Charcot foot, also called Charcot neuropathy, is a condition caused by a combination of peripheral neuropathy and vascular disorders that results in progressive joint damage and eventually foot instability¹. If left untreated, the consequences for patients are devastating, with reduced quality of life, inability to weight-bear, and an increased risk of amputation².

The initial management of acute Charcot foot relies on offloading the affected foot to prevent further damage, either with a total contact cast, or alternatives such as the Charcot-restraint orthotic walker³. The aim is to preserve the soft tissue envelope by preventing or limiting the impact of any bony deformity that may occur⁴. Dr. Stephanie Oexeman, DPM, says: “I have a very low threshold for offloading to try and prevent as much damage and collapse of the foot.”

However, conservative Charcot foot treatment may not be enough, especially in more advanced stages, when patients present with a disabling deformity or severe instability⁵. The indications for Charcot foot surgery include^3,6:

Severe instability or arthropathy
Failure of conservative methods to obtain a plantigrade foot
Presence of long-standing ulceration or osteomyelitis
Expected ability of the patient to use commercially available footwear after surgery.

The decision to embark on surgical treatment for Charcot foot should also take into account the patient’s characteristics and comorbidities, since it is not a risk-free intervention³.

This article highlights the various techniques for reconstructive and non-reconstructive surgery to treat Charcot foot, as well as what to expect in terms of complications and revision rates.

Charcot Foot Reconstruction

Recently, there has been a heightened level of interest in surgical reconstruction due to a combination of advancements in surgical instrumentation and fixation devices, along with contemporary evidence regarding long term outcomes^4,7. The goal of Charcot foot reconstruction is to correct deformity to achieve a stable, plantigrade foot that allows for weight-bearing.

A range of techniques have been developed and described to obtain a plantigrade foot that can weight-bear, but it is difficult to identify a single technique and/or procedure that will be effective for all patients, given that patients with Charcot foot also have conditions such as diabetes, osteoarthritis, and/or vascular problems, which can complicate outcomes⁴.

The midfoot is the most frequently affected region by Charcot neuropathy, followed by the hindfoot and ankle⁸. Figure 1 illustrates a case of Charcot foot with excessive motion upon midfoot and hindfoot.

Surgical reconstruction is ideally performed during the quiescent stage of the disease process⁹. Since the goal is to achieve a biomechanically stable foot, surgical reconstruction often involves restoration of the normal alignment angles in the foot (Figure 2)⁹. However, it is important to not compromise the vascularity and soft tissue integrity of the foot in a quest to obtain perfect radiological angles⁹.

Surgical reconstruction of the deformed Charcot foot can be obtained with internal fixation, external fixation, or a combination of both, depending on patient characteristics and other factors, such as soft tissue integrity. For a detailed overview of the devices used in Charcot foot surgery, read our article on surgical approaches.

In an article detailing the cost-effectiveness of various treatment strategies for Charcot foot, Albright et al. showed that the most effective strategy for patients without foot ulcers or with uninfected ulcers was reconstruction, which resulted in an additional 1.63 or 1.04 quality-adjusted life-years gained compared with lifetime bracing¹⁰.

Complications of surgical reconstruction of Charcot foot include delayed healing, dehiscence, and major lower extremity amputation, especially in patients with vascular problems and diabetes¹¹. The presence of peripheral arterial disease increased the risk of delayed healing by more than 2-fold, and increased the risk of major lower extremity amputation by 4.41-fold, highlighting the need for a careful vascular evaluation prior to a planned surgical intervention¹¹.

Charcot Foot Non-reconstructive Surgery

Ideally, every collapsed or deformed Charcot foot would be surgically transformed into a stable and ambulatory limb segment, but unfortunately not all patients can undergo major reconstructive surgery⁷. Furthermore, the patient’s healing capacity is a major predictor of outcomes, so it is important to carefully select the patients that have the most potential to benefit from each surgery.

