medical education continuing developing a objectives ...uing medical education by the council on...

and found 7 required amputation.19 of the patients required arthrode-sis while 7 required ostectomy.77

Saltzman, et al., found that out of127 Charcot feet treated with onlynon-operative care, 49% had recur-rent ulceration, 23% required longterm bracing, and there was a 2.7%annual amputation rate.78 Many au-thors have referenced Saltzmans’

Continued on page 182

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $139 (yousave $61). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred-its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test atno additional cost. A list of states currently honoring CPME approved credits is listed on pg. 192. Other than those entitiescurrently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be accept-able by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best effortsto ensure the widest acceptance of this program possible.

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

Following this article, an answer sheet and full set of instructions are provided (p. 193).—Editor

MARCH 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 181

Objectives

1) The reader shouldbe able to list the indica-tions for reconstructionof a neuroarthropathicdeformity.

2) The reader should beable to list the surgical cri-teria for reconstruction ofthe neuroarthropathic deformity.

3) The reader should beable to discuss the possiblecomplications of Charcotreconstruction.

4) The reader shouldbe able to discuss themain procedures used toreconstruct Charcot neuroarthropathy.

and found that three had primaryamputation and five had amputa-tion after failed salvage surgery.Three quarters of the patients hadmidfoot deformity rather than ankle.59.2% of the midfoot cases reacheddesired endpoint without surgery. Ofthe 40.8% that required surgery,more required osteotomy than sim-ple ostectomy.76 Myerson, et al., re-viewed 116 Charcot midfoot cases

Developing aComprehensiveDiagnostic andTreatment Plan forCharcotNeuroarthropathy—Part 2

By Brent Bernstein, DPM and JohnMotko, RN

Surgical TreatmentIn part 1, we discussed the con-

servative treatment of Charcot foot.In this part, we discuss the surgicalmanagement of this debilitatingcondition. We begin with a reviewof the literature.

Pinzur reviewed 201 Charcot feet

When conservative therapy is insufficient to manage symptoms, surgery becomes a viable choice.

Developing aComprehensiveDiagnostic andTreatment Plan forCharcotNeuroarthropathy—Part 2

D I A B E T I C F O O TD I A B E T I C F O O T

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tions have healed. While some clin-icians have discussed the possibilityof arthrodesis in the active phase of

Charcot, most agree that the risksof performing reconstructions in


182 www.podiatrym.comPODIATRY MANAGEMENT • MARCH 2008

CME–Part. 2...

paperfrom the

standpointof the fal-lacy of of-f e r i n gonly non-s u r g i c a lcare tothese pa-tients. Inthose pa-tients whom conservative has failedto achieve a stable, non-ulcerated,pain-free foot that can be placed in

footwear—surgery should be offered.When deciding between surgery

and some other stop-gap measure(such as permanent use of aCROW), the surgeon must considermany criteria before proceeding(Table 10). Generally, we prefer tosurgerize only after all soft tissue ul-cers have healed, edema has re-solved and the neuroarthropathyhas become inactive to minimizepost-operative infections, dehis-cence and hardware purchase prob-lems respectively.

Patients with soft tissue or boneinfection are taken immediately tofirst-stage surgery for radical de-bridement of all devitalized tissue,deep biopsies, placement of antibi-otic-loaded cement spacers fol-lowed by culture-guided long-termintravenous antibiotics prior to per-forming corrective surgery andplacing hardware. Patients are nottaken to the operative theatre forosseous reconstruction until tem-peratures have equilibrated to thecontralateral side, edema is re-solved, and ulcerations and infec-

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Figure 12: Diagram ofSimple Exostectomy

Figure 13: Diagram of Transpedal Os-teotomy

TABLE 10

Criteria for Charcot Reconstruction

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

Figure 14a Case 1: Infrareddermal temperature measure-ments of acute neuroarthropa-thy

Stable Soft Tissue Envelope

In-Active Neuroarthropathy

Medical Clearance and Optimization

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

Adequate Vascular Perfusion and Presence of the Plantar Arch

Ability to Non-Weight-bear or Reside in Skilled Nursing Unit x 3 months

Fully Treated Infections of Soft Tissue and Bone

Cessation of Smoking

HbA1C 7

Weight Loss and Conditioning


go smoking cessation due to theoverwhelming literature notingbone healing complications relatedto nicotine.

