Charcot Arthropathy Treatment & Management

Treatment of Charcot arthropathy has been primarily nonoperative. Treatment is carried out in two phases: an acute phase and a postacute phase. Management of the acute phase includes immobilization and reduction of stress (see Medical Therapy below). ^[15]

Surgery is warranted in fewer than 25% of cases and generally is used as a preventive measure. Surgery is performed when a deformity places the extremity at risk of ulceration and when the extremity cannot be safely protected in accommodative footwear. The goal of reconstruction is to create a stable, plantigrade foot that can be appropriately protected in accommodative footwear and that can support ambulation. ^[16]  Surgery is indicated for malaligned, unstable, or nonreducible fractures or dislocations, as well as for cases in which nonsurgical means fail.

The major contraindication for surgery is active inflammation. Studies have shown less favorable outcomes when surgery is performed on an acute joint.

Several authors, including Simon et al, ^[17] have suggested that early surgical treatment in the acute phase may be a feasible alternative to nonoperative management. However, the optimal timing of surgery remains to be determined. ^[18]

Immobilization usually is accomplished by casting. Total contact casting (TCC) has been shown to allow patients to ambulate while preventing the progression of deformity. Casts must be checked weekly to evaluate for proper fit, and they should be replaced every 1-2 weeks. Patients with concomitant ulceration must have their casts changed weekly for ulcer evaluation and debridement.

Wang et al studied 21 patients with plantar ulceration associated with diabetic Charcot midfoot neuroarthropathy who were treated either with TCC alone or with TCC plus extended medial column arthrodesis. ^[19]  Although healing times did not differ significantly between the two groups, patients in the TCC + arthrodesis group had fewer lesions after treatment, and they had no recurrences after 12 months (compared with a 33.3% recurrence rate in the group treated with TCC alone).

Serial plain radiographs should be taken approximately every month during the acute phase to evaluate progress. Casting usually is necessary for 3-6 months and is discontinued on the basis of clinical, radiographic, and dermal thermometric signs of quiescence. Other methods of immobilization include metal braces and ankle-foot orthoses (AFOs), but they may prolong healing times.

Reduction of stress is accomplished by decreasing the amount of weightbearing on the affected extremity. Total nonweightbearing (NWB) is ideal for treatment; however, patients are often not compliant with this treatment. Studies have shown that partial weightbearing (PWB) with assistive devices (eg, crutches, walkers) also is acceptable without compromising healing time. However, full weightbearing (FWB) in the acute phase tends to lengthen total time in the cast.

Healing time varies according to the location of the disease. Pattern 1, or forefoot pathology, heals in two thirds the time needed for pattern 3 or pattern 4. One study revealed that the mean time in a cast is 18.5 weeks, whereas another study showed that the acute phase lasts 12.5 weeks.

Management following the removal of the cast includes lifelong protection of the involved extremity. Patient education and professional foot care on a regular basis are integral aspects of lifelong foot protection. After cast removal, patients should wear a brace to protect the foot. Many types of braces may be used, including a patellar tendon-bearing brace, accommodative footwear with a modified AFO, a Charcot restraint orthotic walker (CROW), and a double metal upright AFO. ^[20]

Custom footwear includes extra-depth shoes with rigid soles and a plastic or metal shank. If ulcers are present, a rocker-bottom sole can be used. Also, Plastazote inserts can be used for insensate feet. This regimen may be eliminated after 6-24 months, depending on clinical, radiographic, and dermal thermographic findings. Continued use of custom footwear in the postacute phase for foot protection and support is essential.

The total healing process typically takes 1-2 years. Preventing further injury, noting temperature changes, checking feet every day, reporting trauma, and receiving professional foot care also are important tenets of treatment.

Although immobilization and NWB on the affected extremity remain the mainstays of therapy, other treatment options are being tested. ^[5] One option is the use of bisphosphonates, which are potent inhibitors of bone resorption that have minimal effect on bone formation. ^{[21, 22]}  This action stops the osteoclastic activity of bone breakdown, promotes healing, and decreases local inflammation. However, only a few case reports have examined this treatment as an alternative.

