This document discusses the minimally invasive surgical management of the diabetic foot, specifically the Charcot foot. It provides statistics on the epidemiology of diabetes and its complications like foot ulcers and amputations. Diabetic foot complications represent a huge economic burden. The causes of foot ulcers and infections in diabetes are explored, including mechanical, vascular, immunological and more factors. Surgical management techniques for the diabetic foot are described, including soft tissue procedures and osteotomies to offload pressure and promote healing. The stages and natural history of Charcot arthropathy are outlined. Long term bracing and custom orthotics are recommended for Charcot foot management.

1. MINIMALLY INVASIVE
SURGICAL MANAGEMENT
OF DIABETIC FOOT
(The Charcot Foot)
PROF. SALAH EL-NOUR, F.R.C.S.
DEPARTMENT OF ORTHOPEDICS
SECURITY FORCES HOSPITAL PROGRAM
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2. Diabetes Mellitus
EPIDEMIOLOGY
 800,000 new cases / year (USA)
 10,000,000 people currently diagnosed
 5,000,000 Potential
 Leading cause of lower extremity amputations
(LEA) in both the U.S.A. & Europe
 50% of all non-traumatic LEA occur in people with
diabetes = 56,000 cases / year
 20% of all diabetic patients will develop a
significant ulcer = 1,500,000 cases
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3. Diabetes Mellitus
THE COST of CARE - $$$$$$$$
 2005 = $120,000,000,000 (billion!)
 Hospital related care = $44.1 Billion
 Ulcer Care = $4,595 / ulcer
 $28,000 more for next 2 years of care
 1999 – 800,000 prevalent ulcers @ $5,457 /
patient = $5 Billion
 Cost of LEA = $20,00 - $40,000
ECONOMICS:
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4. AETIOLOGY
 ENDOCRINE
 VASCULAR
small & large vessels (Arteriosclerosis, Microangiopathy, V. Nervousa
 NEURAL
Central & Peripheral Nervous System
Segmental Demylination
Degeneration of Sensory Fibers
Neurodystrophic changes
 BONE
Vascular & Neural element
Osteopathic lesion
Charcot Arthropathy
Infection
 MUSCLOSKELETAL
Ulceration, Charcot Arthropathy, Infection
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5. ULCER FORMATION
 Callosity, Dryness
 Breakage
 Cavity Contamination
 Blockage Spread
 Pressure Point
 Trophic Changes
 Perforating Planter Ulcer

6. MIS

7. DEEP
HOSPITALIZE
IV ANTIBIOTICS
SURGICAL CARE
(Local & Causes)
SUPERFICIAL
OUT- PATIENT
ANTIBIOTICS, REST,
CARE
IMPROVED 48 - 72
HRS.
NOT
IMPROVED
DIABETIC FOOT INFECTION
PROTECTION
CONTACT PLASTER,
AFO, DIABETIC SHOES
Aim: Plantigrade stable, shoeable foot
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8. FACTORS CAUSING AND PROMOTING
ULCERATION & INFECTIONS
INFECTION
GOOD
FOOTCARE
ULCERATION
PROMOTE
HEALING
 Mechanical
 Vascular
 Hematological
 Immunological
 Bacteriological
 Chemotaxis & Phagocytosis
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9. LOAD DISTRIBUTION & PRESSURE POINTS
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10. Patterns of Bone &Joint Destruction
(Ulcers & Charcot)
 Forefoot: MTP, IP
 Lisfranc:
 Chopart: TN-, CC- joint
 Ankle joint
 Calcaneus
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11. Surgical Management of Diabetic Foot
 Prophylactic surgery: (MIS)
 Soft tissue release (ETA, G.Recession)
 T. Achillis lengthening ( 80% for foot, 10% hind
foot ulcer healing)
 Osteotomis and fusion
 Limb salvage procedure (Vascular)
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13. Lengthening of Achilles
Tendon
 aim: pressure release
on midfoot
 technic: gastrocnemius
resection
 G. Release, ETA
 Load Mid & Fore foot
 Prerequisite for Ulcer Prevention & Healing
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14. Exostosectomy
 remove plantar bony
prominences
 produce a plantigrade
foot - to give the
shoemaker a chance
Internal decubitus
Exostectomy
M/L Incision, Plantigrade surface
Contact Cast, AFO, >> Chance Shoemaker
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15. Diabetic Charcot Arthropathy
THE SEQUENCE OF EVENTS
 Maintain Suspicion Index  Recognize at risk patient
 A Swollen Foot -------- MISDIAGNOSIS
 Deformity of the Foot
 Foot Ulceration(s)
 Infection / Osteomyelitis / Disintegration
 Partial / Complete Amputation
 Dilemma: Progressive, Non Infective Destructive
Process Associated with Neuropathy
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16. Natural History of Charcot Foot
 Stage of acute, destructive period
 Stage of coalescence: destruction, healing
 Stage of reconstruction: further repair and
remodelling of bone, restore stability
Charcot joints 1966 Springfield III
STAGES:
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17. MIS
2007

18. Diabetic Charcot Arthropathy
Case Presentation
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20. Stage 0 Charcot Foot
LONG TERM TREATMENT
 Custom Bracing
 Custom Orthotic Devices
 Custom Shoes
 Periodic Monitoring
 Serial Radiographs
 Prophylactic Bracing of
Contralateral Limb
 Further Patient & Family
Education
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21. The Charcot Joint
 Deformily 
 Instability 
 Pain 
 Prophylactic Surgery?
 Anthrodesis (Regidity)
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26. MIS

28. MIS

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30. Diabetic Charcot Arthropathy
RELOCATION ARTHRODESIS
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31. Thank You
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