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CME Surgery

Is Surgery Really the Primary Option for the Charcot Foot: Evidence from the Literature

Aksone Nouvong, DPM

Aksone Nouvong, DPM discusses the conservative treatment of Charcot versus surgical options.

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Goals and Objectives
  1. Recall different modalities for the treatment of Charcot
  2. Recognize the advantages and disadvantages of surgical treatment for Charcot
  3. Describe different diagnostic modalities for Charcot
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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Aksone Nouvong, DPM

    Associate Clinical Professor
    David Geffen School of Medicine UCLA
    Chief of Podiatric Medicine and Surgery
    DVA Greater Los Angeles, CA

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  • Lecture Transcript
  • Dr. Hadi: Basics of conservative care. Now we’re going to move on to give you some clarity in terms of one, is it appropriate to consider surgical intervention in this regard if you are so incline or the patient who is not responsive to conservative care. So I’ve asked Dr. [Navon] [00:19] to come back and talk to us about her approach to surgical management and probably surgical evaluation of these patients. Dr. [Navon] [00:30].

    Dr. Navon: Thank you. So Dr. [Hadi] [00:34] kind of gave a great overview of non-surgical options for Charcot. And I just want to go over some surgical options and to me consider that a primary option for our Charcot patients. I have nothing to disclose but our learning objectives are also available online for you. I kind of just want to briefly go over the epidemiology and prevalence. Because unfortunately, there are no – there’ll be don’t know the true evidence – true prevalence of Charcot because unfortunately it’s not always diagnosed appropriately as Dr. Hadi alluded to earlier. But it is estimated approximately 0.08 to 7.5% of diabetic patients get a Charcot and that’s based on the standards by Bergs review in 2007. However those patients who are high risk have a 13% of getting Charcot. Of course mainly in the fifth, sixth decade of life and patients often have diabetes for approximately 10 and 15 years after the onset. Interesting enough, Dr. Hadi said that patients had come to a lot of Charcot. It’s estimated approximately 30 to 40% of patients who get Charcot can happen on the contralateral limb also. There’s also bigger number, the relapse for the same limb is approximately 23 and 30%. And then which is something I didn’t really know before is that there is no gender difference between Charcot in males and females. So I know Dr. Hadi discussed already in terms of classification but there are three main ones I think we should all be familiar with. One is Brodsky. The second is Sanders and Frykberg classification system and the third is the Eichenholtz or the modified Eichenholtz. The Brodsky classification system describes anatomic location but more importantly the Sanders-Frykberg classification system. Not only describes the anatomic location but it also talks about the prevalence. And as you can see here, pattern two is the most prevalent in terms of Charcot foot and ankle. Patterns three and four which is the rear foot and also ankle are more rare than the pattern two. Again as a review, I know Dr. Hadi just went over this but I just want to go over this so that we can be reminded of the stages again. Stage zero is prodromal. Stage one is destructive. Stage two, the coalescence. Stage three is remodeling. In the past, and people discuss surgical options for Charcot patients most people describe doing Charcot in the third or the remodeling stage. However, there had been new research or new literature out there that talks about doing surgery, the more the coalescence. There is two main articles that describe doing surgery and the destructed stage which is the very, very acute stage. However, there is no good evidence that states that that’s a good option. So some literature, I’ll be discussing today basically discuss this doing surgery mainly in the coalescence and then early remodeling stage. So when is it appropriate for us to do surgery? It’s alluded earlier by the early presenter. When should we consider doing surgery is when there is joint instability. When the patient has a non-plantigrade or non-function foot. When there is recurring ulcers or when there’s deformity or sort of gear that foot accommodations AFOs cannot accommodate them. It’s alluded to earlier, patients who have rear foot and ankle Charcot often those who have in that particular area do not respond very well with non-surgical treatment. So ankle and rear foot should have its own consideration in terms of surgery. And then patients who have limited activity of daily living, surgery should be considered. And as discussed early about the Saltzman and – why these articles really important because it talks about the fact that a lot of patients who have non-surgical treatments. There is not a lot of high risk in terms of re-ulceration. So I stated 49% of patients had re-ulcerations that are just non-operative. So this is why surgery should be considered. So I just want to briefly go over for ankle again because unfortunately there is not one main studies talk about Griffon ankle Charcot.

