developing objectives acomprehensive diagnostic ...my is performed to relieve pressure under the...

MARCH 2013 | PODIATRY MANAGEMENT | 187www.podiatrym.com

Surgical TreatmentIn part 1, we discussed the conserva-

tive treatment of Charcot foot. In thispart, we discuss the surgical manage-ment of this debilitating condition. Webegin with a review of the literature.

Pinzur reviewed 201 Charcot feetand found that three had primary ampu-tation and five had amputation afterfailed salvage surgery. Three quarters of

the patients had midfoot deformity ratherthan ankle. 59.2% of the midfoot casesreached desired endpoint withoutsurgery. Of the 40.8% that requiredsurgery, more required osteotomy thansimple ostectomy.76 Myerson, et al., re-viewed 116 Charcot midfoot cases andfound 7 required amputation. 19 of thepatients required arthrodesis while 7 re-quired ostectomy.77 Saltzman, et al.,

found that out of 127 Charcot feet treatedwith only non-operative care, 49% hadrecurrent ulceration, 23% required longterm bracing, and there was a 2.7% an-nual amputation rate.78 Many authorshave referenced Saltzmans’ paper fromthe standpoint of the fallacy of offeringonly non-surgical care to these patients.In those patients whom conservative has

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Objectives1) The reader should

be able to list the indi-cations for reconstruc-tion of a neuroarthro-pathic deformity.

2) The readershould be able to listthe surgical criteria forreconstruction of theneuroarthropathicdeformity.

3) The reader shouldbe able to discuss thepossible complications ofCharcot reconstruction.

4) The reader shouldbe able to discuss themain procedures usedto reconstruct Charcotneuroarthropathy.

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You may enroll: 1) on a per issue basis (at $22.00 per topic) or 2) per year, for the special rate of $169 (you save $51).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also takethis and other exams on the Internet at www.podiatrym.com/cme.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earnedcredits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake thetest at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 196. Other than those en-tities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be ac-ceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best ef-forts to ensure the widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of thisprogram is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts bynoted authors and researchers. If you have any questions or comments about this program, you can write or call us at:Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected].

Following this article, an answer sheet and full set of instructions are provided (pg. 196).—Editor

Developinga ComprehensiveDiagnostic

and Treatment Planfor Charcot

Neuroarthropathy—Pt.2

CLINICAL PODIATRY

Successful outcomes for this insidious conditionare dependent on a proper work-up.

BY BRENT BERNSTEIN, DPM, HUOI LAM, DPM AND JOHN MOTKO, RN

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188 | MARCH 2013 | PODIATRY MANAGEMENT

failed to achieve a sta-ble, non-ulcerated, pain-

free foot that can be placedin footwear—surgery shouldbe offered.

When deciding betweensurgery and some otherstop-gap measure (such aspermanent use of aCROW), the surgeon mustconsider many criteria be-fore proceeding (Table 10). There is noconclusive evidence as to the proper tim-ing or method of surgical intervention.114

However, most clinicians will agree thatthe indications for surgical interventioninclude but are not limited to pain, anonplantergrade foot, recurring ulcer sec-ondary to exostosis, misalignment andjoint instability.115 Generally, we prefer tosurgerize only after all soft tissue ulcershave healed, edema has resolved and theneuroarthropathy has become inactive tominimize post-operative infections, de-hiscence and hardware purchase prob-lems respectively.

Patients with soft tissue or bone in-fection are taken immediately to first-stage surgery for radical debridement ofall devitalized tissue, deep biopsies,placement of antibiotic-loaded cement

spacers followed by cul-ture-guided long-term intra-venous antibiotics prior toperforming correctivesurgery and placing hard-ware. Patients are not takento the operative theatre forosseous reconstruction untiltemperatures have equili-brated to the contralateralside, edema is resolved, and

ulcerations and infections have healed.While some clinicians have discussed thepossibility of arthrodesis in the activephase of Charcot, most agree that therisks of performing reconstructions in theactive phase of neuroarthropathy are toogreat and optimal fixation can be difficultto acheive.79-82

Researchers have shown that a 25%infection rate exists when patients under-go Charcot reconstructions while ulcera-tions are open.83 Typically, patients willbe brought to the operative theatre withthe total contact cast intact. All patientsreceive pre-operative doses of prophylac-tic antibiotics in accordance with goodmedical practice. Most procedures areperformed under general anesthesia dueto the length of procedures and the mid-lower leg level of pin placement and

Achilles tendoncorrections. Occa-sionally, in patientsthat cannot tolerategeneral anesthesia,a spinal block willbe performed withtetracaine.