“The decision on the surgical technique depends on the underlying biomechanics and the progression of the deformity. Tendon lengthening and tenotomies can be powerful tools to achieve a braceable foot. However, in the presence of osseous deformities, reconstruction is the preferred option.” — Dr. Stephanie Oexeman, DPM, Oexeman Foot and Ankle, Chicago.

Apart from reconstruction, common surgical interventions for Charcot foot include ulcer debridement and exostectomy of bone prominences⁴. The typical rocker-bottom deformity associated with midfoot Charcot foot (Figure_3) can cause pressure and mechanical stress on the tissues that cover the exostosis, eventually leading to ulceration¹². Consequently, soft tissue surgical interventions are often a standard approach to manage pressure imbalances in a Charcot foot¹³.

Figure 3: Rocker-bottom foot

Non-infected, acute ulcers may be treated with local debridement, but recalcitrant, large chronic ulcers in high-pressure areas may require more aggressive surgical debridement in the operating room, as well as those with concomitant soft tissue or bone infection⁷.

Surgical ostectomy or exostectomy of areas with bony prominences are a non-reconstructive method to relieve pressure and allow for ulcer healing⁷. When deciding to perform this procedure, the most important factor to consider is the patient’s foot stability. Those patients with major instability may not benefit and may be harmed by further bone excision, resulting in further instability and collapse⁷.

Other non-reconstructive surgical options include⁷:

Muscle flaps may be used to provide soft tissue coverage, with the advantage of providing vascularity
Equinus correction, through Achilles tendon lengthening, gastrocnemius recession, or a complete tenotomy
Correction of residual varus deformities, through tibialis anterior and tibialis posterior tendon transfers.

Unfortunately, despite surgeons’ best efforts, there are instances when even surgical management fails, and amputation must be considered. It is indicated in cases of unstable arthrodesis, recurrent ulceration, refractory infections, and cases in which the patient is unlikely to ambulate on their own or benefit from other procedures^14-16. Amputation may be performed at various levels, but transtibial is usually preferred, if possible, since it facilitates prosthetic fitting^7,17.

Choosing the right surgical approach for a Charcot foot is unquestionably a challenge for the orthopedic specialist¹⁷. Become a subscriber to gain more insight and access a series of Charcot Foot Reconstruction Case Reports, available here .

References

1. Hester T, Kavarthapu V. Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy. Foot and Ankle Clinics. 2022/09/01/ 2022;27(3):583-594. doi:https://doi.org/10.1016/j.fcl.2022.03.002

2. Wukich DK, Sung W, Wipf SAM, Armstrong DG. The consequences of complacency: managing the effects of unrecognized Charcot feet. Diabetic Medicine. 2011;28(2):195-198. doi:https://doi.org/10.1111/j.1464-5491.2010.03141.x

3. Schmidt BM. Clinical insights into Charcot foot. Best Pract Res Clin Rheumatol. Jun 2020;34(3):101563. doi:10.1016/j.berh.2020.101563

4. Ha J, Hester T, Foley R, et al. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma. May-Jun 2020;11(3):357-368. doi:10.1016/j.jcot.2020.03.025

5. Galhoum AE, Trivedi V, Askar M, et al. Management of Ankle Charcot Neuroarthropathy: A Systematic Review. Journal of Clinical Medicine. 2021;10(24):5923.

6. Salvaterra P. The Surgical Management of Neuropathic (Charcot) Foot – A Practical Guideline. 2017;

7. Chen S, Miller JD, Steinberg JS. Management of the Charcot Foot and Ankle: Nonreconstructive Surgery. Clinics in Podiatric Medicine and Surgery. 2022/10/01/ 2022;39(4):559-570. doi:https://doi.org/10.1016/j.cpm.2022.05.003

8. Rosemberg DL, Sposeto RB, Godoy-Santos AL. Arthrodesis in the Deformed Charcot Foot. Foot and Ankle Clinics. 2022/12/01/ 2022;27(4):835-846. doi:https://doi.org/10.1016/j.fcl.2022.08.005

