CHARCOT FOOT SALVAGE…
THE GREATEST CHALLENGE?
Guy R. Pupp, D.P.M., FACFAS
Director of Foot & Ankle Clinic
Oakland Regional Hospital
Residency Training Committee
Providence Hospital
Southfield, Michigan

Diabetic Neuropathic Arthropathy
(Charcot Foot)
 Noninfective,
destructive bone and
joint fractures and
dislocations associated
with peripheral
neuropathy.

Medical-Legal Aspects
of Charcot
 Charcot Malpractice Cases Increasing!!!
 UNDERSTAND PATHOPHYSIOLOGY
Clinical Appearance…Diff. Dx…Classification… Dx Methods…
Tx. Options…Specific Pathology Considerations

Diabetic Neuroarthropathy
Pathophysiology
 Loss of pain and proprioception
 Glycosylation of supporting soft
tissue
 Unrecognized injury?
 Continued repetitive stress on
injured unstable structure
 Adequate blood supply?
 Still poorly understood

Diabetic Neuroarthropathy
 Incidence and Demographics
1. Between 1% and 2.5%
2. Incidence is increasing with a greater number
of diabetics living longer
3. Equal distribution in males and females
4. Equal distribution in type-I and type-II
diabetes
5. Average age of patient is 40 years
6. Average duration of diabetes is 10 years
7. 30% bilateral

Medical-Legal Aspects of
Charcot
TIMELY DIAGNOSIS & TREATMENT
Differential Diagnosis: Address multiple
signs/symptoms until Final Diagnosis is
confirmed…NWB, Abx, LMWH

11/17/97

1/17/98

4/16/98

3/29/2000

6/20/2000

B-K Amp?

Charcot Arthropathy Tx Challenges
-multiple medical co-morbidities
-infection
-non-ambulatory gross deformity, not
shoeable
-no quick cure

Diabetic Limb Salvage
 A TEAM APPROACH AT A TEACHING
INSTITUTION
---19 DM Pts scheduled or at risk for BKA
-4 mos to 9.2 yr followup…
18 pts successful salvage
1 pt AKA
Denamur, Pupp: JAPMA, 2002

Medical-Legal Aspects of Charcot
 TEAM APPROACH…REFER, REFER, REFER
Primary Physician/Internist
Podiatrist
Endocrinologist/Diabetes Educator
Vascular Surgeon/Endovascular Specialist
Cardiologist
Anesthesiologist
Limb Salvage Surgeon
Infectious Disease Specialist
Plastic Surgeon
Nephrologist
Psychiatrist-Psychologist
Home Health Care Team
Orthotist-Pedorthotist

MANAGEMENT OF THE CHARCOT
ARTHROPATHY
A Multidisciplinary Approach
-Medical Evaluation…including Cardiology
-Wound Care
-Vascular Evaluation
-Preop Workup…including education
-Surgical Correction
-Rehabilitation
-Orthotist
-Long Term Management*

CHARCOT LIMB SALVAGE
Contemporary success rates due to:
I. increased knowledge of Pathophysiolology
II. improved Endovascular techniques
III. refined Surgical approaches & fixation

Overall Team Goal:
“LIMB SALVAGE”

I. PATHOPHYSIOLOGY
Charcot Anomalies
 Osseous Structures
• Increased osteoporosis
• Reduced bone density
• Increased osteoclastic activity
 Soft Tissue Structures
• Abnormal collagen
 Grant et al. nonenzymatic glycosylation leads to
histological and morphological changes (J Foot Ankle
Surg 1997;36(4)272 -278)
 Myerson et al. hyperglycemic state has adverse effects
ligamentous structures increasing potential for
structural failure (Biomech 1999; 9:37 -46)

Charcot Anomalies
 Impaired healing secondary to Diabetes
 Gandhi et al. decreased levels of PDGF and TGF-ß (49th
Annual Meeting of Ortho Res Society 2004)
 Baumhaumer et al. Increased osteoclasts, Il-1, Il-6 cell
mediators involved in bone resorption (AOFAAS:2004)
 Gooch et al. decreased collagen formation and
chondrocytes maturation in induced diabetic animals
(Connect Tissue Res 2000;41(2):81-91)

II. ENDOVASCULAR TECHNIQUES
-constantly emerging technologies
-LACI trial: 93% 6 month limb salvage
-less invasive, quicker, <hospitalization,
<morbidity/mortality
-long term failure due to REOCCLUSION
BUT successful short-term establishment
of perfussion allowing healing of ulcers
and surgery
-3 year limb salvage rate: 77-94%
Laird, Zeller, Gray. J Endovasc Ther. 2006.