The surgicalgoals are coverageof deep exposedstructures, correc-tion of ankle equi-nus, restoration ofcalcaneal inclina-tion and tibia tofloor angles, cor-rection of the rear-foot to leg relation-ship, correctionand stabilization ofd e g e n e r a t i v ejoint.84-85 We alsorequire that all pa-tients contemplat-ing surgery under-go smoking cessa-tion due to the

overwhelming literature noting bonehealing complications related to nicotine.

Another requirement is condition-ing, weight loss and gait training withthe required assistive devices prior tosurgery so that compliance with non-weight-bearing can occur. The patientcomes to his/her pre-surgical interviewnon-weightbearing on the selected as-sistive device to “prove” ability to benon-weightbearing to the surgeon. Pa-tients who take this seriously generallydrop the glycosylated hemoglobin lev-els to a range that we consider the“ticket” to surgery. When patients arerequired to develop “ownership” of the

condition prior to the surgery, we’venoted good compliance levels withpost-operative restrictions as comparedto the general consensus in the Charcotsurgeon community. Currently, allCharcot reconstruction patients are pre-scribed a low molecular weight heparinpre-operatively and complete trainingon self-administration.

Lastly, all patients are seen by ourinternists for clearance and optimiza-tion prior to scheduling so that thepatient already has a relationshipwith them prior to being admittedafter surgery. We take pride that ourpatients enter the surgical arena phys-ically and mentally prepared for thesurgical procedures and well-educatedon the complications that can occur.

Specific Reconstructive SurgicalProcedures

Equinus CorrectionDue to the fact that ankle equinus is

a determining factor to the severity ofCharcot deformity many of our non-sur-gical patients and all of our surgical re-


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TABLE 10

Criteria for CharcotReconstructionStable Soft Tissue Envelope

In-Active Neuroarthropathy

Medical Clearance and Optimization

Patient Willingness to Comply with and Tolerate Long TermOff-Loading/Casting/External Fixation

Adequate Vascular Perfusion and Presence of the Plantar Arch

Ability toNon-Weight-bear or Reside in SkilledNursingUnit x 3months

Fully Treated Infections of Soft Tissue and Bone

Cessation of Smoking

HbA1C 7

Weight Loss and Conditioning

Figure 12: Diagram of SimpleExostectomy

Figure 13: Diagram of Transpedal Osteotomy


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constructions will have correction of theAchilles tendon contracture. It is the firstand most powerful step in correction ofthese patients. We’ve noted that our pa-tients undergoing casting have fewer dif-ficulties in the casts when this contrac-ture is corrected and they cool down intothe in-active phase more quickly. Gener-ally, these patients undergo a percuta-neous triple hemi-section either in ourclinic at the time of casting or in our am-bulatory procedure unit in the hospital.86

In our reconstruction patients, theAchilles must be corrected to allow bony

repositioning of the osteotomies and toprevent attenuation of our correctionover time due to the strong pull of the tri-ceps. In these patients, we more oftenperform an open procedure with com-plete Z-tenotomy and suturing at the cor-rected physiologic length.

Occasionally, we encounter frail,non-surgical patients that simply requiretenotomy in order to be shoeable andbraceable and we accomplish thisthrough a 3 mm. incision over the centralaspect of the tendon with a #64 mini-blade followed by cast application with

the foot at 90 degrees to the leg. Wegenerally do not perform gastrocne-mius recession (open nor endoscop-ic) due to invariable finding that thecontracture is of the conjoined ten-dons rather than of the gastrocne-mius only. This is bolstered byGrant’s and others’ unique work ontendon glycosylation.87-90

PlaningPatients with a simple promi-

nent bony exostosis, usually underthe medial column, can forego afull reconstructive osteotomy withfusion. (Figure 12) In those pa-tients, in addition to the mandatoryAchilles release, a simple exostecto-my is performed to relieve pressureunder the prominent bone. Thesepatients do very well generally, andhave a low incidence of ulcer re-currence both in our program andin the literature.91-94 Patients withlateral column ulcers can havelocal exostectomies, but it has beenour experience that they have ahigher recurrence rate and havebetter outcomes when coupled

with transpositional flaps.Rosenblum, et al., had similar re-

sults when they performed a retrospec-tive review of lateral column ulcers andperformed flaps either as a primary pro-cedure or as a revisional procedure inabout half of a 32-patient cohort.95

In patients with a varus hindfoot orankle with lateral foot ulcers, local exos-tectomy will be rarely met with successand a triple arthrodesis is indicated.96 Inpatients with complete collapse into aconvex arch with massive forefoot ab-duction or with severe deformity, somuch bone would have to be removedthat destabilization of the foot can occur.Planing should not be contemplated inthese patients. The procedure of choicewould be a midfoot osteotomy.

