In Charcot neuro-osteoarthropathy (CNO), deformity-induced ulcers significantly increase the risk of amputation. Reconstructive foot surgery (RFS) is essential to prevent this, but peripheral artery disease (PAD) and diabetes increase complication risks.
Methods
All patients from a single center treated with RFS for midfoot CNO between 2019 and 2023 were included. Treatment followed a multidisciplinary protocol aimed at optimizing 4 factors: hyperglycemia, infection, pressure, and arterial blood flow.
Results
Seventeen patients were included (mean follow-up 20 months). Sixteen patients (94%) achieved an ulcer-free, plantigrade foot. No amputations were performed. Fifteen patients (88%) were diabetic, 67% of whom had elevated HbA1c levels, and 80% of these normalized after treatment. Four patients had PAD (24%), of whom 2 required revascularization. Deep infections occurred in 4 (24%) cases, and 6 (35%) required additional surgery.
Conclusions
Ulcer-free and good functional outcomes can be achieved, and amputation prevented, in patients with midfoot CNO provided they are treated by a multidisciplinary team.
RogersLCFrykbergRGArmstrongDG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129. doi:10.2337/dc11-0844
2.
SchaperNCvan NettenJJApelqvistJ, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657. doi:10.1002/dmrr.3657
3.
PakarinenTKLaineHJMäenpääHMattilaPLahtelaJ.Long-term outcome and quality of life in patients with Charcot foot. Foot Ankle Surg. 2009;15(4):187-191. doi:10.1016/j.fas.2009.02.005
4.
GazisAPoundNMacfarlaneRTreeceKGameFJeffcoateW.Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot). Diabet Med. 2004;21(11):1243-1246. doi:10.1111/j.1464-5491.2004.01215.x
5.
ArmstrongDGSwerdlowMAArmstrongAAConteMSPadulaWVBusSA.Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13(1):16. doi:10.1186/s13047-020-00383-2
6.
NilsenFAMolundMHvaalKH.High incidence of recurrent ulceration and major amputations associated with Charcot foot. J Foot Ankle Surg. 2018;57(2):301-304. doi:10.1053/j.jfas.2017.10.008
7.
SaltzmanCLHagyMLZimmermanBEstinMCooperR.How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet?Clin Orthop Relat Res. 2005;(435):185-190. doi:10.1097/00003086-200506000-00026
8.
RaspovicKMWukichDK.Self-reported quality of life in patients with diabetes: a comparison of patients with and without Charcot neuroarthropathy. Foot Ankle Int. 2014;35(3):195-200. doi:10.1177/1071100713517097
9.
YammineKBoulosKAssiCHayekF.Amputation and mortality frequencies associated with diabetic Charcot foot arthropathy: a meta-analysis. Foot Ankle Surg. 2022;28(8):1170-1176. doi:10.1016/j.fas.2022.08.004
10.
O’LoughlinAKellegherEMcCuskerCCanavanR.Diabetic Charcot neuroarthropathy: prevalence, demographics and outcome in a regional referral centre. Ir J Med Sci. 2017;186(1):151-156. doi:10.1007/s11845-016-1508-5
11.
WukichDKSadoskasDVaudreuilNJFourmanM.Comparison of diabetic Charcot patients with and without foot wounds. Foot Ankle Int. 2017;38(2):140-148. doi:10.1177/1071100716673985
12.
WukichDKRaspovicKMHobizalKBRosarioB.Radiographic analysis of diabetic midfoot Charcot neuroarthropathy with and without midfoot ulceration. Foot Ankle Int. 2014;35(11):1108-1115. doi:10.1177/1071100714547218
13.
SohnMWStuckRMPinzurMLeeTABudiman-MakE.Lower-extremity amputation risk after Charcot arthropathy and diabetic foot ulcer. Diabetes Care. 2010;33(1):98-100. doi:10.2337/dc09-1497
14.
IDF Diabetes Atlas 10th edition. Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Published 2021 Accessed July 12, 2024. https://diabetesatlas.org/
15.
SvendsenOLRabeOCWinther-JensenMAllinKH.How common is the rare Charcot foot in patients with diabetes?Diabetes Care. 2021;44(4):e62-e63. doi:10.2337/dc20-2590
16.
FabrinJLarsenKHolsteinPE.Long-term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care. 2000;23(6):796-800. doi:10.2337/diacare.23.6.796
17.
WukichDKFrykbergRGKavarthapuV.Charcot neuroarthropathy in persons with diabetes: it’s time for a paradigm shift in our thinking. Diabetes Metab Res Rev. 2024;40(3):e3754. doi:10.1002/dmrr.3754
18.