9. Kavarthapu V, Vris A. Charcot midfoot reconstruction—surgical technique based on deformity patterns. Annals of Joint. 2020;5

10. Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer’s Perspective? Clinical Orthopaedics and Related Research®. 2020;478(12)

11. Cates NK, Elmarsafi T, Akbari CM, et al. Complications of Charcot Reconstruction in Patients With Peripheral Arterial Disease. The Journal of Foot and Ankle Surgery. 2021/09/01/ 2021;60(5):941-945. doi:https://doi.org/10.1053/j.jfas.2019.08.039

12. Laurinaviciene R, Kirketerp-Moeller K, Holstein PE. Exostectomy for chronic midfoot plantar ulcer in Charcot deformity. Journal of Wound Care. 2008/02/01 2008;17(2):53-58. doi:10.12968/jowc.2008.17.2.28178

13. Botek G, Figas S, Narra S. Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management. Clinics in Podiatric Medicine and Surgery. 2019/10/01/ 2019;36(4):663-684. doi:https://doi.org/10.1016/j.cpm.2019.07.002

14. Schon LC, Bae S-Y, Mousavian A. Procedure 27 – Charcot Neuroarthropathy of the Midfoot. In: Pfeffer GB, Easley ME, Hintermann B, Sands AK, Younger A, eds. Operative Techniques: Foot and Ankle Surgery (Second Edition). Elsevier; 2018:216-228.

15. Güven MF, Karabiber A, Kaynak G, Öğüt T. Conservative and surgical treatment of the chronic Charcot foot and ankle. Diabetic Foot & Ankle. 2013/01/01 2013;4(1):21177. doi:10.3402/dfa.v4i0.21177

16. Pinzur MS. Surgical treatment of the Charcot foot. Diabetes/Metabolism Research and Reviews. 2016;32(S1):287-291. doi:https://doi.org/10.1002/dmrr.2750

17. Galli M, Scavone G, Vitiello R, Flex A, Caputo S, Pitocco D. Surgical treatment for chronic Charcot neuroarthropathy. The Foot. 2018/09/01/ 2018;36:59-66. doi:https://doi.org/10.1016/j.foot.2018.02.001

Surgical Management of the Charcot Ankle2024-01-17

Charcot neuroarthropathy of the ankle is an especially challenging condition that often leads to instability and destruction of the joint with significant morbidity requiring an amputation in many instances^1-3. According to Brodsky et al., the ankle is affected in 9% of patients with Charcot neuroarthropathy, whereas the hindfoot is involved in 30-35%³. The overall goal of Charcot ankle reconstruction is to achieve a painless, plantigrade and stable foot, and thus avoid ulceration with subsequent infection^1,2. However, this procedure is also associated with a high complication rate^1,2.

Postoperative Management in Charcot Foot Reconstruction2024-01-10

The successful treatment of Charcot foot does not end with a completed surgery; success also requires a diligent postoperative care regime. This devastating condition mainly affects patients with diabetes and peripheral neuropathy, resulting in bone destruction and joint deformation¹. During the initial, inflammatory stage, the recommended treatment consists of off-loading with total contact casts or custom orthotics to prevent further damage, although surgical management is indicated in cases of severe instability or soft tissue compromise². After the acute stage, the focus of treatment is on deformity correction and foot reconstruction to prevent further damage and improve the patients’ quality of life².

Foot and Ankle Charcot Reconstruction with External Fixation2023-12-20

Surgical reconstruction of foot and ankle Charcot with external fixation is especially useful in the presence of poor bone quality, ulceration, compromised soft tissue, active infection, or osteomyelitis – cases in which the use of internal fixation is limited or contraindicated¹.