Another re-quirement is con-ditioning, weightloss and gait train-ing with the re-quired assistive de-vices prior to sur-gery so that com-pliance with non-weight-bearing canoccur. Patientswho take this seri-ously generallydrop the glycosy-lated hemoglobinlevels to a rangethat we considerthe “ticket” to surgery. When pa-tients are required to develop “own-ership” of the condition prior to thesurgery, we’ve noted good compli-ance levels with post-operative re-strictions as compared to the generalconsensus in the Charcot surgeoncommunity.

Lastly, all patients are seen byour internists for clearance and op-timization prior to scheduling so

the active phase of neuroarthropa-thy are too great.79-82

Researchers have shown that a25% infection rate exists when pa-tients undergo Charcot reconstruc-tions while ulcerations are open.83

Typically, patients will be broughtto the operative theatre with thetotal contact cast intact. All pa-tients receive pre-operative doses ofprophylactic antibiotics in accor-dance with good medical practice.Most procedures are performedunder general anesthesia due to thelength of procedures and the mid-lower leg level of pin placementand Achilles tendon corrections.Occasionally, in patients that can-not tolerate general anesthesia, aspinal block will be performed withtetracaine.

The surgical goals are coverageof deep exposed structures, correc-tion of ankle equinus, restorationof calcaneal inclination and tibia tofloor angles, correction of the rear-foot to leg relationship, correctionand stabilization of degenerativejoint.84-85 We also require that all pa-tients contemplating surgery under-

Neuroarthropathy–Pt.2... that the patient alreadyhas a relationship withthem prior to being admitted

after surgery.We take pridethat our patientsenter the surgicalarena physicallyand mentally pre-pared for the sur-gical proceduresand well-educat-ed on the compli-cations that canoccur.

SpecificReconstructiveSurgicalProcedures

Equinus CorrectionMany of our non-surgical pa-

tients and all of our surgical recon-structions will have correction of theAchilles tendon contracture. It is thefirst and most powerful step in cor-rection of these patients. We’venoted that our patients undergoingcasting have fewer difficulties in thecasts when this contracture is cor-


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Researchers

have shown that a

25% infection rate

exists when patients

undergo Charcot

reconstructions while

ulcerations are open.

Figure 14c Case 1: MRI of foot confirmingacute neuroarthropathy

Figure 14d Case 1: Triple Hemisection ofAchilles Tendon Under Local Anesthesia

Figure 14e Case 1: Articulated AnkleFoot Orthosis

Figure 14f Case 1: Healed and Braced

PlaningPatients with a simple promi-

nent bony exostosis, usually underthe medial column, can forego afull reconstructive osteotomy with

fusion. (Figure12) In those pa-tients, in additionto the mandatoryAchilles release, asimple exostecto-my is performedto relieve pressureunder the promi-nent bone. Thesepatients do verywell generally,and have a lowincidence of ulcerrecurrence bothin our programand in the litera-ture.91-94 Patientswith lateral col-umn ulcers canhave local exos-tectomies, but it

has been our experience that theyhave a higher recurrence rate andhave better outcomes when cou-pled with transpositional flaps.

Rosenblum, et al., had similarresults when they performed a ret-rospective review of lateral columnulcers and performed flaps either asa primary procedure or as a revi-sional procedure in about half of a32-patient cohort.95

In patients with a varus hind-foot or ankle with lateral foot ul-cers, local exostectomy will berarely met with success and a triplearthrodesis is indicated.96 In pa-tients with complete collapse into aconvex arch with massive forefootabduction or with severe deformity,so much bone would have to be re-moved that destabilization of thefoot can occur. Planing should notbe contemplated in these patients.The procedure of choice would be amidfoot osteotomy.

One important caveat whentreating those patients presentingwith the “old burnt-out” Charcotfoot is to never assume that theinitial perfusion that was undoubt-edly present during the acute pro-cess still exists. In the period oftime from onset of Charcot to thepresentation in the office—arterial


CME–Part. 2...

rected and they cool downinto the in-active phase more

quickly. Generally, these patientsundergo a percuta-neous triple hemi-section either inour clinic at thetime of casting orin our ambulatoryprocedure unit inthe hospital.86

In our recon-struction patients,the Achilles mustbe corrected toallow bony repo-sitioning of theosteotomies andto prevent attenu-ation of our cor-rection over timedue to the strongpull of the triceps.In these patients,we more oftenperform an open procedure withcomplete Z-tenotomy and suturingat the corrected physiologic length.

