Current Concepts Review: Charcot Arthropathy of the Foot and Ankle

Abstract

For information on the cost and availability of reprints, call 210-494-4994 X226 Assessment questionnaire. 56 The goal of this current concepts review is to summarize our current understanding of this process named after the famous French neurologist and to examine the clinical and scientific evidence available to guide the management of this destructive and potentially devastating disorder of the foot and ankle.

Should One Consider Primary Surgical Reconstruction in Charcot Arthropathy of the Feet?

“…Nonoperative measures such as total contact casting are regarded as treatment of choice for a majority of patients if the treatment is likely to provide a plantigrade foot without major bony destruction and deformities [6,7,31]. According to some series, however, 40% to 50% of these patients may have secondary surgery due to recurrent ulcers or residual deformity [3,5,12,23,29]. This two-step approach may be associated with prolonged immobilization and increased morbidity, diminished quality of life, and increased costs [3,21,26].…”

“…First, knowing which degree of instability and deformity will be at high risk of failure with nonsurgical treatment relies on judgment [21,23] and the risk factors are not well understood. Expert assessment of these key parameters represents the basis for most treatment protocols from centers with wide experience in Charcot feet [18,19,21,23,24,29]. On the other hand, we believe decision making for surgery in Charcot feet on the basis of any given algorithm requires assessment by someone with considerable experience with Charcot feet and it should not be left to the inexperienced [21].…”

“…Charcot neuroosteoarthropathy represents a devastating process that today is mostly observed in diabetic patients [2,5,7,12,22,23]. Quality of life is seriously impaired in patients with Charcot arthropathy more than in the average diabetic patient including a more profound limitation of physical activity than most severe medical illnesses [5,9].…”

“…At least 30% to 50% of patients with Charcot neuroosteoarthropathy are estimated to develop a recurrent ulceration [1][2][3][4]. Limbs with open ulceration at the initial presentation and limbs with recurrent ulceration have decreased limb survival rate compared to feet without ulcers, adding to an annual limb amputation rate of approximately 1% to 5% [21,23,29]. The goals of treatment should not be merely to save the limb [10,[19][20][21][22]: Pinzur proposed the goal include a long-term infection-and ulcer-free plantigrade and stable foot that allows the patient to walk with commercially available depth-inlay therapeutic footwear [21].…”

“…An underlying fixed deformity or osseous prominence is one of the main reasons for recurrence of ulceration [35]. As such, more than 40% of the patients with midfoot disease who had been managed primarily nonoperatively may require surgery in the further clinical course [21,23]. While formerly corrective arthrodesis of nonplantigrade neuroarthropathic feet has been regarded as a salvage procedure and an alternative to amputation [20], more recent reports relying on biomechanically sound stabilization techniques have demonstrated maintenance of walking independence using commercially available therapeutic footwear and an infection-free foot [26] despite a high complication rate varying from 10% to more than 30% [3,19].…”