One important caveat when treatingContinued on page 190

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Figure 14b Case 1: Infrared dermal temper-ature measurements of contralateral controlside unaffected by neuroarthropathy

Figure 14a Case 1: Infrared dermal temperaturemeasurements of acute neuroarthropathy

Figure 14c Case 1: MRI of foot confirming acute neu-roarthropathy

Figure 14d Case 1: Triple Hemisection of Achilles Ten-don Under Local Anesthesia

Figure 14eCase 1: Articulated Ankle FootOrthosis

Figure 14f Case 1: Healed and Braced

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those patients presenting with the“old burnt-out” Charcot foot is to

never assume that the initial perfusionthat was undoubtedly present during theacute process still exists. In the period oftime from onset of Charcot to the presen-tation in the office—arterial stenosis cancertainly occur. If the foot is pulseless, ifonly monophasic flow is audible with ahand-held Doppler, or if lack of retro-grade flow of both main arteries isnoted—a full noninvasive arterial exami-nation and vascular consultation shouldbe obtained. Treat these patients just asyou would the typical patient with a dia-betic foot ulcer even when planning themost simple exostectomy or Achilles ten-don lengthening.

Midfoot OsteotomyAccording to Lowery et al., the

most common location requiring surgi-

cal intervention for Charcot deformity isthe midfoot, accounting for 59% of thetime.114 Most midfoot deformities arecharacterized by a collapse of the medi-al and lateral longitudinal arches with arocker bottom deformity, abduction ofthe forefoot, and loss of calcaneal pitchdue to triceps pull. Many orthopedicand podiatric surgeons perform a bipla-nar transpedal osteotomy with anachilles tendon lengthening. (Figure 13)The primary differences surround fixa-tion techniques and post-operative re-strictions. Osteotomies are described asfixated with standard internal fixationwith small screws, plantar plating, stat-ic tensioned external framing, bent-wiretensioned external framing, and combi-nation of internal and external fixa-tion.97-102 Some surgeons initially applyan external frame over the osteotomyand at frame removal apply internal

screws to any unstable areas.113

Our procedure is basically a re-verse Cole osteotomy with biplanarwedges to correct both the sagittalplane collapse as well as the forefootabduction. We utilize K-wire “guide-rails” to mark the bone cuts and per-form the cuts with a large power saw.An initial stabilization of the medialand lateral columns is performed withlarge bore 7.3 mm cannulated screwsthat act as beams. We take care tomake sure that the shank-to-thread junc-tion is not close to the joint fusion site.

Our goal is completecorrection of the 1stmetatarsal to talus anglein both the coronal andsagittal plane and thebeams virtually guaran-tee this. Once this is ac-complished, we apply anexternal fixator foot ringwhich is secured to thecalcaneous. A forefootwire is than placed in abent configuration that istensioned, causing a dra-matic pull back againstthe calcaneal wire. Thebent wire technique cou-

pled with the screw “beams” causes adramatic synergy of compressionacross the osteotomy site that has beendemonstrated clinically as well in saw-bone and cadaver models.103

We do question patients during ourpre-surgical interview about any histo-ry of claustrophobia or “cast anxiety”as indicators of potential for intoler-ance of the external fixation (so called“Cage Rage”). If we feel that there is ahigh likelihood of intolerance we mayselect another form of fixation or con-sider post-op anti-anxiety medications.

We’ve abandonedsmall screws due to thelarge moment arms pre-sent in the midfoot, theroughly million plus loadcycles that can occur in anormal patient’s year, andthe frequency of hardwarefailure noted in the litera-ture. Our feeling is thatwith the triceps surgicallyweakened and with tri-plane external bracing, alarge diameter screwspanning a fibrousnonunion in a Charcot pa-


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Figure 15c Case 2: Surgical Exposure for Exostec-tomy

Figure 15b Case 2: Incisional Planning Prior toExostectomy

Figure 15a Case 2: Pre-Operative Lateral PlainRadiograph Showing Exostosis

Figure 15d Case 2: Bone Removal with Os-teotome

Figure 15e Case 2: LayeredClosure Over Drain

Figure 15f Case 2: Post-Opera-tive Lateral Plain RadiographAfter Exostectomy


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ty correction and func-tionality.

