The Surgical Management of Neuropathic
(Charcot) Foot: From Initial Diagnosis
to Surgical Procedures and Beyond

Charcot arthropathy is a complex problem, arising from peripheral neuropathy that is more prevalent among patients with diabetes. Surgical reconstruction is a challenging procedure associated with a high complication rate. Despite its complexity, foot reconstruction is indicated in cases of advanced disease, with the goal being to salvage the patient’s limb and improve their quality of life.

Timely diagnosis and appropriate treatment are essential to prevent joint instability and bone destruction and, in extreme cases, limb amputation.

Are you a patient? Go to LimbHealing.com

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What is the essential
literature about
Charcot arthropathy?

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How do experts
define Charcot
arthropathy?

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What are the initial
symptoms and how is
Charcot arthropathy
diagnosed?

charcot neuropathy, Inbound C2 Pillar Page

What are the various
surgical approaches
when performing
Charcot foot
reconstruction?

charcot neuropathy, Inbound C2 Pillar Page

Which surgical
procedures and
fixation methods are
available for Charcot
arthropathy?

charcot neuropathy, Inbound C2 Pillar Page

What is the optimal
postoperative
treatment after foot
reconstruction?

charcot neuropathy, Inbound C2 Pillar Page
charcot neuropathy, Inbound C2 Pillar Page

What Is the Essential Literature
About Charcot Arthropathy?

There are many scientific articles about Charcot foot, and it may be difficult to sift through the existing literature.
Still, it is possible to have a collection of essential reviews, books, and articles pertaining to this pathology.

For an overview of all aspects of Charcot arthropathy, clinicians are advised to read:

  • “The Charcot Foot in Diabetes,” a summary of the available evidence on the pathophysiology, natural history, presentations, and treatment recommendations. This publication was authored by of an international task force of experts who were brought together by the American Diabetes Association and the American Podiatric Medical Association.
  • “The Essentials of Charcot Neuroarthropathy,” 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.

For articles on the treatment, we suggest:

  • “Nonoperative Treatment of Charcot Neuro-osteoarthropathy,” by Felix W.A. Waibel and Thomas Böni, which has a specific focus on conservative management but also advises when surgical treatment should be considered.
  • “Surgical Considerations for the Acute and Chronic Charcot Neuroarthropathy of the Foot and Ankle,” by Alan C. Stuto and John J. Stapleton. In this article, the authors explain how surgical procedures are chosen based on the clinical scenario and the specific goals of the surgery.

There are several articles on fixation devices for Charcot foot reconstruction, including:

  • “Charcot foot reconstruction outcomes: A systematic review,” where the authors report on a total of 1116 feet in 1089 patients, who were managed with external or internal fixation, or with a combination of both.
  • “Beaming the Charcot Foot,” by Drs. William Grant and Lisa Grant-McDonald. In this article, the authors address the mechanics, technique, and hardware considerations of ‘superconstructs,’ a method where some of the normal principles of orthopedic techniques are abandoned to improve stability and reduce the likelihood of failure.

There is an ever-expanding number of articles about Charcot arthropathy, and we will be updating our collection regularly to provide you with the most current information.

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charcot neuropathy, Inbound C2 Pillar Page

How Do Experts Define
Charcot Arthropathy?

According to an international task force of experts, Charcot arthropathy can be described as:

 

“A condition affecting the bones, joints,
and soft tissues of the foot and ankle,
characterized by inflammation in the
earliest phase.”

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In later stages, the interaction of metabolic, neuropathic, and traumatic factors “may lead to varying degrees
and patterns of bone destruction, subluxation, dislocation, and deformity.”

Although it was first diagnosed more than 130 years ago, Charcot arthropathy in the diabetic patient remains
a challenge for clinicians to treat. Due to its rareness, a general practitioner may only encounter a Charcot case every 13 years.

The natural progression of diabetic Charcot foot typically follows three stages, as described by Eichenholtz in 1966:

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Stage I

Acute or
fragmentation phase

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Stage II

Subacute or
coalescence phase

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Stage III

Consolidation and
reconstructive phase

Each one of these stages is accompanied by radiographic findings. Later, the modified Eichenholtz classification introduced an additional stage named prodromal or stage 0, to reflect the clinical findings related to inflammation that are not yet visible on radiographs.

