TAPE STARTS – [00:00]


Male Speaker: – friend and colleague, Nick Bevilacqua, who practices here in Teaneck to speak about the Charcot foot surgery necessary. I've known Dr. Bevilacqua, I guess, it's over 10 years now and he trained here in New York, did a fellowship in Chicago and then, for a short while, practiced in Des Moines, Iowa until his wife demanded that she come back home. So he's got a – he's published a number of papers. There's a great deal of experience in this area. And so I'm happy to welcome Dr. Nick Bevilacqua to the podium. Okay, Michael.

Nicholas Bevilacqua: All right. Thank you, Dr. Frykberg. Thank you, everyone, for sticking it out at 6 PM when you guys are still looking alive and awake, so that's great. So I will do my best to answer the question when describing the Charcot foot, is surgery necessary? Let's see if this works here.

All right, so I have nothing to disclose for this talk. So some quick learning objectives. Basically, before we jump right into treatment strategy for Charcot, I think it's important to understand the diagnostic clinical signs that we're going to be looking for.

And as you all see, I'm going to state it over and over again the importance of early diagnosis and it's important to understand the natural history and the progression of the deformity. And then we'll discuss if and when surgery is necessary.
So why are we talking about Charcot? As we know, we're all familiar with the devastating complications of just any diabetic foot, lower extremity complication. But when we talk about Charcot, it's sort of in a class in its own. So there's been a lot of papers published that highlight the negative impact it has on patients on their lifestyle and also, not just the patient, but family members. So I'm sure we're all familiar of these patients, they're – you're seeing them either weekly in the office or sometimes in wound centers.

[02:04]

They have family members that have to change their dressings. They have to drive them to the office. So it impacts the entire family. Often, it leads to permanent disability and premature retirement, increased risk of morbidities and mortality.

And as you all see in some studies that I'm going to reference, there's an increased amputation rate. Studies, you know, show anywhere from patients with a Charcot foot with a wound anywhere from – they're 6 to 12 times more likely to undergo a major lower extremity amputation, major being below or above knee. So this is sort of a classic presentation that we're familiar with. So that Charcot foot with a wound, they're at, you know, increased risk for losing that limb.

So Mary Hasting, she had an interesting study. She looked at the progression of foot deformity in patients with Charcot. So she looked at 15 subjects of people that have Charcot foot and she also looked at 19 subjects of patients that had diabetes and peripheral neuropathies without Charcot foot and she followed them for one year.

So she had baseline radiographs, six-month radiographs and one year radiographs. And these patients were treated for that year, and she found that at the one year mark, patients with Charcot had worsening of Meary's angle, calcaneal pitch, and cuboid height.

And as we're familiar with, these are radiographic, the worsening Meary's angle and that loss of cuboid height is radiographic indictors of worse outcome. So this study highlights the radiographic evidence of worsening foot alignment over time and it supports the need for aggressive treatment.

Dane Wukich, so if you're all not familiar with Dane Wukich, he's orthopedic foot and ankle surgeon, you know, one of the premier thought leaders on Charcot foot. And I mentioned that because he runs, you know, so this was when he was a UPMC.

[04:00]

It's a tertiary referral center, you know, sort of a center of excellence. And he looked at over a 10-year period, just a consecutive cohort of 255 patients and some of them had bilateral involvement. So they're 280 feet and I'm going to reference his paper kind of throughout the talk because he also looked at outcomes with surgery and risk factors for complications.

But for this slide, we'll focus on one part of the study, was to separate patient – the population into two groups. So one of them had Charcot-related foot wounds and the second group were patients with Charcot without a foot wound, and he found that the presence of Charcot-related foot wounds, at the time of presentation, increased their likelihood again for a major, that's above and below knee amputation by a factor of six. And what's interesting, because when we think about the progression of the deformity, the natural history of it, the majority of feet that had wounds, so 75% presented with Eichenholtz stage 3.