TibiocalcanealArthrodesis

Undoubtedly themost challenging neu-roarthropathy to correctis the Charcot ankle. Inmany cases, extremevalgus or varus angula-tion occur as the tibialmortise drives towardsthe ground and the footis pushed out of theway. In addition, thetalus will often be pul-verized and will virtual-ly dissolve away. Whilesome authors will at-tempt to salvage por-tions of the talus, it hasbeen the practice of ourprogram to generallyresect all of the non-vi-able bone and cartilagefragments of talus andperform a distal fibulec-tomy which allows usto easily reposition thefoot on the leg due tothe adequate slack thatresults.

We burr intohealthy bleeding boneon both the tibia andcalcaneous and performwedge resections as necessary to placethe foot in a plantigrade sagittal plane po-sition and in slight valgus in the frontalplane. At this point, we generally aug-ment the fusion with multiple drillingsand placement of recombinant humanbone morphogenic protein in a bovinecollagen sponge to increase the chances

tient will still likely maintain the align-ment of the foot. We generally secure ourfootring to either multiple tibial wires andrings or to a delta configuration with thefoot at 90 degrees to the leg.

When we are dealing with anacute, isolated dislocation such as themedial cuneiform, we occasionallyforego the external fixation constructand use a plate buttress over a medialcolumn beam.

In the end, our goal in the midtar-sus is not just stabilization, but a defini-tive re-building of the medial and later-

al arches with correction of the coronaland sagittal plane deformities. It is im-portant for podiatrists to understandthis concept even if Charcot reconstruc-tions are not part of their practice.

When referring a patient for such areconstruction, any podiatrist should beable to evaluate the post-operative filmson their patient. The astute clinician willlook past all of the fancy hardware thatmay be present on plain film and honein on the radiographic angles present.What should be expected is correctionof the first metatarsal to talus angle inboth planes both immediately post-sur-gically and after full-weight-bearing be-gins post-frame removal. Far too often,temporary framing results in attenuationof the original correction and recurrenceof deformity. Full osseous fusion on ra-diograph is less important than deformi-

of bony fusion.We occasionally

utilize implantable directcurrent bone stimulators.Any small deficits areback-filled with ceramicputty, although our aim ishealthy raw bone to bonerather than large amountsof fillers, allografts, or au-tografts. The foot is posi-tioned and temporarilypinned with a large diam-eter Steinman pin. Afterfluoroscopy guaranteesgood positioning, we thenapply fixation. We’ve typ-ically used a retrogradeintramedullary nail in thepast.104-107 Although wehaven’t experienced someof the complications suchas loosening, infection,and hardware breakagethat have been reportedin the literature, we dohave questions regardingthe true compression ob-tained.108-109

We also prefer tohave adjustable fixationthat can be re-com-pressed post-surgically.Due to this, we havebeen phasing into two


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Figure 17d Case 3: Healed Flap with Resolved Ulcera-tion, Scar and Deformity

Figure 17a Case 3: Plantar Midfoot Ulcerationand Scarring Associated with Rocker-bottomDeformity

Figure 17b Case 3: Surgical Resectionof Ulcer, Scar, and Bone with Inci-sional Planning for Transposition Flap

Figure 17c Case 3: Flap Raised andInset Into Defect of Midfoot CharcotDeformity

Figure 17e Case 3: Double Upright Braceand Shoe Combination Utilized WhenCompletely Healed

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external fixator options. We ei-ther use a large mono-lateral exter-

nal fixator laterally with Schanz bonescrews coated with hydroxyapetite intothe tibia proximally and through a T-clamp into the calcaneous distally witha retrograde Steinman pin from calca-neous to tibia to prevent shifting or an-gulation or a standard multi-ring exter-nal cage. We then apply compression tothe osteotomy. Both can be augmentedwith percutaneous screws. We’ve hadgood success with both techniques.