Occasionally, we encounterfrail, non-surgicalpatients that sim-ply require tenoto-my in order to beshoeable andbraceable and weaccomplish thisthrough a 3 mm.incision over thecentral aspect ofthe tendon with a#64 mini-blade fol-lowed by cast ap-plication with thefoot at 90 degreesto the leg. We gen-erally do not per-form gastrocne-mius recession(open nor endo-scopic) due to in-variable findingthat the contrac-ture is of the con-joined tendonsrather than of theg a s t r o c n e m i u sonly. This is bol-stered by Grant’sand others’ uniquework on tendonglycosylation.87-90

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In our reconstruction

patients, the Achilles

must be corrected to

allow bony

repositioning of the

osteotomies and to

prevent attenuation of

our correction over

time due to the strong

pull of the triceps.

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

Figure 15b Case 2: Incisional PlanningPrior to Exostectomy

Figure 15a Case 2: Pre-OperativeLateral Plain Radiograph Show-ing Exostosis

184 PODIATRY MANAGEMENT • MARCH 2008

as fixated with standard internalfixation with small screws, plantarplating, statictensioned exter-nal framing,bent-wire ten-sioned externalframing, andcombination ofinternal and ex-ternal fixation.97-

102 Some surgeonsinitially apply anexternal frameover the osteoto-my and at frameremoval apply in-ternal screws toany unstableareas.113

Our procedureis basically a re-verse Cole os-teotomy with bi-planar wedges tocorrect both thesagittal plane col-lapse as well as the forefoot abduc-tion. We utilize K-wire “guide-rails”to mark the bone cuts and performthe cuts with a large power saw. An

185

stenosis can certainly occur. If thefoot is pulseless, if only monopha-sic flow is audible with a hand-heldDoppler, or if lack of retrogradeflow of both main arteries isnoted—a full noninvasive arterialexamination and vascular consul-tation should be obtained. Treatthese patients just as you wouldthe typical patient with a diabeticfoot ulcer even when planning themost simple exostectomy orAchilles tendon lengthening.

Midfoot OsteotomyMost midfoot deformities are

characterized by a collapse of themedial and lateral longitudinalarches with a rocker bottom defor-mity, abduction of the forefoot,and loss of calcaneal pitch due totriceps pull. Many orthopedic andpodiatric surgeons perform a bi-planar transpedal osteotomy withan achilles tendon lengthening.(Figure 13) The primary differ-ences surround fixation tech-niques and post-operative restric-tions. Osteotomies are described

Neuroarthropathy–Pt.2... initial stabilization ofthe medial and lateral

columns isp e r f o r m e dwith large bore7.3 mm cannu-lated screws thatact as beams. Wetake care to makesure that theshank-to-threadjunction is notclose to the jointfusion site.

Our goal iscomplete correc-tion of the 1stmetatarsal totalus angle inboth the coronaland sagittalplane and thebeams virtuallyguarantee this.Once this is ac-complished, weapply an external

fixator foot ring which is securedto the calcaneous. A forefoot wireis than placed in a bent configura-tion that is tensioned, causing a

dramatic pull backagainst the cal-caneal wire. Thebent wire tech-nique coupledwith the screw“beams” causes adramatic synergyof compressionacross the osteoto-my site that hasbeen demonstratedclinically as well insawbone and ca-daver models.103

We’ve aban-doned small screwsdue to the largemoment arms pre-sent in the mid-foot, the roughlymillion plus loadcycles that canoccur in a normalpatient’s year, andthe frequency ofhardware failurenoted in the litera-ture. Our feeling isthat with the tri-ceps surgicallyContinued on page 186

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One important

caveat when treating

those patients

presenting with the

“old burnt-out”

Charcot foot is to

never assume that the

initial perfusion that

was undoubtedly

present during the

acute process

still exists.

Figure 15d Case 2: Bone Removal with Osteotome

Figure 15e Case 2: Layered Closure Over Drain Figure 15f Case 2: Post-Operative LateralPlain Radiograph After Exostectomy

MARCH 2008 • PODIATRY MANAGEMENT

should be expected is correctionof the first metatarsal to talusangle in both planes both imme-diately post-surgically and afterfull-weight-bearing begins post-frame removal. Far too often,temporary framing results in at-tenuation of the original correc-tion and recurrence of deformity.Full osseous fusion on radiographis less important than deformitycorrection and functionality.