So the Eichenholtz is that radiographic classification. You're familiar with 0, 1, 2, 3, 4. Zero is sort of that red, hot, swollen foot, no radiographic changes and it sort of, you know, progresses. One is that fragmentation, no severe deformity. Two is when you're starting to get that coalescence. Three is that remodeling. Often times, if they're presenting into stage 3, it's probably a misdiagnosis. So they probably have that, you know, rigid rocker bottom foot.

And those are the patients at risk for developing a foot wound that are at risk for limb loss. So again, it's important to recognize the early signs so we can prevent the progression to that stage 3 with a chronic rocker bottom foot.

So when you think about Charcot, you know, I'll talk to whether it's like family practice or internal medicine and they, you know, they're thinking that classic rocker bottom foot. That's kind of like their like diagnostic criteria and I tried to tell them that that rocker bottom foot, that to me, represents a misdiagnosis. I mean we should hopefully never get to that point because we know these patients are at risk for developing plantar foot ulcerations.

[06:03]

So how do we diagnose these patients? Unfortunately, I'm sure you've all had situations where patients present red, hot, swollen foot. They go to the emergency department. They go to the urgent care, diagnosed with cellulitis, given an antibiotic, told to follow up with you, diagnosed maybe with gout, given an anti-inflammatory, told to follow up or even worked up for a DVT.

But sort of the common sort of treatment is that they continue to walk and sometimes these patients, obviously, they don't feel pain. They think, “Oh, you know what? I have the antibiotic. I have the steroid or the non-steroid anti-inflammatory. I'll follow up maybe in a week or two or three.” And by the time they get to you, they have worsening condition.

So we can also think of Charcot simpler classification kind of like that acute – sorry, active versus inactive. Active is going to be that sort of acute process, that red, hot, swollen foot. Inactive is when skin temperature is kind of normalized, edema resolves and that will help guide treatment in a sense.

So I think one of the take-home points for this lecture is going to be that early recognition and diagnosis is paramount. Without that, we're sort of our backs are up against the wall to start. So we have to look at any patient that presents with a red, hot, swollen foot should be treated as a Charcot foot until proven otherwise.

So often times, it's confusing because, like I said, they present to urgent care or emergency room and the radiographs are normal. You know, you can look for hidden stress injuries, but this requires a heightened index of suspicion. Bone marrow edema represents an early sign sort of that, you know, stress reaction and really, any abnormal finding on an X-ray or an MRI in a patient with diabetes in neuropathy with an intact skin envelope should be treated as a Charcot foot. So early radiographic changes, what can we expect? So sometimes, they're normal in that stage 0.

[08:01]

But some of the early signs we can look for, you know, real subtle fractures or little diastasis, subchondral cyst or erosions – periarticular erosions can result in join instability and subluxation, but that’s sometimes a little bit later on in the process.

So here’s just a simple example, hopefully, you see that x-ray, you look at that, you know, diastasis, being in first and second met. But again, someone without that heightened index, a suspicion, they may think or, you know, sprained your foot, follow-up in a week or two. But unfortunately, this patient didn’t have pain, continued to walk on it and it progresses.

So when we think about treatment, so active Charcot, patient presents red hot swollen foot. So let’s just say in this scenario, prompt diagnosis, they come to your office and you’re thinking this is Charcot foot until proven otherwise. You know, what are the treatment options?

Obviously, you want to initiate a strict non-surgical, non-operative. So when we think about, is surgery necessary? Ideally in this situation, it’s not. You want to immobilize these patients, offload it, on-weight bearing. And they’re difficult patient population. They don’t have the upper, you know, energy reserves to use crutches, so you have to find, you know – it’s sort of a case-by-case basis, you know, wheelchairs, but then you have to, you know, consider their home environment, is it applicable for a wheelchair, oftentimes you can use the knee scooters.

But they’re going to – you’re going to treat this aggressively, not surgically. And oftentimes it takes about four to six months for that active process to resolve. You can do a total contact cast, you can do, what do you call that, instant total contact cast where you take the… render it, irremovable with, you know, by wrapping it with Coban or plaster. And you basically want to see them very frequently just to monitor the resolution of the edema, the return of the normal skin temperature.

[10:03]

And then you can gradually transition them to more of a support of a shoe or sometimes brace if it’s a stable deformity.