Charcot Foot Reconstruction Using Internal Fixation2023-12-12

Appropriate timing for surgical intervention is a matter of controversy among specialists¹. While in the past Charcot foot surgical reconstruction was mainly reserved to salvage the limb, today surgeons also perform operative corrections to ensure patients can use commercially available footwear instead of cumbersome orthoses¹. Regardless, the main goal of Charcot foot surgery, independent of the fixation method, is to create a stable and plantigrade foot. This article will discuss different approaches for Charcot foot surgery with internal fixation, focusing on midfoot reconstruction.

Expert Tips on How to Medically Diagnose Charcot Arthropathy2023-11-30

The diagnosis of Charcot neuroarthropathy of the foot and ankle can be challenging due to a lack of information in the patient's history, clinical assessment, imaging, and laboratory findings¹. It is assumed that one in four cases of acute foot and ankle Charcot are undiagnosed or misdiagnosed¹. However, correct diagnosis and effective treatment are crucial to avoid ulceration, worsening deformity, infection, or amputation¹.

Charcot Arthropathy Symptoms and Initial Stage2023-11-21

Charcot arthropathy occurs in the presence of peripheral neuropathy and metabolic abnormalities. Today it is seen more commonly in patients with long-standing diabetes^1,2. Its pathogenesis, although still largely unknown, involves several pro-inflammatory pathways, which stimulate osteoclastic activity³.

Medical Resources for Charcot Foot & Ankle Specialists2023-11-14

There is an overwhelming wealth of scientific literature available on Charcot foot. In this article, we gather and summarize some of the most interesting sources, including Charcot neuroarthropathy of the foot and ankle reviews, diabetic foot reviews, and diabetic foot care articles.

The Experts’ Definition of Diabetic Charcot Foot2023-11-14

Charcot foot is a progressive, devastating pathology defined by bone and joint changes that occur as a result of loss of sensation. Also called Charcot joint or neuropathic arthropathy, this condition is almost always associated with the vascular and neurological changes caused by poorly controlled diabetes¹.

Surgical Approaches for Charcot Foot2023-11-14

Charcot neuroarthropathy is a rare, but devastating complication of diabetes¹. Progressive destruction of the bones and joints of the foot cause deformities and thus alter foot biomechanics¹. If not recognized nor treated properly, the disease can result in ulcer formation, infection, and progression of the disease with joint instability and bone destruction^2,3. In the worst case, limb amputation is required^4,5.

Tips for Timely Diagnosis of Charcot Foot and Ankle2022-01-17

It is known that around 9 per cent of patients with diabetic neuropathy and foot ulcers develop a Charcot foot and ankle. This pathology often goes unrecognized, particularly during the acute phase, until severe complications occur, such as an abnormal pressure distribution on the plantar fascia with bones weakened enough to fracture, followed by a marked foot and ankle deformation and, in the worst cases, by amputation. Thus, today, one of the most crucial questions is how to timely diagnose this condition.

Magnetic Resonance for Charcot Foot and Ankle Diagnosis2021-12-21

Charcot Foot and Ankle is a significant problem caused by peripheral neuropathy, with an estimated incidence of 0.3 to 7.5% in the diabetic population. This condition, which is also known as Charcot arthropathy, Charcot joint, or neuropathic arthropathy, affects the soft tissues, joints, and bones in the foot and ankle. If left untreated, it may lead to progressive foot deformity, ulceration, or osteomyelitis. In the most advanced stages, it may be necessary to resort to limb amputation.

Tips for the Prevention of Charcot Foot and Ankle2021-12-17

Charcot Foot and Ankle is a severe condition that, if left untreated, may lead to deformity, permanent disability, amputation or ultimately to the patient’s death. People with diabetic neuropathy are at high risk of developing Charcot Foot and Ankle, because of the decreased sensation and diminished ability to feel temperature, pain or trauma.

