A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle

Abstract

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

The diabetic foot in 2015: an overview

“…Advances in surgical reconstructive procedures after the resolution of the acute phase has made them popular in recent decades . Moreover, surgical intervention during the acute phase is under investigation, and, despite the encouraging results, the evidence is weak in support of this new approach . Several studies have assessed the use of bisphosphonates, but with largely equivocal results so far .…”

The Biology of Bone and Ligament Healing

“…Recent studies demonstrate that plain radiographs are insufficient at diagnosing Charcot foot injuries. 9,82,83 Many studies have shown that advanced imaging such as magnetic resonance images (MRIs) are better at properly diagnosing CN. 9,[83][84][85][86][87][88][89][90] CN 's cause is thought to be multi-factorial resulting from several components such as diabetes, sensory-motor neuropathy, or metabolic abnormalities of the bone.…”

“…9,82,83,89,98,100,101 The duration of immobilization is dependent upon the extremity and radiographic evidence of ossification at the site but on average it can range between 8-52 weeks. 77,82,84,87,89,95,98 Conservative treatment however has its challenges. Prolonged casting and immobilization can lead to complications such as ulceration and patient compliance during prolonged immobilization periods is not easy to guarantee.…”

“…82 If the process has reached the stage III, arthrodesis is typically more difficult to achieve because an ostectomy needs to be conducted and may result in ulcerations. 82,97,102,109 Surgical intervention for CN includes non-locking and locking plate and screw fixation, intramedullary screw or nail fixation, external fixation, internal fixation or a combination of these methods. [110][111][112] Surgical method choice is typically dependent upon bone quality.…”

“…Incorporating orthobiologics, such as bone morphogenetic protein (BMP), bone marrow aspirate, or plateletrich plasma, into the wound or osseous region can enhance healing. 82,127,128 In a recent study, patients at high risk for surgical failure (immunodeficient, multiple comorbidities, recurrent infections) underwent CN surgery for deformity correction using allogenic bone graft supplemented with platelet-rich plasma. 129 Arthrodesis was achieved in 90% of the patients and that were also infection free at 26 months.…”