Balloon it
Subintimally Stent it
dissect it
PAD
Sand it!!!
Excise it
Laser it Freeze it Remove it

III. SURGICAL TECHNIQUES
Improved Charcot results due to
contemporary insight into the
pathophysiology and into the
”NEW” surgical techniques including
fixation methods

Realignment Arthrodesis for
Charcot Deformity
Midfoot Stabilization
Is ARTHRODESIS Primary Approach???
- Exostectomy is preferred for recurrent ulcers or
ulcers that fail nonoperative care
- Arthrodesis indicated for failed exostectomy or
gross instability
FAILURE=Inability to walk with Shoe-Brace

Realignment Arthrodesis for
Charcot Deformity
Timing of Surgical Intervention
 Surgery is traditionally recommended in the
quiescent stages (Stage 2 or 3)…GRP: Stage 1???
 Certain fractures in neuropathic patients may be
surgically reduced and fixed if treatment is
performed early
 Remains controversial
 Timing based on multiple factors

Realignment Arthrodesis for
Charcot Deformity
Contraindications
1. Acute inflammatory phase (Stage 1) ? ? ?
2. Uncontrolled diabetes or malnutrition
3. Poor arterial perfusion
4. Medically unfit (Cardiology consult…)
5. Active infection of soft tissue or bone
6. ***Inability to comply with post-op regiment

CONTROVERSY?
Internal vs External Fixation
Internal Fixation External Fixation
- AO ASIF - Difficult learning
- Foundation for foot curve
and ankle surgical - Provides BETTER
correction
compression than
- Difficult to use for internal fixation.
poor bone stock.
- Unpredictable - Reduced issues with
results with non- non-compliant patient
compliant patient groups by allowing
groups. early weight bearing.
- Predictable results

WHY?
External Fixation Advantages
I. Physical Handicaps
- Motor/sensory neuropathy
- Neuro-muscular dysfunction
- Obesity
- Geriatrics
- Upper extremity pathology
- Bilateral surgery

External Fixation Advantages
II. Poor Bone Stock
- Charcot
- Steroid usage
- Cigarette smoking
- Non-union
- AVN
- Tumor/cyst
- Osteopenia …CRPS,
Metabolic, Gastric Bypass

External Fixation Advantages
III. Early Guarded Weight
Bearing
-virtually eliminates
complications associated
with NWB non-
compliance
-stimulates circulation…
arterial & venous
benefits
<DVT
>blood flow…healing

External Fixation Advantages
IV. Infections/ Open
Wounds
- span infected part
- frame off-weights
plantar ulcer

Compression Study
 Mechanical testing of fixation methods for generation of
compression across a mid-tarsal osteotomy with a
comparison of internal and external fixation devices
 Authors Involved in the Study
- William P. Grant, D.P.M.
- Guy R. Pupp, D.P.M.
- Lawrence Rubin, D.P.M.
- George Vito, D.P.M.
- Dwayne Jacobus, D.P.M.
JFAS: Sept. 2007

Compression Study
 Study performed
using a pressure
plate to measure
compression across
midfoot osteotomy
in bone models and
cadaver specimens
comparing internal
and external
fixation.

Pressure-Sensitive Film Placed
Between Osteotomy

Two 4.0 Screw Placement

Standard AO Technique

Compression Using External Fixation

Cadavader Participants

Cadaver Study
 Same template used
for creating
osteotomy.
 Pressure film placed
into osteotomy for
testing with two 4.0
screws and external
fixation system

Cadaver: Two 4.0 Screws

Cadaver: Ex Fix
With tension and
compression

Combination of Internal and
External Fixation
1. Synergistically stabilize the surgical site:
- tensioned, arched wire frames increase
compression and decrease shear across
the surgical site.
- internal fixation directs the force vectors
across the osteotomy site.
2. GRP: Chance of successful result if
device is removed prematurely

Ring Fixator Applications In
Foot & Ankle Surgery
Predictable Results

Midfoot Reconstruction With
Plantar Plate

Midfoot Reconstruction With
Plantar Plate

PLANTAR PLATE
 BEWARE of Poor Bone Stock for
Fixation
-Glycosylation of Hard & Soft
Tissues
? PREDICTABLE RESULTS ?

Case 1 : Charcot Limb
Salvage
54 y.o. female with Right Ankle Charcot &
Ulceration… in wheelchair for 11 months
-Scheduled for B-K Amp
PMH: Type 2 DM x12 yrs, HTN, ESRD,
Exogenous Obesity
MEDS: Novolog Insulin, Accupril, Norvasc,
Dyazide
PSH: tonsils, gallbladder
MRSA…I.D.: Vanco

Clinical Presentation

VASCULAR MEDICINE
REFERRAL REFERRAL
ABI 0.67 Right Blood Glucose

Lower Extremity Reduction: 324---
Atherectomy: 141
Right Posterior
Tibial Artery
-Silverhawk

Insert pics/scanned
xrays and dates

Radiographs

1st Surgery
Talectomy
Ulcer excision/secondary healing
Vanco impregnated PMMA beads
BK NWB cast
Wound Vac

