Surgery
Reconstructive surgery may be considered for a deformity that cannot be controlled effectively or accommodated by conservative means. In this case, continuing instability in the foot or ankle leads to excessive plantar pressure on the deformed foot and ulcerations, infections and, potentially, amputations.
A number of surgical procedures have been described for the Charcot foot. For deformities along the lateral column of the plantar foot, exostectomy of a bone prominence along the plantar surface of the foot has been successful.5
When dealing with medial column deformities or a more severe Charcot deformity, arthrodesis procedures that realign the foot are preferred to osteotomies because they have a lower failure rate. The arthrodesis achieves a more rigid and stable construct for the plantigrade foot when weight bearing.
A tendo-Achilles lengthening (TAL) is done frequently as an adjunctive procedure because an equinus deformity is usually present, adding to the increased plantar pressures and ground reactive forces on the forefoot and midfoot.
Complications
Complications occur frequently in this patient population secondary to the delayed diagnosis and the complicated disease process. A delay in diagnosis of greater than 3 months adversely affects the quality of life and functional outcome of diabetic patients.6 The most common complication is an infection that becomes superimposed on the Charcot foot secondary to plantar ulcerations. The infectious processes may worsen, leading to osteomyelitis and eventually to an amputation. When this occurs, these patients exhibit a loss of function, which along with the loss of a limb, creates increased energy expenditure during ambulation, thus further stressing the cardiovascular system, which is likely already compromised. Despite the critical need for exercise in this population, patients become more limited and their overall health can deteriorate more rapidly.
Recommendations
Treatment is intended to convert the Charcot foot from an active to a quiescent stage by offloading the affected joint through immobilization and non–weight bearing, which may be done with a TCC. Progression to protected weight bearing with custom footwear and ankle-foot orthoses accommodating the deformity is advisable after the active Charcot phase has ceased.
Surgical intervention remains controversial. Reconstruction of the deformed Charcot foot is recommended when the foot remains unstable, leading to recurrent ulcerations and increasing the potential for infections and amputations. Surgical reconstruction, such as arthrodesis with malalignment correction and TAL, is commonly required in Charcot disease that affects the ankle because of the greater degree of instability.
Conclusion
The surgical goal is to achieve a stable, plantigrade foot to assist ambulation and prevent recurrence of the acute degenerative phase and ulcerations along with the respective sequelae.