    [05:04]

    However, Burns and Wukich, and also the consensus that Dr. Frykberg discussed earlier the Charcot foot in diabetes both discussed separately. When patients have Charcot of the Griffon ankle. And even though in those particular areas it is much less common in midfoot. Unfortunately, the deformities that occur is much more severe and the deformity in that area is much more difficult to accommodate which just utilizing unconservative therapy alone. And oftentimes it’s a deformity resulting a varus or a valgus, it is more unstable and much more difficult to accommodate with accommodated footwear. And then [Saltzman] [05:48] talked about how that this should be approach whether should be an external fixation initially or internal/external fixation or combined, unfortunately there are no good studies described what treatment we should have for Griffon and ankle. It’s just that the one thing is conservative therapy often fails. And as I stated in the Charcot foot and diabetes consensus, again a similar finding was discussed similar to the Wukich study. So what our surgical goals? Well the goals for surgery of our patient is to provide our patient with a stabilized plantigrade and functioning foot. And also in hopes that we can prevent ulcerations and amputation. We talked about using all these modalities to treat our patients after the Charcot resolves. However, I’ll go over study in which people talk about performing surgery not just to give our patients a plantigrade foot for a common devices but perhaps provide our patients the opportunity to use non-prescriptive shoe wear. And then also hopefully in terms of surgery, we can improve the activity of daily living for our patients. So literature out there in terms of surgery, the literature by Mittlmeier basically looked at whether surgery should be considered for our Charcot arthropathy of the foot. And unfortunately, most of this is mainly on the midfoot. They asked the questions. Can primary surgery in high risk patients provide a plantigrade foot for the three following; one, can our patient be ulcer free and infection free? Two, can an increase the physical activity of daily living for our patient? And then three, if these surgeries are performed, this primary surgeries are performed, what are their complication rate as compared to secondary surgery? And what secondary surgery these patients who are treated non-operatively who end up with ulcerations and then had surgery done as a secondary method, the treatment? So they did a retrospective study, they looked at 26 feet. And these patients who underwent surgery were determined to be patients who are high risk. And this is the part of the study that was a little bit unusual. They determined high risk as patient understandably who had an unstable foot or who had non-plantigrade foot. But they also concerned patients who are high risk and not patients who they deemed to have an overt deformity in which they thought would develop ulcer in the future. Despite they have patients never developed an ulcer. They followed these patients for approximately 2.7 years and eight of those patients had ulcers prior the surgery. What they found is all those patient’s ulcers actually healed. And that all the patients who they did surgery on, no patients actually ulcerated or nor did they ulcerate. They did a nine complications of the complications I did have. They have five hematoma and four instability. Of the four patients who are unstable, they repeated this. They had performed a different procedure and all the patients actually healed subsequently. So what they conclude was that early surgery in these patients can provide timely restoration and improve quality of life. And they found that the complication rate for these type of procedures is very equal to the secondary procedures that performed by others. Unfortunately, this study was very limited and in fact that there’s obvious a small number of cases that performed. And unfortunately there was no comparison in terms of patients who were treated non-surgically. Another, so that was done by Pinzur and Pinzur wrote many of the surgical studies. But he again also looked at surgical versus accommodative treatment for Charcot of the midfoot.