Insert pics and
dates

2nd Surgery
Remove PMMA beads
Tib-calc fusion
Tib-navicular fusion
External Ring Fixator
Bone Stimulator
P.O. Wound Care…DERMAGRAFT

Obtain a Shoeable Foot

Case 2: Triple Arthrodesis/ Medial
Column Beam (Navicularectomy)
 42-year -old male referred to clinic with cc of DM
neuropathic fracture with deformity right foot…
previous ORIF of Navicular
 PMH: IDDM, HTN, Kidney transplant
 Meds: prednisone, cellcept , lipitor, protonix,
ASA, cozaar, novolog insulin pump, prograf.
 PSH: ORIF of Fx/dislocation right navicular with
progressive deformity midfoot/rearfoot.
Right wrist ORIF 10 years ago.

Case 2

EZ Frame
6 ½ Weeks Post Op

Case 2: Post Frame Removal@ 6.5 wks
7 weeks Post Op

Case 3: Lisfranc/Midtarsal Arthrodesis,
TAL, Med./Lat. Column Beam,
Arthroeresis, Platelet Rich Plasma,
External Fixator
48 year old Male with Diabetes Mellitus
and Peripheral Neuropathy & severe
Midfoot Charcot
-Initial Diagnosis: Cellulitis

Pre-op: Charcot Fracture-Dislocation of
the Midtarsal and Lisfranc’s joints

AP view

Application of External Fixator (EZ Frame)

12 weeks post-op status: post frame removal.
Note ensuing fusion and bone consolidation

12 weeks post-op

Case 4: Midfoot Biplane Osteotomy, Medial
Beam, TAL, Platelet Growth Factor, External Fixator
Severe Rigid Frontal Deformity

Radiographic Evaluation
Midfoot collapse
Ulceration Site

Surgical Correction
Derotating frontal
plane deformity
1.5cm Correction
Reduction of Deformity

Surgical Correction
7.0mm x 70mm Screw
Drilling for Cannulated Screw for
Medial Column Beam through
Trephine hole in 1st Met Head

Surgical Correction
Replacing Trephined Bone

Application of Three Ring External
Fixator

Post-Operative X-Rays

Post-Operative X-Rays

Case 5
 45 year old Type 2 Diabetic with Midfoot
Charcot Fracture-Dislocation
SURGICAL PROCEDURES:
-TAL, triple arthrodesis, external fixator
(Ace DePuy), Platelet Growth Factor

Intra-op radiograph demonstrates lack of viable
bone medially secondary to severe Charcot
fracture-dislocation

Lateral view intra-op demonstrates defect
engendered by severe Charcot midfoot
fracture-dislocation after debridement
with K-wire scaffold

Intra-operative radiograph subsequent to
large diameter screws bridging defect and
platelet growth factor bone graft amalgam
filling void

Note ensuing fusion and production of bone
from bone graft amalgam

12 weeks Post Op…Note ensuing solid fusion
from bone graft amalgam

12 weeks Post Op

Case 6
 58 year old Diabetic Male
Dx: Lisfranc Charcot
SURGICAL PROCEDURES:
-TAL, Lisfranc’s Arthrodesis, Platelet
Growth Factor, Ring Fixator(EZ Frame)

Lisfranc’ s C-Arm Guided Osteotomy

Lisfranc’ s Osteotomy
Debriding “Charcot Bone”

Platelet Rich Plasma bone graft amalgam
inserted across Lisfranc’s joint for fusion in
Charcot subluxation and collapse

Medial Column Beaming

Lateral Column Stabilization

Intra op Radiograph
Growth factor amalgam filling fusion site

Application of Hybrid Ilizarov type Frame (EZ-Frame)
for Compression of the Fusion Site.

Post op Radiograph evaluation

Case 7: 36 y.o. Female with Severe
Charcot Midfoot recommended for
Midfoot or B-K Amputation
 Gross Edema
unresponsive to
treatment

Pre Op Severe Charcot Fractures
36 y.o. Type II DM

Fracture-Dislocation Navicular, Cuboid,
& Cuneiforms

Charcot Bone Debrided

K-wire Scaffold gives Anatomical Alignment
Leg
Toes
heel

Bone Graft with PGF

Navicular, Cuneiform & Cuboid Grafting

Bone grafting and stabilization with
internal beaming

External Fixator

5 MONTHS POST OP

CHARCOT RECONSTRUCTION
 Team Approach…Endo, Cardio, Vascular
 Carefully Chose Patient…educate
 Fixation Difficult…Understand Pathophysiology
 Utilize Adjunctive Aids…AGF, bone stim
 Need for Studies/Publications

T
H
A Y
N O
K U

Summary
 Utilization of autologous growth factors
increase fusion rates
 Patient population may determine which
of the preparations is indicated
 Further studies will include evaluation of
soft tissue

PRP bone graft amalgam for insertion
into defect site (Symphony system)