Another therapy of interest is low-intensity ultrasound. ^[23]  Pulsed low-intensity ultrasound has been shown to transmit micromechanical force and strains to the fracture site and to promote bone formation. Studies have demonstrated an acceleration in healing and an increase in strength at the callus site.

Finally, the use of electrical stimulation and of magnetic field therapy to stimulate bone formation has been discussed in a few case reports. These therapies have shown some benefit in accelerating healing times. However, no prospective studies indicate a positive effect.

Surgical procedures and techniques used to treat Charcot arthropathy vary, depending on the location of the disease and on the surgeon's preferences and experience with this condition. Such procedures have had excellent results, and it has been argued that they may be underused. ^[24] Patients treated with surgery have longer healing times than those treated medically. ^[15]

Surgical procedures that may be considered include the following:

• Exostosectomy of bony prominence
• Osteotomy
• Arthrodesis
• Screw and plate fixation
• Open reduction and internal fixation (ORIF)
• Reconstructive surgery
• Fusion with Achilles tendon lengthening
• Autologous bone grafting
• Amputation

The superconstruct reconstruction has yielded promising early results. Frokjaer reported a 95% rate of satisfactory results in a group of 20 patients with midfoot Charcot neuroarthropathy, while noting the potential for incisional wound problems and the risk of overloading the ankle and thereby giving rise to a new Charcot attack. ^[25] The technique is demanding, and there remains a need for further studies.

Surgical methods can be based on Schön's classification system. The following recommendations may be made:

• Augmented ORIF should be used for an ankle with displaced fractures
• Ankle arthrodesis is necessary in patients with tibiotalar destruction
• In cases in which the hindfoot has avascular necrosis of the talus, a talectomy with tibiocalcaneal fusion is necessary
• Arthrodesis may be necessary for patients with hindfoot involvement
• For a midfoot pattern, surgical correction of rocker-bottom deformity and osteotomies for bony prominences are used
• If there is an associated hindfoot/ankle equinus contracture, then a posterior release/Achilles tendon lengthening procedure is required
• For forefoot patterns, patients with bony prominences or recurrent ulcerations may need a resection arthroplasty or cheilectomy

Wirth et al reported on the use of the Ilizarov ring fixator for surgical treatment of Charcot arthropathy, ^[26] citing results from their own experience and from the literature. The concluded that the Ilizarov ring fixator is a viable method for preserving the affected foot in patients with Charcot neuro-osteopathy. They recommend that in assembling the apparatus, the principles of Ilizarov be followed to avoid failure and that a detailed preoperative analysis of corrective osseous and soft tissue interventions be undertaken.

Sohn et al performed a retrospective study to compare the risks of lower-extremity amputation in patients with Charcot arthropathy alone and those with diabetic foot ulcers. ^[27] They found that Charcot arthropathy by itself does not pose a serious amputation risk, but amputation risk is multiplied in the presence of ulcer complications. In patients younger than 65 years, amputation risk was seven times higher for patients with ulcer alone than for those with Charcot arthropathy alone, and 12 times higher for those with Charcot and ulcer.

Della Paola et al evaluated, as an alternative to amputation in patients with Charcot arthropathy, surgical treatment of osteomyelitis of the midfoot or the ankle and stabilization with external fixation. ^[28] Of the 45 patients studied, 39 healed when treated with emergency surgery to drain an acute infection with maintenance of fixation (average, 25.7 weeks); two were treated with intramedullary nails in follow-up surgery; and in four, infection could not be controlled and amputation was still necessary. ^[28]

Hegewald et al retrospectively assessed the clinical and radiographic outcomes of combined internal and external fixation for reconstruction in 22 patients with diagnosed diabetes mellitus and documented peripheral neuropathy. ^[29]  During a mean follow-up period of 58.60 ± 42.37 weeks (range, 16-164), limb salvage was achieved in 20 patients, and below-the-knee amputation was required in two. Wound dehiscence occurred in eight, pin tract infection in 10, and superficial wound infection in nine. On radiographic analysis of pre- versus postoperative alignment, statistically significant changes were noted in the lateral talar–first metatarsal angle and the lateral talar declination angle.