Other ProceduresLess frequently, our patients will re-

quire more exotic procedures such assupramalleolar os-teotomies of the tibia,open reduction and fix-ation of calcaneal in-sufficiency fractures(Type V Sanders) andSymes amputations innon-reconstructiblefeet.

Our ExperienceA retrospective

analysis of our primaryauthors’ patient popu-lation reveals thatwe’ve treated a total of140 patients with neu-roarthropathy since2005. 17% of these pa-tients suffered from bi-lateral disease. The fe-male to male ratio was54 to 86. The underly-ing neuropathy causingthe Charcot joints inour population wascaused by alcohol consumption in 4 pa-tients. Cord compression, syphylis,hemachromatosis and gouty neuropathyeach contributed 1 patient. The remain-ing 103 patients had varying types of dia-betes mellitus. 18 underwent a simplepercutaneous Achilles tendon lengthen-ing, while 43 underwent an operativeprocedure of some type (arthrodesis,bone resection, etc.). Therefore, 57% ofour patient population were managedwithout surgical intervention of any sort.The majority of our patients were re-ferred by other podiatrists, vascular sur-geons, plastic surgeons, pedorthists, andprimary care physicians.

Case Studies

Case 1This diabetic neuropath female in

her sixties presented with an warm,swollen, tender Right foot and was diag-nosed with active phase neuroarthropa-thy based on her history, clinical exami-nation, infrared temperatures, radio-graphs, and serologic bone markers. (Fig-ures 14a-c) A significant equinus defor-mity was noted but the foot was planti-grade and not ulcerated. She began acourse of oral bisphosphonate therapy aswell as total contact casting and also hada percutaneous triple hemisection of herAchilles tendon. (Figure 14d) The patient

progressed from the active to in-activephase without collapse and was transi-tioned to an articulated, molded footankle orthosis. (Figure 14e-f)

Case 2This middle-aged male with history

of peripheral neuropathy secondary tohemachromatosis presented with a Rightin-active Charcot midfoot deformity anda history of chronic and recurrent foot ul-cers despite shoe and insert modifica-tions. (Figure 15a) The patient under-went local exostectomy and when healedwas shod in custom inserts in depthshoes without recurrence. (Figures 15a-f)

Case 3This male diabetic neuropath in his

seventies presents with chronic and re-current Left plantar lateral midfoot ulcerunder a collapsed, in-active Charcot de-formity (Figure 17a). An equinus deformi-ty was present. The patient had suffered acontralateral below-knee amputation. Al-though we healed the wound through off-loading, the area was chronically scarredand unstable with an underlying exosto-sis. The patient underwent a local exos-tectomy with excision of the scarred area.A transposition flap was inset to cover thedeficit and a split thickness skin graft washarvested from the ipsilateral calf andused for donor site coverage. (Figure 17b-

d) The patient pro-gressed uneventfullyto healing and was fi-nally transitioned tofootgear with custominsoles and a doubleupright calf brace(Figure 17e).

Case 4This middle-aged

diabetic female pre-sented with an insen-sate, warm, swollen,erythematous Rightfoot. She had a historyof developing os-teomyelitis of her 2ndtoe on the same footand had underwentan elective toe ampu-tation which healeduneventfully (Figures18a-b).Within onemonth, however, shedeveloped inflamma-

tory signs and sought multiple opinionsuntil finally referred to the author. Shewas diagnosed with active Charcot neu-roarthropathy based on the history of re-cent trauma (surgery), neuropathy, asym-metric infrared cutaneous temperaturereadings, flail first ray, and positive radio-graphs for sudden arthrosis and disloca-tion of the first metatarso-cuneiform joint(Figures 18c-e).

The patient underwent immediateoff-loading with knee scooter, compres-sion wraps, ice therapy, and elevation.When edema had resolved, she proceed-ed with surgical fusion of the first


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TABLE 11

Surgical Complications ofCharcot SurgeryDehiscence Stress Fractures of Tibia

Deep infection Nonunion/Fibrous Anklyosis

Dissecting hematoma Recurrence of Deformity

Significant Blood Loss and Need for Re-Activation of Acute NeuroarthropathyTransfusion in Ipsilateral Extremity

Superficial infection/Pin Tract Infection New Onset Neuroarthropathyin Contralateral Extremity

Hardware Failure

Pain

Edema


CLINICAL PODIATRY

NEUROARTHROPATHY

metatarso-cuneiform joint with plate andbeaming with correction of the dorsi-flexed first ray (Figures 18f-g). She con-tinued non-weight-bearing with scooter;finally transitioning through total contactcasts to depth shoes and insoles.