So when we get these patients that we get them through that active process, now they’re sort of inactive, they don’t have that red hot swollen foot. The first question you ask yourself, “Can you accommodate the deformity?” Because, you know, oftentimes, just like we saw with those earlier studies, even though you’re treating these patients aggressively, there’s still going to be some worsening, you know, the radiographic findings.

So if you can accommodate it, then you want to consider accommodate a footwear with or without bracing. But again, these patients require frequent follow-up. Again, another take-home point, because once they get to that inactive phase, they’re not out of the woods and we saw from that study that the one-year mark, it’s going to continue to progress. So you have to keep an eye on these patients.

So when is surgery not necessary? So patients that have a stable deformity and a plantigrade foot, but again, requires close follow-up. What’s the goal of non-operative care? Really early diagnosis that’s key, initiate off-loading and immobilization, try to prevent or minimize deformity.

And just going back to that Wukich, that study that I referenced earlier, so in his consecutive cohort of patients, he was able to successfully treat about 28% of the patients. So you can see 78 out of 280 were successfully treated non-operatively and that’s over about a mean of about a four-year follow-up.

So when do we have to consider surgery? So, can the deformity be accommodated with bracing, with shoes? If the answer is no, then to prevent ulceration or sometimes the healing ulceration, you have to consider surgery.

[12:01]

So there’s different types of surgeries we can… and we’ll go over each of these, sort of limited surgery, tendon Achilles lengthening or gastroc recession, usually in combination with an exostectomy, and then we’re talking more reconstruction with osteotomies and fusions and then amputation.

So even going back to that Dane Wukich study, there was a fair amount of patients that were offered amputation right from the start. Because I think when we talk surgery, we have to think about what’s the successful outcome? So a successful outcome is a stable functional foot and the keyword is functional. So what you don’t want is these patients to undergo reconstruction, have this lengthy, you know, recovery process, whether it’s 10 months, 12 months, 14 months and end up with a non-plantigrade foot, that’s still at risk for ulceration because, you know, they would – some patients – not all, some patients, might do better off with that lower extreme… the below knee amputation from the start. So it is an option and you should discuss that with the patient. So we know that if it’s non-plantigrade foot, the patients are at heightened risk for ulcer infection and limb loss.

So exostectomy, it’s useful when these patients are kind of stage 3. They have that sort of rigid deformity. There might be a bony prominence, that’s putting pressure on the skin. But, you know, relatively stable deformity, contents are really and see the group out of West Pan. They looked at comparing exostectomies for those plantar wounds, medial versus lateral. So the, you know, plantar medial wounds that they just debrided some bone, get a lot better than the lateral ones, the plantar lateral ones. Just because, oftentimes the plantar lateral ones, you resect that exostosis and it results in a more unstable foot. So you have to be careful that you don’t resect too much bone and you take a relatively stable foot and you turn it unstable. And that’s often in combination with the TAL because we know these patients, you know, they’ll have equinus deformity.

So this is just an example of a simple. It was a rigid deformity, you could just resect that medial and plantarly.

[14:00]

And put him in a good accommodated footwear and they can potentially do well.

So when do we can consider reconstructions? So these are deformed unstable feet. So these are non-braceable and these patients are either in pending skin breakdown or they have a wound that’s not healing. And you can consider single stage versus gradual correction.

So the goals of surgical reconstruction, again, I mentioned it, it’s a stable, functional, ideally a shoeable foot. So something that you don’t have to necessarily put it in a crow boot. It could be, you know, it can fit and be stable in just over-the-counter that orthopedic extra depth orthopedic shoe. Increased function, we want to get these wounds healed and ideally where correcting the underline deformity, so they – lowers the chance of ulcer recurrence.

And again, I’m going to look at some studies, looking at outcomes. So our goal is osseous fusion. So there are some patients that can do well. They have a pseudo fusion. But a non-union is a risk factor for lower extremity amputation after reconstruction. We’ll go over that in some of the studies. So that’s where sort of, you know, good surgical technique and I – and good stable fixation comes in handy.