Tibiocalcaneal ArthrodesisUndoubtedly the most chal-

lenging neuroarthropathy to cor-rect is the Charcot ankle. In manycases, extreme valgus or varus an-gulation occur as the tibial mor-tise drives towards the groundand the foot is pushed out of theway. In addition, the talus willoften be pulverized and will virtu-ally dissolve away. While someauthors will attempt to salvageportions of the talus, it has beenthe practice of our program togenerally resect all of the non-vi-able bone and cartilage fragmentsof talus and perform a distalfibulectomy which allows us toeasily reposition the foot on theleg due to the adequate slack thatresults.

We burr into healthy bleedingbone on both the tibia and calca-

neous and perform wedge resec-tions as necessary to place the footin a plantigrade sagittal plane posi-tion and in slight valgus in thefrontal plane. At this point, we gen-erally augment the fusion withmultiple drillings and placement ofrecombinant human bone mor-phogenic protein in a bovine colla-gen sponge to increase the chancesof bony fusion.

We occasionally utilize im-plantable direct current bonestimulators. Any small deficits areback-filled with ceramic putty, al-though our aim is healthy rawbone to bone rather than largeamounts of fillers, allografts, orautografts. The foot is positionedand temporarily pinned with alarge diameter Steinman pin. Afterfluoroscopy guarantees good posi-tioning, we then apply fixation.We’ve typically used a retrogradeintramedullary nail in the past.104-

107 Although we haven’t experi-enced some of the complicationssuch as loosening, infection, andhardware breakage that have beenreported in the literature, we dohave questions regarding the truecompression obtained.108-109

We also prefer to have ad-justable fixation that can be re-compressed post-surgically. Due to


CME–Part. 2...

weakened and with triplaneexternal bracing, a large diame-

ter screw spanning a fibrousnonunion in a Charcot patient willstill likely maintain the alignmentof the foot. We generally secure ourfootring to either multiple tibialwires and rings or to a delta config-uration with the foot at 90 degreesto the leg.

When we are dealing with anacute, isolated dislocation such asthe medial cuneiform, we occasion-ally forego the external fixationconstruct and use a plate buttressover a medial column beam.

In the end, our goal in the mid-tarsus is not just stabilization, but adefinitive re-building of the medialand lateral arches with correctionof the coronal and sagittal planedeformities. It is important for pod-iatrists to understand this concepteven if Charcot reconstructions arenot part of their practice.

When referring a patient forsuch a reconstruction, any podia-trist should be able to evaluatethe post-operative films on theirpatient. The astute clinician willlook past all of the fancy hard-ware that may be present on plainfilm and hone in on the radio-graphic angles present. What

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Figure 16a Case 3: Plantar Midfoot Ul-ceration and Scarring Associated withRocker-bottom Deformity

Figure 16b Case 3: Surgical Resection ofUlcer, Scar, and Bone with IncisionalPlanning for Transposition Flap

Figure 16c Case 3: Flap Raised and InsetInto Defect of Midfoot Charcot Defor-mity

186 PODIATRY MANAGEMENT • MARCH 2008

in her sixties presentedwith an warm, swollen,tender Right foot and was di-agnosed with active phase neu-roarthropathy based on her histo-ry, clinical examination, infraredtemperatures, radiographs, and

serologic bonemarkers. (Figures14a-c) A signifi-cant equinus de-formity wasnoted but thefoot was planti-grade and not ul-cerated. Shebegan a course oforal bisphospho-nate therapy aswell as total con-tact casting andalso had a percu-taneous triplehemisection of

her Achilles tendon. (Figure 14d)The patient progressed from the ac-tive to in-active phase without col-lapse and was transitioned to an ar-ticulated, molded foot ankle ortho-sis. (Figure 14e-f)

Case 2This middle-aged male with his-

tory of peripheral neuropathy sec-ondary to hemachromatosis pre-sented with a Right in-active Char-

cot midfoot deformity and ahistory of chronic and re-current foot ulcers despiteshoe and insert modifica-tions. (Figure 15a) The pa-tient underwent local exos-tectomy and when healedwas shod in custom insertsin depth shoes without re-currence. (Figures 15a-f)