    [10:02]

    And unlike other surgical procedure, his endpoint was just a little bit different as I state before. His endpoint wasn’t to prevent patients from having ulcers or re-ulcerations only. His endpoint was can he get these patients like in to commercially available footwear. So this is a much more aggressive surgical therapy. And he did look at these patients, two different groups. The first group are patients who had a plantigrade foot that was treated with accommodation. And then transition into commercial available shoes. Then he looked at patients who had a non-plantigrade foot and treat them surgically with surgery and then transits them to a commercial available footwear. He looked at a 147 feet and then followed them for approximately six years. Out was that 59% of the patients that were treated conservatively actually did well and we’re able to go into conservative or commercially available shoes without needing any surgery. However, if the endpoint of your treatment is to get patients into commercially available footwear surgery should be considered. And that’s the complication rates were very similar. So what type of surgeries are out there? Dr. [Lapoya] [11:33] is going to go over some surgical options for Charcot. But the main surgical options are exostectomy TLs realignment or arthrodesis and then a combination of all these procedures. Go over a little bit each of these procedures and what the evidence in the literature states about each one of them. So exostectomy. So Catanzariti actually looked at exostectomy in patients with neuropathic ulcers in the midfoot. Again a retrospective review, they performed a exostectomy for patients who had chronic ulcers or reulceration. They looked at patients who had and underwent 27 procedures. What they actually found out was 74% of their patients actually healed. However, 26% of their patients did not heal exostectomy and patients re-ulcerated. But interesting enough the majority the patients who did not heal of those patients who did not heal, 677 of those patients is because the exostectomy or the prominence for the lateral side. So what they concluded from this exostectomy is a viable option for patients mainly for the medial column ulcer. Especially those have failed conservative therapy however, performing a exostectomy in patients who have lateral ulcers or lateral prominence, the procedure is less predictable. Unfortunately, again the limitation of the study is the subjects were pretty small. Another study that was done also for a exostectomy is by – I won’t say his name, I think that’s [Ladamas Ducien] [13:25] there you go. So I think it pronounce my own last name let alone his. But again he discussed exostectomy in the chronic midfoot ulcer. And his a little bit different and he was looking to see whether exostectomy actually improve healing rate, reduce complication, reduce ulceration. Again it was about retrospective review looking at 20 feet that underwent exostectomy. And followed them up for possibly 29 months. As a result of their procedure, what he found out was after the first procedure 55% of those patients healed. However, after all the procedures if they re-ulcerated, 82% of those patients healed. Unfortunately three patients which is a pretty large amount of the subjects died. Of those 44 that developed new ulcers, 26% of those again were lateral column ulcerations. So what they concluded was that this procedure for exostectomy is actually very safe however again lateral columns had a higher rate of failure. Again very similar to other studies, the limitation is a very small sample and unfortunately in terms of the death, they didn’t discuss whether it’s attributed to the surgery or not. So we talked about exostectomy as one of the procedure. The next procedure is the TAL.

    [15:00]

    So TLs have been studied on multiple levels. The two main ones that I want to discuss is the TL that was published with Armstrong and Dr. Harkless. And what they did is they involved 10 subjects with diabetes who had neuropathic, 10 for ulcer. They performed a TAL on these patients. What they did do was a delegate analysis of the plantar peak pressure before and after surgery of approximately eight weeks post-op. And what they found out was actually a very promising results. They noted that in terms of post-operatively, the peak pressure decreased by approximately 27%. As you can see here, pre-operatively is in this orange. The peak pressure is approximately 86 and then right afterwards post-operatively the peak pressure was only 63. They also looked at the ankle dorsiflexion and then they basically looked at pre-operatively ankle dorsiflexion was approximately zero and post-operatively the ankle dorsiflexion is approximately 9 degrees which is very opposed to what we would want for our patients in general. Another study on TALs is actually by Miller. And this is one the very first and few randomized controlled trials on TALs. What they did is they looked at 64 patients minimizing them to two groups. One group was with the TCC alone and the second group was in TCC and had TALs performed in addition. They again measured peak pressure pre and post-operatively. They followed these patients for approximately seven months and then interestingly as you can see here in the grey, it’s the TCC alone and then in the orange color here is TCC plus TAL. And what they found out was a healing rate for TCC was approximately 88% but those that had TCC alone with the TAL had a 100% healing rate. Also they looked at the recurrence rate and patients with TCC alone had a high recurrence rate of approximately 81%. And for those had TC alone with the TAL, the recurrence rate was only 38%. Again they did peak pressure and the peak pressure pre-operatively was 89% and then post-operatively was approximately 65%. So for TALs, seems like a pretty promising in terms of surgical treatment for Charcot patients. Now in terms of looking at arthrodesis of the midfoot of the rear foot, a recent publication by Lavery and Wukich actually did a very comprehensive systematic review. And they looked at all the literatures that were out there in terms of the management of Charcot. Within this Lavery systematic review they looked at the subsets of patients who had surgery. They looked at the outcomes of surgeries these patients whether it was a simple arthrodesis surgery or whether it’s arthrodesis plus TL plus other procedure. And what they did was they looked at surgeries with internal fixation, external fixation, destructions, osteotomy, and any combined fixation procedures that were done. They actually found 43 studies of that method criteria. Unfortunately all of these studies have poor done were actually level four studies. Again level four, level five or clinical case studies and also expert opinion. But within these studies there are approximately 246 subjects who had certain procedures performed on them. And what did they found out was that patients who had these procedures, 76% of the patients actually had complete fusion. However 22% had incomplete fusion whether it’s a fibrous union or whether it was a nonunion. However, in that same study they discussed the fact that those patients who had nonunion or incomplete union still had a plantigrade foot and were pretty functioning. They did have 1% of patients had an amputation. So in that systematic review, they concluded that a surgery appropriate. Yes, it is appropriate however keep in mind that these surgeries that we discussed had all been based on level four utmost. Mainly, they’ve been discussed on the level four and level five. But despite that these outcomes shows that there is moderate fusion rate for arthrodesis. And then in – again as I stated in patients who did not have a full union despite that they still have ulcer free and plantigrade foot.