PinzurM.Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int. 2004;25(8):545-549. doi:10.1177/107110070402500806
19.
SammarcoVJ.Superconstructs in the treatment of Charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin. 2009;14(3):393-407. doi:10.1016/j.fcl.2009.04.004
20.
FrøkjærJ.Surgical treatment of midfoot Charcot neuroarthropathy review of literature and our results after superconstruct reconstruction of midfoot Charcot neuroarthropathy. J Clin Orthop Trauma. 2021;17:59-64. doi:10.1016/j.jcot.2021.02.003
21.
FordSECohenBEDavisWHJonesCP.Clinical outcomes and complications of midfoot Charcot reconstruction with intramedullary beaming. Foot Ankle Int. 2019;40(1):18-23. doi:10.1177/1071100718799966
22.
RichterMMittlmeierTRammeltSAgrenPHHahnSEschlerA.Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction—Results from a multi-centre study. Foot Ankle Surg. 2015;21(4):269-276. doi:10.1016/j.fas.2015.02.003
23.
WukichDKCrimBEFrykbergRGRosarioBL.Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery. J Bone Joint Surg Am. 2014;96(10):832-839. doi:10.2106/JBJS.L.01302
24.
WukichDKLoweryNJMcMillenRLFrykbergRG.Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am. 2010;92(2):287-295. doi:10.2106/JBJS.I.00080
25.
MyersTGLoweryNJFrykbergRGWukichDK.Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int. 2012;33(1):20-28. doi:10.3113/FAI.2012.0020
26.
SooHooNFKrenekLEaganMJGurbaniBKoCYZingmondDS.Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am. 2009;91(5):1042-1049. doi:10.2106/JBJS.H.00653
27.
WukichDKJosephARyanMRamirezCIrrgangJJ.Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011;32(2):120-130. doi:10.3113/FAI.2011.0120
28.
CollierBDossettLAMayAKDiazJJ.Glucose control and the inflammatory response. Nutr Clin Pract. 2008;23(1):3-15. doi:10.1177/011542650802300103
29.
ArmstrongDGBoultonAJMBusSA.Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375. doi:10.1056/NEJMra1615439
30.
DubskýMJirkovskáABemR, et al. Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis in the Eurodiale subgroup. Int Wound J. 2013;10(5):555-561. doi:10.1111/j.1742-481X.2012.01022.x
31.
ConnorHMahdiOZ.Repetitive ulceration in neuropathic patients. Diabetes Metab Res Rev. 2004;20(suppl 1):S23-S28. doi:10.1002/dmrr.446
32.
CatesNKElmarsafiTAkbariCM, et al. Complications of Charcot reconstruction in patients with peripheral arterial disease. J Foot Ankle Surg. 2021;60(5):941-945. doi:10.1053/j.jfas.2019.08.039
33.
BrekelmansWvan LaarWTolenNJHoencampRBorger van der BurgBLS. Recurrent diabetic foot ulcers: results of a maximal multidisciplinary approach including reconstructive foot/ankle surgery. Int Wound J. 2023;20(6):1866-1873. doi:10.1111/iwj.14045
34.
BuggyAMooreZ.The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. J Wound Care. 2017;26(6):324-339. doi:10.12968/jowc.2017.26.6.324
35.
RosenbaumAJDiPretaJA.Classifications in brief: Eichenholtz classification of Charcot arthropathy. Clin Orthop Relat Res. 2015;473(3):1168-1171. doi:10.1007/s11999-014-4059-y
36.
TrepmanENihalAPinzurMS.Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int. 2005;26(1):46-63. doi:10.1177/107110070502600109
37.
BevanWPTomlinsonMP.Radiographic measures as a predictor of ulcer formation in diabetic Charcot midfoot. Foot Ankle Int. 2008;29(6):568-573. doi:10.3113/FAI.2008.0568
38.
DrongeASPerkalMFKancirSConcatoJAslanMRosenthalRA.Long-term glycemic control and postoperative infectious complications. Arch Surg. 2006;141(4):375-380. doi:10.1001/archsurg.141.4.375
39.
WukichDKRaspovicKMSuderNC.Prevalence of peripheral arterial disease in patients with diabetic Charcot neuroarthropathy. J Foot Ankle Surg. 2016;55(4):727-731. doi:10.1053/j.jfas.2016.01.051
40.
AssalMSternR.Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg Am. 2009;91(4):812-820. doi:10.2106/JBJS.G.01396