Case 3This male diabetic neu-

ropath in his seventies pre-sents with chronic and re-current Left plantar lateralmidfoot ulcer under a col-lapsed, in-active Charcot de-formity (Figure 17a). Anequinus deformity was pre-sent. The patient had suf-fered a contralateral below-knee amputation. Althoughwe healed the woundthrough off-loading, thearea was chronically scarred

Continuing

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eral disease. The female to maleratio was 54 to 86. The underlyingneuropathy causing the Charcotjoints in our population wascaused by alcohol consumption in4 patients. Cord compression,syphylis, hemachromatosis andgouty neuropathyeach contributed1 patient. The re-maining 103 pa-tients had varyingtypes of diabetesmellitus. 18 un-derwent a simplep e r c u t a n e o u sAchilles tendonl e n g t h e n i n g ,while 43 under-went an operativeprocedure ofsome type(arthrodesis, boneresection, etc.) .Therefore, 57% of our patient pop-ulation were managed without sur-gical intervention of any sort. Themajority of our patients were re-ferred by other podiatrists, vascu-lar surgeons, plastic surgeons, pe-dorthists, and primary care physi-cians.

Case StudiesCase 1

This diabetic neuropath female

187

this, we have been phasing intotwo external fixator options. We ei-ther use a large mono-lateral exter-nal fixator laterally with Schanzbone screws coated with hydrox-yapetite into the tibia proximallyand through a T-clamp into the cal-caneous distally with a retrogradeSteinman pin from calcaneous totibia to prevent shifting or angula-tion or a standard multi-ring exter-nal cage. We then apply compres-sion to the osteotomy. Both can beaugmented with percutaneousscrews. We’ve had good successwith both techniques.

Other ProceduresLess frequently, our patients

will require more exotic proceduressuch as supramalleolar osteotomiesof the tibia, open reduction and fix-ation of calcaneal insufficiencyfractures (Type V Sanders) andSymes amputations in non-recon-structible feet.

Our ExperienceA retrospective analysis of our

primary authors’ patient popula-tion reveals that we’ve treated atotal of 140 patients with neu-roarthropathy since 2005. 17% ofthese patients suffered from bilat-

Neuroarthropathy–Pt.2...

Undoubtedly the

most challenging

neuroarthropathy

to correct is the

Charcot ankle.


Figure 16d Case 3: Healed Flap with Re-solved Ulceration, Scar and Deformity

Figure 16e Case 3: Double Upright Braceand Shoe Combination Utilized WhenCompletely Healed

MARCH 2008 • PODIATRY MANAGEMENT

an elective toe amputation whichhealed uneventfully (Figures 18a-b).Within one month, however,she developed inflammatory signsand sought multiple opinions untilfinally referred to the author. Shewas diagnosed with active Charcotneuroarthropathy based on the his-tory of recent trauma (surgery),neuropathy, asymmetric infrared

cutaneous temperature readings,flail first ray, and positive radio-graphs for sudden arthrosis and dis-location of the first metatarso-cuneiform joint (Figures 18c-e).

The patient underwent immedi-ate off-loading with knee scooter,compression wraps, ice therapy,and elevation. When edema had re-



a n dunstable

with an un-derlying exos-

tosis. The patientunderwent a localexostectomy withexcision of thescarred area. Atransposition flapwas inset to coverthe deficit and asplit thicknessskin graft was har-vested from theipsilateral calf andused for donorsite coverage. (Fig-ure 17b-d) Thepatient progresseduneventfully tohealing and wasfinally transi-tioned to footgearwith custom insoles and a doubleupright calf brace (Figure 17e).

Case 4This middle-aged diabetic fe-

male presented with an insensate,warm, swollen, erythematous Rightfoot. She had a history of develop-ing osteomyelitis of her 2nd toe onthe same foot and had underwent

