Surgey in active Charcot

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I am looking for other opinions!!

I referred a 77 year old male with suspected Charcot to an Orthopaedic surgeon in 2/2006. The initial xrays were not conclusive, but suspicious. The Pt was but into a moon boot (NWB). One month later xrays revealed definate fracture of the 2nd proximal phalange. The medial cuneiform was not reported on but seemed irregular to me.

3 months later the Pt was refered for me to provide a "valgus filler". The patient has been instructed to walk without the moon boot as the fracture of the 2nd phalange had healed well. The problematic foot is red, swollen and warm (+++warmer than contralateral). There is now deformity in the medial cuneiform-navicular region. I have queried this with the surgeon, he is adament that the Pt must walk without the moon boot (no gradual loading). He claims that if the midfoot collapses he will just fuse it, in the active stage.

I have put the Pt back into the moon boot, sorry!!!!!

My available literature restricts the foot until the temperature difference between each foot is similar (a nice test for the patient). I have not found any literature to support surgery on an active Charcot foot. Can the podiatric surgeons provide me with any advice/back up??!!

Much appreciated.
Joanne Crawford

 

active charcot

From what I have read and seen most surgeon prefer to wait until at least the development stage of charcot is over before attempting surgery. However, some of the newer literature speaks of using ex-fix to restore alignment and improve functional outcomes of the foot while it is in the development stage. But if it is active charcot, I believe most surgeons will say the standard of care dictates cast immobilization.

 

Active charcots (ie temp difference between feet) = total contact cast (anything less is below the 'standard of care').

 

Ms. Crawford:

I believe that you have been going in the right direction. In general, the prevailing wisdom is to cast (or offload in some effective manner) the affected foot until skin temperatures equilibrate. When the foot cools, then one evaluates the feasibility of long-term footwear/bracing. If this is possible, which it is in at least 75% of cases, then one might move in this direction, with 1-3 month follow ups to ensure no change in foot shape or shoe irritation for the remainder of the patient's life. If this is not effective, then one may entertain surgery. There are two types of surgery:

1. If there is a stable, but readily definable deformity (bump), then an exostectomy with possible tendon balancing is in order (2/3s of surgeries)

2. If there is an unstable or massive deformity, then one may entertain more involved procedure with internal/external stabilization.

There are more and more surgeons who are doing surgery on "hot" Charcot feet (including us, from time to time). However, I am not at all convinced that this is the best option in most cases. There are very few data to guide us, however, either way. In the absence of these data, then I'd suggest that common sense (and communication with all members of the team) should prevail.

Cheers,

DGA

David G. Armstrong, DPM, PhD
Professor of Surgery
Chair of Research and Assistant Dean
Dr. William M. Scholl College of Podiatric Medicine at
Rosalind Franklin University of Medicine and Science
3333 Green Bay Road
North Chicago, IL 60064
520-360-0044
847-557-1457 (FAX)
www.rosalindfranklin.edu/scpm/CLEAR
*
Director,
Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science

 

Dave,

Good to see you adding your considerable expertise to Podiatry Arena. Hope to see you at the APMA conference in Las Vegas and it looks as if I will definitely be seeing you at the PFOLA conference in Chicago.

Here's a question for you that may stimulate some more good dialogue in this regard for this forum:

When you clinically suspect a very early Charcot arthopathy from the patient's clinical presentation, what diagnostic tests, and in what order, would you perform these tests to best determine the proper diagnosis?

By the way, congratulations on all your fine work over the past few years that has certainly thrust the podiatric profession toward the forefront of diabetic foot research both nationally and internationally. And the rumor on the streets is that it has all been done with the help of caffeinated sodas???

 

First,in regard to Dr.Kirby's question,an X ray would show multiple fractures and the "bag of bones" appearance of the foot.Maybe an X ray plus clinical findings is a good start.

 

You can run what ever you like. The radiologist will not give you a clear answer nor will the nuclear guys. I like runing MR, bone scans , I have always like an esr or c-reactive protein. Could always check alk-phos. but nothing is going to say charcot alone. If the foot is read and hot i can drive a nail in the foot with out the pt senseing pain and the pulses are bounding along with any other test i would go with a charcot change until proven otherwise Oh forgot a wbc wnl.

 

AsHenry says,you really can run any test but in my experience,this diagnosis is made clinically with the hot,insensitive foot that one sees.

 

TCC for 3 mo.NWB and 2-4 mo. PWB and gradual trial walking on custom made shoe if develop warm & swallen you check x-ray for fracture then put in TCC again for another period or fusion surgery.If good improved pt. you have to care after him for new callus formation may be need bumpectomy.
Dr.TAWEESAK SRIKUMMOON , BBK THAILAND