Computerized Tomography for Charcot Foot and Ankle Diagnosis2021-12-14

Charcot Foot and Ankle, also known as Charcot arthropathy or Charcot joint, is a condition caused by peripheral neuropathy, leading to the progressive degeneration and destruction of the soft tissue, joint, and bone. In modern society, the most common cause for this neuropathic neuropathy is diabetes mellitus, with long-term diabetic patients having an increased risk of developing the condition.

Radionuclide for Charcot Foot and Ankle Diagnosis2021-12-09

Early Charcot Foot Diagnosis is essential to a proper management, but this can be challenging. There are some factors that should increase clinical suspicion for acute Charcot arthropathy, namely if the patient presents with:

Radiography for Charcot Foot and Ankle Diagnosis2021-12-07

Charcot Foot and Ankle, also known as Charcot arthropathy, neuropathic arthropathy or Charcot joint, is a progressive condition that affects the bones, joints and soft tissue of the foot and ankle. It is caused by peripheral neuropathy. Today, diabetes is the most common cause for developing Charcot Foot and Ankle.

Charcot Foot and Ankle Diagnosis: The Multidisciplinary Approach2021-12-02

Patients with Charcot neuroarthropathy, a condition that affects the bones, joints, and soft tissues of the foot and ankle, greatly benefit from a timely diagnosis and appropriate treatment. However, Charcot Foot and Ankle diagnosis can be quite challenging, especially in an early stage, where acute symptoms can be similar to other conditions.

Charcot Foot and Ankle: Patient Questions and Doctor Answers2021-11-30

Linked to peripheral neuropathy, Charcot Foot and Ankle is one of the serious foot complications affecting people with diabetes. Foot injuries that go unnoticed due to the reduced pain sensation accumulate, and, over time, there is bone deformation, ulceration, and infection. In a worst-case scenario, amputation may be necessary.

Charcot Foot and Ankle Causes: Where the Pathology Starts2021-11-25

Charcot Foot and Ankle, also known as Charcot arthropathy, is a progressive, inflammatory condition that affects the bones, joints, and soft tissues in the feet of people with peripheral neuropathy. If left untreated, Charcot of the foot and ankle leads to severe deformity, ulceration, and – worst-case scenario – to limb amputation.

The Stages of Charcot Foot and Ankle Disease and The Importance of a Quick Diagnosis2021-11-23

When dealing with Charcot Foot Disease, a swift diagnosis is crucial to improve patient outcomes and avoid complications such as foot deformity, ulceration, and in a worst-case scenario, limb amputation. However, not all physicians are able to recognize the initial signs of a Charcot Foot and Ankle in their diabetic patients.

Emergency in Diabetic Foot and Ankle2021-11-16

Diabetic foot is one of the most important sources of morbidity in patients with diabetes, affecting 6.4% of patients worldwide. It is the most common cause of lower extremity amputation.

Charcot Foot and Ankle: Definition and Classification2021-11-12

Charcot Neuroarthropathy, also called Charcot Foot and Ankle, is a progressive and inflammatory condition that weakens the soft tissues, bones, and joints of the foot and ankle. This complex and challenging type of neuropathic arthropathy is commonly linked to diabetes. If left untreated, it can lead to devastating consequences, such as deformity, ulceration, and infection. In the worst-case scenario, it may result in limb amputation.

The Surgical Approach to the Charcot Foot and Ankle Treatment2021-05-24

Charcot Foot and Ankle is a complex, challenging and sometimes devastating inflammatory foot disease which causes loss of sensation, weakening of the bones and collapse of the weight bearing joints. Most often due to diabetes and underlying neuropathic arthropathy, it needs a multidisciplinary team approach in order to treat it properly and prevent amputation.

What Is Arthrodesis (Joint Fusion)?2021-05-06

Arthrodesis may be defined as the surgical immobilization of a joint by fusion of the bones. It is commonly referred to as joint fusion, also known as artificial ankylosis or syndesis. It can be performed in several parts of the body, and it is indicated in the presence of painful joints, often due to arthritis or osteoarthritis, with highly compromised mobility.

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