So this was a study comparing patients that had midfoot Charcot treated with osteotomy and arthrodesis compared to a group of patients treated with just total contact casting along and the patients that had surgery, so they had that deformity corrected. They had zero ulcer recurrence rated 12 months versus the patients in a total contact cast at 33%.

So we know, total contact cast gold standard for offloading, wounds are going to heal. The problem becomes if they have that deformity and they are unstable. Once you get them out of the total contact cast back in a shoe, they’re just going to breakdown. So that’s the problem with total contact cast, is their recurrence rate. So again, I mentioned the goals of surgery is a plantigrade foot to prevent ulcer recurrence.

[16:00]

So when we think about midfoot Charcot, quickly just highlight some of the concepts that we’re looking at. You want to find the apex of deformity and you want to correct malalignment. So oftentimes, that involves an osteotomy with midfoot fusion. So you do this biplanar wedge and what that does is you’re basically separating that into two segments and you can really dial in the correction in all three planes, and you can just see just an example.

And then this triplane correction you could see with the video, you can really dial in that correction. So the goal here is to correct Meary’s angle, increase the calcaneal height, and result in a planar grade foot. So no – just reverse that rocker bottom deformity.

So you’re provisionally fixated and then we have choices with fixation, whether it’s internal, external, or maybe a combination of the two. So in the past, internal fixation has been fraught with complications. You know, cancellous or cortical screws, and these often – the equivalent of putting a screw in a wet piece of log often result in failure.

So the concept of the technology has advanced with locking plates and also the concept of super constructs where it’s extending the fusion beyond that zone of injury. You can consider plantar plates, beaming, and that will result in a more rigid fixation construct, again, to get the goal of osseous healing, or osseous fusion I should say.

So if we’re going to consider plates, you want to extend the fusion beyond that zone of injury. So oftentimes, you take that midfoot wedge, but the plate, you’re going to put screws for distal and for proximal. And any sort of joint that the plate is spanning needs to be prepared for fusion because otherwise you’re just creating a non-union.

And just an example, a combination of a compression screw and a plate. Beaming, we had a great lecture on that yesterday. So just a relatively newer concept similar to re-baring concrete, that’s how I sort of explained it to patients.

[18:04]

Many terms, super construct, axial screw fixation, intramedullary metatarsal fixation. Really the benefits of beaming, relatively minimally invasive. I mean, you still make the incision, osteotomy, prepare the joints for fusion. It spans multiple joints. It’s rigid intraosseous fixation. And I think the key is – one of the main benefits compared to plating is that its natural biologic barrier is in place as compared to plates. So you can do the best surgery, correct the deformity, rigid internal fixation with plates, and these patients have wound dehiscence and then you’re staring at the plate and that increases complication. So this gives you that sort of layer of protection there.

And you can combine the two. So here’s just a simple example. This lady sort of relatively early Charcot in the presentation but she had that fractured navicular, collapse of the medial column, and she was at, like, impeding skin breakdown. I mean, the skin thankfully did not have a wound but was quickly on its way to developing a wound.

So this was primarily medial column, so I just ended up using just a bolt screw. So one bolt screw by itself or a beaming screw is usually not sufficient, so you still have some rotation ones to place. So I just supplemented this with a plate and this patient went on to do well at three years.

So what about external fixation? Obviously when talking about Charcot foot, these patients often have deformities with a wound, so it becomes a logical choice, especially patients that have poor bone stocks. So external fixation is independent of poor bone stock. And it allows skeletal stabilization. You can get compression while still allowing treatment of that wound, whether it’s a skin graft or just debriding it because it’s going to be offloaded, they’re going to heal. Typically you’ll use a – if it’s a one-stage static frame, two tibia rings and a foot plate.

[20:02]

So just a quick technique, one or two tension wires placed just proximal and distal to the arthrodesis site. So you can see just going back, simple midfoot deformity. You create that triplanar wedge. You correct it, can provisionally fixate it, and then you just throw a skinny wire just distal to the fusion. And just an example, you kind of walk it back on the frame, which I’ll just show you this – let’s see if this works here. So you just bend it and then you got to tension it manually. So you can see in this video, manually tension it, you’ll see the skin on the plantar surface kind of wrinkles. So you could see we’re getting good compression evenly across that arthrodesis site.