Complications“Surgerizing” these patients is not to

be undertaken lightly even if the patientpresents with one or more surgical indi-cations. Rogers, et al., discussed the com-plication rate of Charcot reconstructionswith external fixators. He found that56% of the patients suffered wound de-hiscence, 25% suffered pin failure, and31% had pin tract infections. The riskfactors associated most strongly withpost-operative complications in his paperwere younger age, long tourniquet time,and pre-operative hyperglycemia. Thor-darson, et al., identified the additionalrisk factors for non-union, including psy-chiatric disorders, illicit drug use, alcohol,nicotine abuse, and open fractures alongwith diabetes as risk factors when dis-cussing ankle fusions. Complications andalternatives such as elective amputation,palliative wound and Charcot care (suchas the CROW boot) are discussed clearlywith our patients when obtaining surgi-cal consent. (Table 11)

ConclusionCharcot neuroarthropathy is a com-

plicated disease process to diagnosis,

classify, and treat successfully. Cliniciansmust review the literature and avoiddogma. A comprehensive diagnostic andtreatment program combing the bestideas and research across multiple spe-cialties, including our own unique addi-tions, has been presented. Through dili-gent care and referral patterns, the clini-cian can tilt the balance in favor of agood outcome when encountering thisdevastating complication. PM

References76 Pinzur M: Surgical versus accommoda-

tive treatment for Charcot arthropathy of themidfoot. Foot and Ankle International. 25(8)August; 545-549, 2004

77 Myerson MS, Henderson MR, Saxby T etal., Management of midfoot diabetic neu-roarthropathy. Foot and Ankle International.15(5) May; 233-241, 1994

78 Saltzman CL, Hagy ML, Zimmerman B, etal., How effective is intensive nonoperative initial


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Figure 18e Case 4: Plain Radiograph Showing FirstMetatarsal Elevatus

Figure 18f Case 4: Post-Reconstruction Lateral Plain FilmShowing Internal Beaming and Buttress Plate

Figure 18d Case 4: Plain Radio-graph of First Metatarsal Base AfterToe Amputation in Same Foot

Figure 18g Case 4: Post-ReconstructionDorso-Plantar Film Showing Internal Fix-ation and Stabilization of Medial Column

Figure 18a Case 4: Neuropathic Pa-tient with Osteomyelitis of SecondToe Stump

Figure 18b Case 4: First MetatarsalBase of Patient Prior to Second ToeAmputation

Figure 18c Case 4: Plain Radio-graph Post-Amputation of Sec-ond Toe

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treatment of patients with diabetes andCharcot arthropathy of the feet? Clinical Or-

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93 Brodsky JW, Rouse AM. Exostectomy forsymptomatic bone prominences in diabeticCharcot feet. Clin. Orthop. 296:21-26, 1993.

94 Myerson MS, Henderson MR, Saxby T, etal., Management of midfoot diabetic neu-roarthropathy. Foot Ankle Int. 15:233-241, 1994.

95 Rosenblum BI, Giurini JM, Miller LB, etal., Neuropathic ulceration plantar to the lateralcolumn in patients with Charcot foot deformity:a flexible approach to limb salvage. J. FootAnkle Surg. 36:360-363, 1997.

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102 Pinzur MS: Neutral ring fixation for high-risk non-plantigrade Charcot midfoot deformity.Foot and Ankle Int. 28(9): 961-966, 2007.

103 Grant WP, Rubin LG, Pupp GR: Mechan-ical testing of seven fixation methods for genera-tion of compression across a midtarsal osteoto-my: A comparison of internal and external fixa-tion devices. Journal of Foot and Ankle Surgery.46(5): 325-335, 2007.

104 Paola LD, Volpe A, Varotto D, et al., Useof a retrograde nail for ankle arthrodesis inCharcot neuroarthropathy: a limb salvage proce-dure. Foot and Ankle Int. 28(9): 967-970, 2007.

105 Goebel M, Gerdesmeyer L, Muckley T, etal., Retrograde intramedullary nailing intibiotalo-calcaneal arthrodesis: a short-term prospectivestudy. The Journal of Foot and Ankle Surgery.45(2):98-106, 2006.