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TABLE 11

Surgical Complications of Charcot Surgery

Dehiscence

Deep infection

Dissecting hematoma

Significant Blood Loss and Need for Transfusion

Superficial infection/Pin Tract Infection

Hardware Failure

Pain

Edema

Stress Fractures of Tibia

Nonunion/Fibrous Anklyosis

Recurrence of Deformity

Re-Activation of Acute Neuroarthropathyin Ipsilateral Extremity

New Onset Neuroarthropathy inContralateral Extremity

Figure 17a Case 4: Neuropathic Pa-tient with Osteomyelitis of SecondToe Stump

Figure 17b Case 4: First MetatarsalBase of Patient Prior to Second ToeAmputation

Figure 17c Case 4: Plain RadiographPost-Amputation of Second Toe

Figure 17e Case 4: Plain Radiograph Showing FirstMetatarsal Elevatus

Figure 17f Case 4: Post-Reconstruction Lateral PlainFilm Showing Internal Beaming and Buttress Plate


tified the additional risk factorsfor non-union, including psychi-atric disorders, illicit drug use, al-cohol, nicotine abuse, and openfractures along with diabetes asrisk factors when discussing ankle

fusions. Compli-cations and al-ternatives suchas elective am-putation, pallia-tive wound andCharcot care(such as theCROW boot) arediscussed clearlywith our pa-tients when ob-taining surgicalconsent. (Table11)

ConclusionCharcot neuroarthropathy is a

complicated disease process to diag-nosis, classify, and treat successful-ly. Clinicians must review the liter-ature and avoid dogma. A compre-hensive diagnostic and treatmentprogram combing the best ideasand research across multiple spe-cialties, including our own uniqueadditions, has been presented.Through diligent care and referral

solved, she proceeded with surgicalfusion of the first metatarso-cuneiform joint with plate andbeaming with correction of the dor-siflexed first ray(Figures 18f-g).She continuednon-weight-bear-ing with scooter;finally transition-ing through totalcontact casts todepth shoes andinsoles.

Complications“Surgerizing”

these patients isnot to be under-taken lightly. Rogers, et al., dis-cussed the complication rate ofCharcot reconstructions with ex-ternal fixators. He found that 56%of the patients suffered wound de-hiscence, 25% suffered pin fail-ure, and 31% had pin tract infec-tions. The risk factors associatedmost strongly with post-operativecomplications in his paper wereyounger age, long tourniquettime, and pre-operative hyper-glycemia. Thordarson, et al., iden-

Neuroarthropathy–Pt.2... patterns, the cliniciancan tilt the balance in favorof a good outcome when en-countering this devastating com-plication. ■

References76 Pinzur M: Surgical versus ac-

commodative treatment for Charcotarthropathy of the midfoot. Foot andAnkle International. 25(8) August;545-549, 2004

77 Myerson MS, Henderson MR,Saxby T et al., Management of mid-foot diabetic neuroarthropathy. Footand Ankle International. 15(5) May;233-241, 1994

78 Saltzman CL, Hagy ML, Zim-merman B, et al., How effective is in-tensive nonoperative initial treatmentof patients with diabetes and Charcotarthropathy of the feet? Clinical Or-thopaedics. and Related Research. 435.185-190.

79 Pinzur MA, Shields N, TrepmanE, et al., Current practice patterns inthe treatment of Charcot foot. FootAnkle Int. 11(21):916-916, 2000.

80 Myerson MS, Henderson MR,Saxby T, et al., Management of mid-foot diabetic neuroarthropathy. FootAnkle Int. 15(5):233-41, 1994.

81 Simon SR, Tejwani SG, WilsonDL. et al., Arthrodesis as an early al-ternative to nonoperative manage-ment of Charcot arthropathy of the


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57% of our patient

population were

managed without

surgical intervention

of any sort.

Figure 17d Case 4: Plain Radio-graph of First Metatarsal BaseAfter Toe Amputation in SameFoot

Figure 17g Case 4: Post-Reconstruc-tion Dorso-Plantar Film Showing In-ternal Fixation and Stabilization ofMedial Column

tar to the lateral column in patientswith Charcot foot deformity: a flexibleapproach to limb salvage. J. Foot AnkleSurg. 36:360-363, 1997.

96 Catanzariti AR, Blitch EK, Kar-lock LG: Elective foot and ankle sur-gery in the diabetic patient. Journal ofFoot and Ankle Surgery 34(1): 23-41,1995.

97 Grant WP, Rubin LG, Pupp GR:Mechanical testing of seven fixationmethods for generation of compressionacross a midtarsal osteotomy: A com-parison of internal and external fixa-tion devices. Journal of Foot and AnkleSurgery. 46(5): 325-335, 2007.