    [20:03]

    So in the same study, the overall study for the systematic review, they actually reviewed 499 articles. 499 articles in the past 46 years, that’s a lot of articles published every single year on Charcot and the treatment of Charcot alone. And what they found out in their systematic review as I stated, all the reports again were level four and level five. And then unfortunately, 50% of the literature regarding surgical management came from four sites. So if you think about it a lot of this information comes from four sites. So what they concluded in their finding is that the most common places where surgeries required is the midfoot of approximately 59% and then the ankle at approximately 29%. And then in their same study I discussed earlier, surgery of acute stage unfortunately, there is not enough clinical evidence to support doing surgery in acute phase which is the stage zero or stage one. However, exostectomy is a viable procedure for bony prominence mainly of the medial side. And so even though the [Indiscernible] [21:36] evidence is poor, the outcome is actually been pretty good. And then in terms of Achilles lengthening, there’s actually fair evidence to support that Achilles lengthening is a good procedure for our Charcot patients. And in terms of arthrodesis for recurrence and for those patients who fail a non-operative treatment again as I stated the evidence is pretty poor however, the outcome seems to be pretty good as we discussed 76% of patients who underwent arthrodesis end up with full union. However, with all their research and also all of my literature search unfortunately, there is no recommendation for whether one type of fixation versus another fixation actually works. Whether it’s using internal fixation alone using external fixation alone or whether it’s using a combined internal/external fixation. However, Dr. [Lapoya] [22:33] will tell us some later on what would work best. And then in terms of our reconstructive surgery and all the surgery again most of the evidence have been on retrospective studies, case studies and expert opinions. So in summary, is surgery will the primary option for Charcot foot? And what is the evidence from the literature basically state? I would agree with Dr. Hadi that I think most important part of treatment is the initial treatment with off waiting and immobilization. And surgery should be reserved for those who have severe and unstable foot and ankle or those who have actually failed conservative therapy or those who end up with a non-healing ulcer and or recurring ulcer. Again we’re basing a lot of what we do on retrospective studies and expert opinion though I definitely believe that a lot of experts had discussed this, have very valid data. And then because of the fact we always talk about level of evidence, we know that the reason why that’s the case is because now Charcot is pretty rare and it’s very difficult to actually randomize our patients. And that’s the reason why we don’t have great evidence based medicine when it comes to surgery for Charcot. And then again in terms of the diversity of joints, it’s hard to compare procedures to another procedure because so many different joints are affected. And again on the literature, there is no optimal technique that’s actually recommended in terms of fixation device. Thank you.