Other authors propose classification systems that focus on the anatomical aspects of neuropathic arthropathy, highlighting the involved joints in each case.

The consequences of untreated Charcot arthropathy can be devastating for patients, so a timely diagnosis is paramount. An attentive clinician can distinguish between a Charcot case and other pathologies and improve their patient’s outcomes.

charcot neuropathy, Inbound C2 Pillar Page
charcot neuropathy, Inbound C2 Pillar Page

What Are the Initial Symptoms and How Is Charcot Arthropathy Diagnosed?

According to the modified Eichenholtz classification, the natural history of the pathology involves four different stages, often grouped in active versus non-active disease states: inflammation, fragmentation, coalescence, and consolidation. Patients usually only go through one round of the different stages, but approximately 23% of them can suffer through multiple cycles, resulting in high morbidity and severe foot deformity.

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There is not a single diagnostic test to clearly diagnose Charcot arthropathy, and the best safeguard for clinicians to avoid missing a case is to always be suspicious. According to the experts, these are the clinical signs that can be found in a patient with Charcot arthropathy:

  • A warm, swollen, and sometimes erythematosus and red foot. These signs indicate inflammation, which is present in acute Charcot foot.
  • Concomitant ulceration or crepitus during examination, with patients often reporting a series of minor trauma.
  • Absence of pain, due to peripheral neuropathy.

In addition to the clinical assessment, the following imaging techniques are recommended:

A rapid and accurate Charcot diagnosis is essential to protect the foot and reduce the chance of further bony collapse of the foot and ankle. Patients benefit from attentive physicians well versed in its treatment and a multidisciplinary approach where all specialists work together.

When is time for a specialist?

Priority

Indications

Timeline

Follow-up

Priority

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Indications

  • Open wounds and deep ulcers
  • Pain at rest
  • Active Charcot Foot deformity
    (red, hot, swollen)
  • Vascular compromise

Timeline

  • Urgent/immediate referral
  • Patient needs interdisciplinary care
    management, off-loading with total
    contact cast devices and/or surgery,
    diabetic orthopedic footwear

Follow-up

  • According to specialist decision

Priority

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Indications

  • No sensitivity
  • Ulcers
  • Chronic vascular venous insufficiency
  • Previous lower limb amputation
    related to diabetes

Timeline

  • Immediate/first available referral
  • Patient needs diabetic orthopedic
    footwear, preventative off-loading
    and appropriate therapy

Follow-up

  • Every 1-2 months

Priority

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Indications

  • Insufficient sensitivity
  • No ulcers
  • Foot deformity
  • Posterior tibial pulse diminished
    or absent
  • Foot swelling, aedema

Timeline

  • No ulcers
  • Foot deformity
  • Posterior tibial pulse diminished
  • or absent
  • Foot swelling, edema
  • Referral within 3 weeks
  • Patient needs prescriptive footwear,
    preventative off-loading and
    appropriate therapy

Follow-up

  • Every 2-3 months

Priority

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Indications

  • Insufficient sensitivity
  • No ulcers
  • No foot deformity

Timeline

  • Referral within 1 months
  • Patient needs prescriptive footwear
    and preventive foot health behaviors
    education

Follow-up

  • Every 4-6 months

Priority

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Indications

  • Satisfactory sensitivity
  • No ulcers
  • Possible foot deformity
  • No peripheral artery disease

Timeline

  • Referral within 3 months
  • Patient needs foot care and preventive
    foot health behaviors education

Follow-up

  • Once a year

Proper surgical procedure is the responsibility of the medical professional. This information is furnished as an informative guideline. Each surgeon must evaluate the appropriateness of a technique based on his or her personal medical credentials and experience.

charcot neuropathy, Inbound C2 Pillar Page
charcot neuropathy, Inbound C2 Pillar Page

What are the various surgical approaches when performing Charcot foot reconstruction?

Regardless of the chosen approach, the goals of Charcot arthropathy treatment are to achieve a stable plantigrade foot resistant to ulceration, prevent amputation, and improve the patient's quality of life.