98 Marks RM, Parks BG, Schon LC:Midfoot fusion technique for neu-roarthropathic feet: biomechanicalanalysis and rational. Foot Ankle Int.Aug; 19(8):507-510, 1998.

99 Neville S, Blume P, Key J: Podia-try Today. Is rocker bottom reconstruc-tion a viable option for limb preserva-tion? Dec; 24, 2004.

100 Garapati R, Weinfeld S: Com-plex reconstruction of the diabetic footand ankle. The American Journal ofSurgery. 187; 81S-86S (Suppl to May2004).

101 Sticha RS, Frascone ST,Wertheimer SJ: Major arthrodeses inpatients with neuropathic arthropathy.Journal Foot and Ankle Surgery.35(6):560-566, 1996.

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

103 Grant WP, Rubin LG, PuppGR: Mechanical testing of seven fixa-tion methods for generation of com-pression across a midtarsal osteoto-my: A comparison of internal and ex-ternal fixation devices. Journal ofFoot and Ankle Surgery. 46(5): 325-335, 2007.

104 Paola LD, Volpe A, Varotto D, etal., Use of a retrograde nail for anklearthrodesis in Charcot neuroarthropa-thy: a limb salvage procedure. Foot andAnkle Int. 28(9): 967-970, 2007.

105 Goebel M, Gerdesmeyer L, Muck-ley T, et al., Retrograde intramedullarynailing intibiotalocalcaneal arthrodesis:a short-term prospective study. TheJournal of Foot and Ankle Surgery.45(2):98-106, 2006.

106 Mendicino RW, Catanzariti AR,Saltrick KR, et al., Tibiotalocalcanealarthrodesis with retrograde in-tramedullary nailing. Journal of Footand Ankle Surgery. 43(2): 82-86, 2004.

107 Caravaggi C, Cimmino M, Caru-so S, et al., Intramedullary compressivenail fixation for the treatment of severeCharcot deformity of the ankle and rearfoot. The Journal of Foot and Ankle Sur-gery. 45(1): 20-24, 2004.

108 Thordarson DB, Chang D. Stressfractures and tibial cortical hypertrophyafter tibiocalcaneal arthrodesis with anintramedullary nail. Foot and Ankle Int.20(8). 497-500, 1999.

109 Bibbo C, Lee S, Anderson RB, etal., Limb salvage: the infected retro-grade tibiotalocalcaneal intramedullarynail. Foot and Ankle Int. 24(5): 420-425,2003.

110 Rogers LC, Bevilacqua NJ, Fryk-berg RG, et al.: Predictors of postopera-tive complications of Ilizarov externalring fixators in the foot and ankle. JFoot Ankle Surg. Sep-Oct; 46(5):372-375, 2007.

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

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

communication


CME–Part. 2...diabetic foot . Journal of Bone

and Joint Surgery. 82-A, (7): July;939-950, 2000.

82 Wang JC, Le AW, Tsukuda RK. Anew technique for Charcot’s foot recon-struction. JAPMA. 92(8):429-436, 2002.

83 Clohisy DR, Thompson RC. Frac-tures associated with neuropathicarthropathy in adults who have juve-nile-onset diabetes. J Bone Joint Surg.70A(8):1192-1200, 1988.

84 Wang JC. Use of external fixa-tion in the reconstruction of Charcotfoot and ankle. Clin Podiatr Med Surg.20:97-117, 2003.

85 Acosta R, Ushiba J, Cracchiolo A.The results of a primary and stagedpantalar arthrodesis and tibiotalocal-caneal arthrodesis in adult patients.Foot Ankle Int. Mar; 21(3): 182-194,2000.

86 Lin SS, Lee TH. Plantar forefootulceration with equinus deformity ofthe ankle in diabetic patients: the ef-fect of tendo-Achilles lengthening andtotal contact casting. Orthop.19(5):465-475, 1996

87 Grant WP, Foreman EJ, WilsonS, et al., Evaluation of young’s modulusin Achilles tendons with diabetic neu-roarthropathy. JAPMA. 95(3):May/June; 242-246, 2005.

88 Reddy GK. Cross-linking in col-lagen by nonenzymatic glycation in-creases the matrix stiffness in rabbitAchilles tendon. Exp Diab Res.5(2):143-53, 2004.

89 Mueller MJ, Diamond JE, DelittoA, et al., Insensitivity, limited mobility,and plantar ulcers in patients with dia-betes mellitus. Phys Ther. 69(6):453-462, 1989.