106 Mendicino RW, Catanzariti AR, SaltrickKR, et al., Tibiotalocalcaneal arthrodesis withretrograde intramedullary nailing. Journal ofFoot and Ankle Surgery. 43(2): 82-86, 2004.

107 Caravaggi C, Cimmino M, Caruso S, etal., Intramedullary compressive nail fixation forthe treatment of severe Charcot deformity of theankle and rear foot. The Journal of Foot andAnkle Surgery. 45(1): 20-24, 2004.

108 Thordarson DB, Chang D. Stress frac-tures and tibial cortical hypertrophy after tibio-calcaneal arthrodesis with an intramedullarynail. Foot and Ankle Int. 20(8). 497-500, 1999.

109 Bibbo C, Lee S, Anderson RB, et al.,Limb salvage: the infected retrograde tibiotalo-calcaneal intramedullary nail. Foot and AnkleInt. 24(5): 420-425, 2003.

110 Rogers LC, Bevilacqua NJ, Frykberg RG, etal.: Predictors of postoperative complications ofIlizarov external ring fixators in the foot and ankle.J Foot Ankle Surg. Sep-Oct; 46(5):372-375, 2007.

111 Perlman MH, Thordarson DB. Ankle fu-sion in a high risk population: an assessment ofnon-union risk factors. Foot Ankle Int. 20:491-496, 1999.

112 Authors’ own data.113 Thomis Roukis, DPM personal commu-

nication.114 Lowery N, Woods J, Armstrong D, et al.

Surgical Management of Charcot Neu-roarthropathy of the Foot and Ankle: A systemicReview. Foot and Ankle International 2012;3(2): 113-121.

115 Wukich D, Sung W. Charcot arthropathyof the foot and ankle: modern concepts andmanagement review. Journals of Diabetes andIts Complications 2009. 23: 409-426.

Dr. Bernstein is boardcertified by the AmericanBoard of Podiatric Surgeryand is a Fellow of theAmerican College of Footand Ankle Surgeons. Hegraduated fromTempleUniversity School of Podi-atric Medicine and com-pleted both a residency

in foot surgery and a fellowship in limb salvagesurgery with Dr. Stanley Kalish in Atlanta, Georgia.He currently practices in the Lehigh Valley and isprogram director of the Charcot and Reconstruc-tive Foot Program at St. Luke’s University andHealth Network, Quakertown Campus. Dr. Bern-stein participates in mission trips to impoverishedregions to perform pe-diatric deformity surgeryon a yearly basis.

Dr. Lam graduat-ed fromTemple Univer-sity School of PodiatricMedicine and is current-ly a third year resident atSt. Luke’s University andHealth Network.

John Motko is a registered nurse whoworksat theWoundManagement Center St. Luke’sHealth Network, QuakertownCampus. He has aBS in Nursing fromMoravian College/ St. Luke’s

School of Nursing. He iscertified in wound carefrom both the AmericanAcademy ofWoundMan-agement and theWound,Ostomy and ContinenceNurses Society. He is alsoa Certified HyperbaricRegisteredNurse. He hasover seven years of clinical

experience in caring for patients with chronic non-healing wounds and Charcot neuroarthropathy.

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CME EXAMINATION

1) Criteria necessary to consideran elective Charcot foot recon-struction include:A) A healed soft tissue envelopeB) Lack of peripheral neuropathyC) patient age under 45 yearsoldD) active, inflammatory stageof neuroarthropathy

2) The preferred option in treat-ment of Charcot deformitieswith concomitant bone infectionincludes:A) primary amputation of theaffected footB) two-stage procedure withresolution of infection followedby reconstructionC) one-stage osteomyelitis re-section and reconstructionD) conservative treatment only

3) Surgical procedures that are in-dicated in a severe rocker-bottomdeformity are:A) Tibiocalcaneal arthrodesisB) Transpedal wedge osteotomyC) Achilles tendon lengtheningD) B & C

4) The appropriate surgical proce-dure for a Charcot foot with afixed varus hindfoot and historyof lateral column ulcerations is:A) ExostectomyB) Syme’s amputationC) Triple arthrodesisD) Tibiocalcaneal arthrodesis

5) Indications for surgery forCharcot foot:A) Uncontrolled painB) Unresponsive ulcerationC) Unshoeable deformityD) Any of the above

6) Optimization of reconstructiveoutcomes in neuroarthropathy in-cludes:A) Pre-operative weight lossand conditioning

B) Peri-operative smokingcessationC) Ability to tolerate off-load-ing and fixation apparatusD) All of the above