In a systematic review of surgical management of Charcot neuroarthropathy, Bajuri et al recommended hybrid fixation (ie, combined internal and external fixation) in the settings of ulceration and more complex deformity, on the grounds that this will improve the rate of limb salvage while causing less irritation of soft tissues. ^[30]

In a study that included 23 patients with severely infected ulcerated and stable Charcot neuropathy of the ankle, Galhoum found that aggressive open debridement of ulcers and joint surfaces, followed by external fixation with an Ilizarov device and early weightbearing, could be successfully used to salvage the ankle, rendering amputation unnecessary in 91.3% of cases. ^[31]

A study by Tiruveedhula et al (N = 33) assessed the use of tendo Achillis lengthening (TAL) followed by a weightbearing TCC to treat midfoot Charcot neuroarthropathy in the outpatient setting. ^[32] At 12 months' follow-up, the disease had either stopped progressing or regressed in 30 patients. Only three patients were not able to return to their preprocedure level of mobilization with their usual aids. No complications (eg, nonhealing wound, complete transection of a tendon, or deep vein thrombosis) were reported.

A large systematic review by Ha et al (N = 1089; 1116 feet) examined outcomes of different reconstruction methods used to treat Charcot foot. ^[33]  Internal fixation was performed in 65% of the feet, external fixation in 31%, and simultaneous internal and external fixation in 44%. The overall bone fusion rate was 86.1%. The postreconstruction amputation rate was only 5.5%, with 91% of patients returning to ambulation. The authors did not find any single technique to have any significant advantages over the others; however, they noted that the quality of the evidence was low. 

Minimally invasive approaches

A small study by Lamm et al found minimally invasive arthrodesis plus gradual Charcot foot correction with the Taylor spatial frame to be an effective treatment. This technique may aid in the avoidance of incomplete deformity correction, fixation failure, infections, shortening of the foot, and the use of long-term casts or braces. ^[34]

Neuropathic minimally invasive surgeries (NEMISIS) were described by Miller in a 2016 review. ^[35]  Among the potential advantages suggested for this approach are that the percutaneous incisions employed cause minimal damage to soft tissues and are made away from blood vessels (thereby lowering the risk of nonhealing wounds, tissue necrosis, and major amputation). Patients with a recurrent ulcer, a deformity that is at risk for ulceration, or progressive joint destruction on serial radiographs may be considered for NEMISIS.

Nonunion has been reported to occur in 5-10% of patients who undergo midfoot arthrodesis, and the rate appears to be higher in those with neuroarthropathy. ^[36]  A study by Siddiqui et al (N = 15) found that performing distal tibial distraction osteogenesis simultaneously with tibiotalocalcaneal or tibiocalcaneal fusion in patients with Charcot neuroarthropathy yielded a high arthrodesis rate of 93.3% (14 patients), with one patient having a hypertrophic nonunion at the regeneration site. ^[37]

A retrospective study of ankle and hindfoot arthrodesis in 44 patients (46 operated sites) with diabetic Charcot neuroarthropathy reported infections in 13% and symptomatic radiologic nonunion at one or more joints in 26%. ^[38]  Primary union was achieved in 65%, with radiologic fusion apparent at an average 6.8 months post surgery; asymptomatic radiologic partial nonunion at one or more joints was seen in 8.5%, but clinical union was noted. A low-energy spiral fracture of the tibia proximal to the locking plate used for fusion occurred in 8.3%. Overally, complete deformity correction with a plantigrade foot was achieved in 69.5% (32 cases).