ultimately to the patient’s death. People with diabetic neuropathy are at high risk of developing Charcot Foot and Ankle, because of the decreased sensation and diminished ability to feel temperature, pain or trauma.

Computerized Tomography for Charcot Foot and Ankle Diagnosis2021-12-14

Charcot Foot and Ankle, also known as Charcot arthropathy or Charcot joint, is a condition caused by peripheral neuropathy, leading to the progressive degeneration and destruction of the soft tissue, joint, and bone. In modern society, the most common cause for this neuropathic neuropathy is diabetes mellitus, with long-term diabetic patients having an increased risk of developing the condition.

Radionuclide for Charcot Foot and Ankle Diagnosis2021-12-09

Early Charcot Foot Diagnosis is essential to a proper management, but this can be challenging. There are some factors that should increase clinical suspicion for acute Charcot arthropathy, namely if the patient presents with:

Radiography for Charcot Foot and Ankle Diagnosis2021-12-07

Charcot Foot and Ankle, also known as Charcot arthropathy, neuropathic arthropathy or Charcot joint, is a progressive condition that affects the bones, joints and soft tissue of the foot and ankle. It is caused by peripheral neuropathy. Today, diabetes is the most common cause for developing Charcot Foot and Ankle.

Charcot Foot and Ankle Diagnosis: The Multidisciplinary Approach2021-12-02

Patients with Charcot neuroarthropathy, a condition that affects the bones, joints, and soft tissues of the foot and ankle, greatly benefit from a timely diagnosis and appropriate treatment. However, Charcot Foot and Ankle diagnosis can be quite challenging, especially in an early stage, where acute symptoms can be similar to other conditions.

Charcot Foot and Ankle: Patient Questions and Doctor Answers2021-11-30

Linked to peripheral neuropathy, Charcot Foot and Ankle is one of the serious foot complications affecting people with diabetes. Foot injuries that go unnoticed due to the reduced pain sensation accumulate, and, over time, there is bone deformation, ulceration, and infection. In a worst-case scenario, amputation may be necessary.

Charcot Foot and Ankle Causes: Where the Pathology Starts2021-11-25

Charcot Foot and Ankle, also known as Charcot arthropathy, is a progressive, inflammatory condition that affects the bones, joints, and soft tissues in the feet of people with peripheral neuropathy. If left untreated, Charcot of the foot and ankle leads to severe deformity, ulceration, and – worst-case scenario – to limb amputation.

The Stages of Charcot Foot and Ankle Disease and The Importance of a Quick Diagnosis2021-11-23

When dealing with Charcot Foot Disease, a swift diagnosis is crucial to improve patient outcomes and avoid complications such as foot deformity, ulceration, and in a worst-case scenario, limb amputation. However, not all physicians are able to recognize the initial signs of a Charcot Foot and Ankle in their diabetic patients.

Emergency in Diabetic Foot and Ankle2021-11-16

Diabetic foot is one of the most important sources of morbidity in patients with diabetes, affecting 6.4% of patients worldwide. It is the most common cause of lower extremity amputation.

Charcot Foot and Ankle: Definition and Classification2021-11-12

Charcot Neuroarthropathy, also called Charcot Foot and Ankle, is a progressive and inflammatory condition that weakens the soft tissues, bones, and joints of the foot and ankle. This complex and challenging type of neuropathic arthropathy is commonly linked to diabetes. If left untreated, it can lead to devastating consequences, such as deformity, ulceration, and infection. In the worst-case scenario, it may result in limb amputation.

What Is Arthrodesis (Joint Fusion)?2021-05-06

Arthrodesis may be defined as the surgical immobilization of a joint by fusion of the bones. It is commonly referred to as joint fusion, also known as artificial ankylosis or syndesis. It can be performed in several parts of the body, and it is indicated in the presence of painful joints, often due to arthritis or osteoarthritis, with highly compromised mobility.

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