7) Virtually all Charcot recon-structions will include thefollowing procedures:A) Intramedullary nail fixa-tionB) Triceps surae lengtheningC) Invasive bone growthstimulatorsD) A & C

8) Charcot neuroarthropathy ofthe ankle with severe valgus orvarus deformity is best treatedsurgically with:A) Tibiocalcaneal or Tibio-talocalcaneal fusionB) Midfoot osteotomyC) Triple arthrodesisD) B & C

9) Stage II Charcot neu-roarthopathy of the midfootwith a severe rocker-bottomdeformity and equinus is besttreated surgically with:A) Tibiocalcaneal fusionB) Achilles tendon lengthen-ing and percutaneous pin-ning of the midfoot jointsC) Achilles tendon lengthen-ing and Midfoot osteotomyD) Achilles tendon lengthen-ing and tibiocalcaneal fusion

10) Patients undergoing neuro-arthropathy reconstructionswhile suffering from an open ul-ceration:A) Have a higher post-opera-tive infection rateB) Have a lower post-opera-tive infection rateC) Have more pain post-oper-ativelyD) Have less pain post-opera-tively

11) Complications associated withexternal fixators in Charcot recon-structions include:A) Pin tract infectionsB) Pin failure/fractureC) “Cage Rage”D) All of the above

12) Options that should be dis-cussed with each patient contem-plating a Charcot reconstructionare:A) Elective amputationB) Palliative careC) ReconstructionD) All of the above

13) A patient suffering from recur-rent ulcerations under a subluxedmedial cuneiform without arockerbottom deformity. The ul-cers recur despite shoegear andbracing modifications. The patientshould be offered:A) Midfoot osteotomyB) Local exostectomyC) Tibiocalcaneal fusionD) An isolated achilles tendonlengthening with boneremoval

14) Recent research has shown thatpatients with neuroarthropathytreated without surgery have anulcer recurrence rate of roughly:A) 0%B) 50%C) 100%D) No one has performed thisresearch

15) The following can be utilizedto enhance bone healing insurgical fusions of Charcotpatients:A) bone growth stimulatorsB) bone morphogenic proteinC) cartilage and subchondralplate debridementD) all of the above


SEE ANSWER SHEET ON PAGE 197.


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16) Complications that should be discussedwith patients prior to considering reconstructioninclude:A) Acute neuroarthropathyB) Worsening of lower extremity peripheralneuropathyC) Infection and DehiscenceD) A & C

17) Recent research has shown that optimal com-pression of an arthrodesis occurs with the use of:A) K-wiresB) ScrewsC) External fixator over screwsD) Jones compression dressing

18) A patient presenting with Stage I neu-roarthropathy of the midfoot, rocker-bottom defor-mity, obesity, nicotine use and an open ulcerationshould be:A) Enrolled in smoking cessation, diabetes ed-ucation, and exercise classesB) Treated with total contact casting until res-olution of ulceration and temperaturesC) Scheduled for surgeryD) A & B

19) A patient presenting with Stage 0 neu-roarthropathy of the midfoot without significantdeformity (non-smoker, physically fit and withoutulceration) should be:A) Enrolled in smoking cessation, diabetes ed-ucation, and exercise classesB) Treated with total contact casting untilequilibration of temperaturesC) Scheduled for surgeryD) A & B

20) A patient (non-smoker, physically fit andwithout ulceration) presenting with Stage 2 neu-roarthropathy of the ankle with severe valgus de-formity, and limited activities of daily living dueto inability to wear brace or shoe should be:A) Told that an amputation is the only optionB) Considered for surgical reconstruction ofthe neuropathic ankleC) Prescribed a wheelchairD) Considered for surgical planing of theprominent bones on the bottom of the foot

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Medical Education Lesson Evaluation

Strongly Stronglyagree Agree Neutral Disagree disagree[5] [4] [3] [2] [1]

1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on thislesson ____

5) This lesson presented quality information with adequatecurrent references ____

How long did it take you to complete this lesson?

______hour ______minutes

What topics would you like to see in future CME lessons ?

Please list :

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

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1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #3/13Developing a Comprehensive Diagnostic and

Treatment Plan for Charcot Neuroarthropathy—Pt. 2 (Bernstein, Lam, and Motko)

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developing objectives acomprehensive diagnostic ...my is performed to relieve pressure under the...

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