When conservative management is not enough to achieve these goals, surgical reconstruction should be considered, and preferably performed during the non-active disease state.

Although ideally every collapsed or deformed Charcot arthropathy case would be surgically transformed into a stable and ambulatory foot, unfortunately not all patients can undergo major reconstructive surgery. Other (non-reconstructive) surgery options include:

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Muscle flaps, which may
be used to provide soft
tissue coverage

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Equinus correction

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Correction of residual varus
deformities

The most common methods of Charcot foot fixation are internal fixation, external fixation, or a combination of both. Selecting the right surgical technique for Charcot arthropathy fixation is challenging, and surgery requires careful planning.

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charcot neuropathy, Inbound C2 Pillar Page

What Surgical Procedures and Fixation Methods
Are Available for Charcot Arthropathy?

In the past, surgical reconstruction to address Charcot arthropathy was considered a limb salvage procedure, used as a last resort to avoid amputation. Currently, there has been a shift in the way of thinking, and surgeons also perform these same reconstructive procedures so that their patients can use commercially available footwear instead of orthoses, thus improving their quality of life.

Charcot foot reconstruction can be achieved with internal fixation, external fixation, or a combination of both internal and external fixation, also called hybrid fixation. Patients with Charcot arthropathy require a highly individualized treatment approach, and the choice of treatment will depend on several factors:

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Internal fixation is often used in midfoot pathologies, commonly employing beams or plates.

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External fixation is recommended in the presence of poor-quality bone, compromised soft tissue, active infection, or osteomyelitis. In such cases, internal fixation is not recommended. External fixation has the additional benefit of allowing early weightbearing.

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Hybrid constructs can be particularly useful in the treatment of Charcot arthropathy of the ankle, where secure fixation is essential to maintain biomechanics and proprioception.

Recently new techniques have emerged, including the use of superconstructs, which maximize stability by extending the use of hardware beyond the zone of injury. This technique uses two or more devices, such as a medial column plate positioned over a beam, which are positioned in a way that optimizes mechanical integrity. By using superconstructs, some of the problems caused by poor-quality bone can be avoided by using non-affected bone
for fixation.

Surgical reconstruction of a Charcot foot is technically demanding, with added challenges posed by the presence
of diabetes, neuropathy, poor bone quality, and possibly infection. Despite these obstacles, it is possible to obtain successful clinical outcomes with thorough preoperative planning and the collaboration of a multidisciplinary team.

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charcot neuropathy, Inbound C2 Pillar Page

What Is the Optimal Postoperative
Treatment After Foot Reconstruction?

To improve the odds of a successful treatment, postoperative care should be a priority in patients with Charcot arthropathy. This is especially true in extensive reconstructive surgeries, for which rehabilitation and postoperative management require extensive resources and patient compliance.

Since Charcot patients have peripheral neuropathy and often also have diabetes, they have a higher risk of complications following surgery, including:

  • Pin site infection when external fixation is used
  • Deep infection
  • Hardware failure
  • Unstable non-union
  • Wound dehiscence
  • Metabolic perturbations, which can change normal glucose homeostasis.

For patients treated with internal fixation, there is a more prolonged period in which weight-bearing is not possible. It is essential to make sure that patients have an adequate support, so they adhere to the non-weightbearing limitation.

Although surgeons might be tempted to overly focus on the operative technical aspects or the best device(s) for each individual case, it is also important to pay close attention to the postoperative treatment, which is critical in ensuring successful surgical outcomes.

Learn more about the surgical management of Charcot
Arthropathy with our Surgical Case Reports

Choosing the right surgical approach and post-operative treatment for a Charcot foot is unquestionably
a challenge for the orthopedic specialist. To know more about how our experts have surgically treated
their patients, we have compiled a series of Charcot Foot Reconstruction Case Reports.

 

 

DOWNLOAD THE CASE REPORT

Timely diagnosis and appropriate treatment are essential to prevent joint instability and bone destruction and,
in extreme cases, limb amputation. If you want to learn more about how to prevent Charcot Foot and Ankle,
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