So external fixation is a great option in patients that have history of infection, they have a concurrently open wound, and you’re concerned with post-op infection with infected hardware, so external fixation is a great choice.

So here’s just another example, 52-year-old lady with midfoot Charcot with that rigid rocker bottom foot. This is a classic example. Treated aggressively, non-operatively, put her in a total contact cache, she healed, but then when she went right back to the shoe, it just kept coming back and coming back. So just decided, correct the apex of deformity. This is just, again, kind of highlighting that midfoot, biplanar wedge, triplanar correction, provisionally fixate. And these patients, as long as they get a good solid fusion across the osteotomy site, they do well.

And you can combine internal and external. So this is a situation that, you know, maybe the patient just needs a little bit extra stability. So you can put a beaming – combine beaming with external fixation. So going back to that Dane Wukich study, so he looked at outcomes and risk factors after Charcot foot reconstruction. And again, so I’m going to highlight the fact that Dane Wukich is one of the key opinion leaders, thought leaders.

[22:02]

And I say that because if you look, there’s a lot of complications and this is someone that has a center of excellence and specializes in it. So he had the overall limb salvage rate in the patients that were deemed reconstructive candidates.

So again, there were some patients that were offered below-knee amputation from the start, so they weren’t included, but he had a 90% limb salvage rate. And as I mentioned earlier, the presence of a Charcot foot related wound at the time of presentation increased the likelihood of a long – or a major amputation by a factor of six. And the risk factors included active infection at the time of initial presentation, and again, non-union and instability after reconstruction and post-op wound problems.

So this was actually just recently published, Journal of Foot and Ankle Surgery, and this is, again, another center of excellence. This is the group out of Georgetown, so this is John Steinberg, Paul Kim, Chris Attinger who’s one of the world-renowned plastic surgeons who specializes in limb salvage, and Paul Cooper who’s an orthopedic foot and ankle surgeon that does lots of Charcot reconstruction. And they looked at 285 patients that underwent Charcot foot reconstruction and the mean follow-up was 29.5 months. And they actually had 49 major lower extremity amputations. So about a 82.5% limb salvage rate.

So initially when you compare it to some of the other published studies, 90%, 95%, you’d think this is maybe a less successful center, but these patients, these were acutely ill. So these are patients that were admitted through the emergency department. So they had, oftentimes, wounds, they often had infections. So these are like lots of co-morbidities, oftentimes even had previous treatment somewhere else with surgery in the past, and 21 minor amputations and that’s trans-metatarsal show parts.

[24:06]

So what were the risk factors for complications? Delayed healing, soft tissue infection, osteomyelitis, and recurring ulcer. And the most significant risk factors comparing those who require a low extremity amputation, and we just go over the top three.

Post reconstruction, non-union so, again, that goes back to just the surgical technique and fixation. So you want to get a rigid fixation construct. You want to consider that – the concept of super constructs going beyond the zone of injury, whether it’s plantar plates, beaming, ex-fix, combinations. Because really a non-union, you see they were 8.5 times more likely to undergo a major low extremity amputation, or, a new site of Charcot. So oftentimes, these patients may present with a mid-foot Charcot, you fuse it. They do well and they may come back with an angle Charcot so that’s another major risk factor, 8.5 times more likely to undergo major low extremity amputation.

And I think also what’s often overlooked is peripheral arterial disease, because we’re, you know, we’re sort of train that these patients have, you know, bounding pulses as one of the diagnostic things we look for. But, you know, Dane Wukich actually found that in his patient population, up to about 40% presenting with peripheral arterial disease. So obviously this is, you know, you have to screen these patients, non-invasive vascular studies, renal disease, delayed post-op healing, post-op osteomyelitis and then increased HbA1c.

So what are the take home points? Again, one thing I want you to leave here with early diagnosis is a key, it’s most important. So look for those early clinical findings, red hot swollen foot, patient has Charcot and neuropathy, treated the Charcot – or patient has a diabetes with neuropathy, treated a Charcot until proven, otherwise initiate an aggressive non-surgical plan.

