What is Charcot foot?
Charcot Neuropathic Arthropathy (CNA) is a problem commonly seen in diabetics with neuropathy, but not exclusively seen in diabetics that can lead to collapse for the foot and ankle making walking difficult, can lead to ulceration, and infection. It is a problem not fully understood but there is evidence that it progresses along an inflammatory pathway. Unfortunately, it is not a reversible process, but the progression can be controlled if caught sooner. However, good blood glucose control and routine followups with a specialist can help limit and control how fast this progresses.
Charcot Neuropathic Arthropathy (CAN) differs from Charcot Marie Tooth (CMT). CMT is a genetic problem that leads to musculoskeletal weakness, high arched feet, hammertoes, and difficulty walking. However, unlike CNA it is not associated with collapse and does not routinely predispose the patient with foot collapse, ulceration, infection, or amputation.
With CNA, the bone most commonly begins to break down in the middle of the foot creating instability and swelling. If it worsens, it can place pressure on the skin and create ulcers that can lead to infection and amputation. In some cases, the breakdown can occur at the level of the ankle, creating instability. The Achilles tendon is routinely involved. The process, coupled with nonenzymatic glycation can make the Achilles tendon tight, pulling up the heel, and worsening the midfoot breakdown.
Unfortunately, most physicians who do not specialize in the treatment of Charcot will miss it. If you are a diabetic it is crucial to follow up with a dedicated foot and ankle specialist who may be familiar with this problem. Charcot neuroarthropathy can be easily misdiagnosed as an infection or a blood clot in the leg. if not properly treated, this can result in further breakdown.
The first line of management is compression therapy and immobilization with specialized casting techniques, and nonweightbearing (NWB) on the affected foot/leg. Staying off the foot/leg can be difficult in this patient population. Nevertheless, remaining NWB is a critical important component in preventing progression of the problem. NWB may be facilitated with ambulatory aides (crutches, rolling walkers, rollators, wheelchairs, motorized wheelchairs and scooters). This may take time to acquire and so it is imperative you see a specialist as soon as possible. The duration of time spent during this initial swelling phase may last weeks to months, depending on how compliant the patient is, how well they can remain off the foot, and how well they control their blood glucose.
Once this inflammatory phase is controlled, and if the bones have not broken down to a level of instability, the patient may be transitioned into Charcot Restraint Orthotic Walking (CROW) Boot potentially for life, with followup radiographs (xrays), to monitor progress. Like with glasses, the boots do not reverse the problem, they merely help the patient accommodate the problem so they continue to function. The level of function however is severely reduced compared to an individual without this issue. The boots can also be bulky and uncomfortable, particularly during warm weather months.
Any planned surgery in this patient population involves the careful evaluation of the patient’s overall health status and level of compliance can influence outcomes. A Hemoglobin A1c%>8% has been associated with increased level of complications. Blood glucose levels, if poorly controlled will need to be controlled to give the patient an opportunity for improved success. If the blood flow is poor, noninvasive vascular testing may be required to determine the vascular status. If the flow is poor, the blood flow will need to be improved and the patient will be sent to see a vascular specialist.
If the bones are prominent but not unstable, lengthening of the Achilles tendon and bone shaving procedures in the outpatient setting are simple mainstay operations that carry lower morbidity compared to complex reconstruction. Postsurgically, the patients are NWB for about a month in a splint. Once the skin is healed in about 1 month, patients may be transitioned into custom braces and shoes, supplemented with ambulatory aides.
If the bones are unstable, it may require more complicated surgery involving staged approaches and multiple potential operations involving internal fixation (screws, plates, rods place under the skin and not visible to the patient) and external fixation (metal cages with pins sticking out of the leg and visible to the patient). Each operation may take 3-6 hours depending on the complexity of what needs to take place. Fundamentally, it involves removing bony prominences that can lead to ulcerations, realignment, fusion/stiffening of unstable joints with large screws, plates, and long rods. The surgery may take place in the outpatient setting. If the operation needs to be performed in the inpatient setting, plans for potential discharge to a skilled nursing facility may depend on the extent of the operation, the postoperative requirements and the individual social circumstances. Every patient is different.
Following the final operation, the acute recovery may require NWB for 3-4 months. Sutures may be removed at 2-4 months following the operations. As previously mentioned, Charcot surgery may be associated with complications such as wound healing complication and infection and so patience by the patient, and close monitoring by the treating physician will be necessary to reduce the likelihood of complications. After the wounds heal, the patient may be transitioned into a CROW Boot for 6 months to one year. Thereafter, if there have been no recurrences, the patient may be transitioned into less bulky custom braces and custom molded diabetic shoes when applicable.
Nonetheless and despite the best efforts, even with reconstruction, failure can still occur and can be a devastating reality following the long and drawn out treatment interventions. And so, it is important that all parties be aware of this fully before the initiation of therapy. In lieu of this process, primary amputation is offered to the patient to emphasize that reconstructive intervention is hopeful but comes with little guarantees.
This is a specialized center that offers our patients excellence in care utilizing a multidisciplinary approach. We have partnered with our Temple University Health Systems (TUHS) colleagues to develop an array of services that range from Podiatry, Vascular, Limb Salvage, Endocrinology, Nutrition, and Psychiatry. We offer a fully functional clinic specializing in wound care, total contact casting, treatment of complicated soft tissue and bone infections, and finally surgical reconstruction for the recalcitrant and unstable lower extremity.
Temple Podiatrists and reconstructive surgeons Dr. Kwasi Kwaadu, Dr. Andrew Meyr, and Dr. Jennifer Van, have collaborated with Vascular Surgeon, Dr. Eric T. Choi, Director of Limb Salvage at TUHS, Infectious Disease physicians Dr. Peter Axelrod and Dr. Rafik Samuel, Endocrinologist Dr. Elias S. Siraj, and Dr. Roy Steinhouse of the Psychiatry department. Studies support that a multidisciplinary approach reduces diabetic complications and decreases the incidence of hospital re-admissions. This collaboration will be used to help decrease the morbidity and mortality associated with diabetes, as well as decreasing the incidence of misdiagnoses or delay in diagnosis through physician education.
Dr. Kwaadu is currently the director and lead surgeon of our Charcot center and has extensive experience on the management on this complicated musculoskeletal disorder of the foot and ankle.
Dr. Kwaadu is board certified and foot and reconstructive foot and ankle surgery. He lectures on the topic in the reconstructive course at the Temple University School of Podiatric Medicine.
Dr. Kwaadu is a graduate of Temple University College of Science and Technology, went on to complete his medical school training at Temple University School of Podiatric Medicine (TUSPM), completed his residency training at Aria Health (currently Jefferson Northeast), and completed a Foot and Ankle Trauma Fellowship under the guidance of Justin Fleming, DPM, FACFAS, at the time at Aria Health 3Bs, prior to joining the TUSPM faculty. He currently serves as the department chair and assistant residency director.
Please see the following publication for further information on the topic. https://pubmed.ncbi.nlm.nih.gov/32146981/
Please click this link to the American College of Foot and Ankle Surgeons (ACFAS) website for additional information on the topic: https://www.foothealthfacts.org/conditions/charcot-foot
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