[26:13]

So I don’t like to call it conservative. It’s an aggressive non-surgical plan. Offload them, immobilize them, see these patients, you know, weekly, bi-weekly, and just – and you got to have to just follow them. You know, I joke with patients that, you know, they are patients for life. I mean, it’s a cliché at this point, but it’s true.

So when a surgery not necessary? These are the patients that you diagnosed them early. You get them from that acute, or from the active to the inactive phase, minimize deformity. They are stable. They are braceable. They are shoeable. And they have a plantar grade foot.

So when is surgery necessary? Deformed foot at risk for skin breakdown, or if they have a chronic non-healing wound, or just repetitive ulcer recurrence despite aggressive nonsurgical treatment. It’s important to define the goals and the expectations with the patients. So those outcome studies are great because now you know, you have these discussions with the patient beforehand and you tell him, you know, this is limb salvage because oftentimes patients thinks, “All right, I’m having the surgery to prevent an amputation.” And then if it leads to an amputation, obviously, they are upset. So you have to, you know, relay this information beforehand, the risks, and you can, you know, quote the studies.

Prepare for complications so in that Dane Wukich’s studies about 60% complications, right? So I don’t tell patients, you know, there’s a chance that we’re going to have a complication. I tell them that we’re going to expect complications. We hope that they are minor and not major, but we have to, you know, recognize it, prepare and treat.

And then it’s a team approach. So it takes everyone, entire medicine to medically optimize these patients, your vascular colleagues to make sure that they have good adequate flow, and obviously important part of the equation as well.

[28:04]

And that should be it. Thank you.

[OFF-MIC]

Dr. Diaz: Hi, Nic.

Nicholas Bevilacqua: Hi, Dr. Diaz, how are you?

[OFF-MIC]

Dr. Diaz: Any correlation, most diabetic are obese at – any correlation of posterior tendon dysfunction in adult acquired flat foot as a precursor of a Charcot foot?

Nicholas Bevilacqua: You know, and I think so oftentimes, there was that posterior tip tendon dysfunction, you know, likely having equinus deformity as well. So I think certainly, if there’s abnormal mechanics in the foot, they have diabetes and they have neuropathy. They are, you know, certainly, at risk. So I think it’s important to stabilize – I mean, those patients require, you know, probably some sort of embrace anywhere which you brace or Arizona brace or something. So I think, I don’t know, I don’t think anything has been studied specifically looking at posterior tip tendons dysfunction with Charcot, but I think – I think it’s a good question and something to be alert for.

Male Speaker: Nic, I have a question, having thought about this entity for over 40 years, still not having the answers. You mentioned Dane Wukich’s paper with the 28% of the patients went on to healing without the need for surgery. That was a retrospective review. But don’t you think you’ve got a control for stage or presentation?

Nicholas Bevilacqua: Absolutely.

Male Speaker: If you have 95% of the patients presenting in a chronic rigid, I can hold stage 3 deformity, you’re obviously not going to be successful most of the time.

[30:10]

So what do you have to say about that? I mean, I think it’s very interesting because it mirrors Pencer’s paper, and about the other one escapes me where they – from Mayo City. What was his name?

Nicholas Bevilacqua: Saltzman?

Male Speaker: Yeah, it was Saltzman and his cohort, where they found they were are successful about 28% of the time with their rigid protocol, but 2% of the patients have to have surgery. So don’t you think there – you made the point that early diagnosis, high index suspicion is always the key because I think your goal is to diagnose these to stage 0. Unfortunately, they get missed too much and that’s the reason why surgery is more often necessary than as not.

Nicholas Bevilacqua: Right. And I think, yeah, and also these patients or those studies, you know, the Georgetown the UPMC, you know, those are referral centers, so often times those patients are coming in, you know, stage 3 ulcers, and things like that. So I think, again, the take home point is just being vigilant in the, you know, heightened index as suspicion and diagnosing them at stage 0. I think that’s the only chance we have, with close follow-up because like we show that even with treatment, unfortunately, they’re going to progress.

All right, thank you.

TAPE ENDS - [31:38]