90 Grant WP, Sullivan R, Sonen-shine DE, et al., Electron microscopicinvestigation of the effect of diabetesmellitus on the Achilles tendon. J FootAnkle Surg 36(4):272-278, 1997.

91 Catanzariti AR, Mendicino R,Haverstock B. Ostectomy for diabeticneuroarthropathy involving the mid-foot. Journal of Foot and Ankle Sur-gery. 39(5): September/October; 291-300, 2000.

92 Pinzur MS, Sage R, Kaminsky S,et al., A treatment algorithm for neuro-pathic midfoot deformity. Foot Ankle14:189-197, 1993.

93 Brodsky JW, Rouse AM. Exostec-tomy for symptomatic bone promi-nences in diabetic Charcot feet. Clin.Orthop. 296:21-26, 1993.

94 Myerson MS, Henderson MR,Saxby T, et al., Management of midfootdiabetic neuroarthropathy. Foot AnkleInt. 15:233-241, 1994.

95 Rosenblum BI, Giurini JM, MillerLB, et al., Neuropathic ulceration plan-

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Dr. Bern-stein is boardcertified by theAmerican Boardof Podiatric Sur-gery and is a Fel-low of the Amer-ican College ofFoot and AnkleSurgeons. Hegraduated fromTemple University School of PodiatricMedicine and completed both a residen-cy in foot surgery and a fellowship inlimb salvage surgery with Dr. StanleyKalish in Atlanta, Georgia. He currentlypractices in the Lehigh Valley and isprogram director of the Charcot and Re-constructive Foot Program at St. Luke’sHospital and Health Network, Quaker-town Campus. Dr. Bernstein partici-pates in mission trips to impoverishedregions to perform pediatric deformitysurgery on a yearly basis.

John Motko is a registered nursewho works at theWound Manage-ment Center St.Luke’s HealthNetwork, Quak-ertown Campus.He has a BS inNursing fromMoravian Col-lege/ St. Luke’sSchool of Nurs-

ing. He is certified in wound care fromboth the American Academy of WoundManagement and the Wound, Ostomyand Continence Nurses Society. He isalso a Certified Hyperbaric RegisteredNurse. He has over seven years of clini-cal experience in caring for patientswith chronic non-healing wounds andCharcot neuroarthropathy.


thy includes:A) Pre-operative weight lossand conditioningB) Peri-operative smoking ces-sationC) Ability to tolerate off-load-ing and fixation apparatusD) All of the above

7) Virtually all Charcot reconstruc-tions will include the followingprocedures:

A) Intramedullary nail fixationB) Triceps surae lengtheningC) Invasive bone growth stimu-latorsD) A+C

8) Charcot neuroarthropathy ofthe ankle with severe valgus orvarus deformity is best treated sur-gically with:

A) Tibiocalcaneal or Tibiotalo-calcaneal fusionB) Midfoot osteotomyC) Triple arthrodesisD) B+C

9) Stage II Charcot neuroarthopa-thy of the midfoot with a severerocker-bottom deformity and equi-nus is best treated surgically with:

A) Tibiocalcaneal fusionB) Achilles tendon lengtheningand percutaneous pinning ofthe midfoot jointsC) Achilles tendon lengtheningand Midfoot osteotomyD) Achilles tendon lengtheningand tibiocalcaneal fusion

10) Patients undergoing neuro-arthropathy reconstructions whilesuffering from an open ulceration:

A) Have a higher post-opera-tive infection rateB) Have a lower post-operativeinfection rateC) Have more pain post-opera-tivelyD) Have less pain post-opera-tively

1) Criteria necessary to consider a Charcot foot reconstructioninclude:

A) A healed soft tissue enve-lopeB) successful pancreatic trans-plantC) patient age under 45 yearsoldD) active, inflammatory stageof neuroarthropathy

2) The preferred option in treat-ment of Charcot deformities withconcomitant bone infection in-cludes:

A) primary amputation of theaffected footB) two-stage procedure withresolution of infection fol-lowed by 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 osteoto-myC) Achilles tendon lengtheningD) B+C

4) The appropriate surgical proce-dure for a Charcot foot with afixed varus hindfoot and history oflateral column ulcerations is:

A) ExostectomyB) Syme’s amputationC) Triple arthrodesisD) Tibiocalcaneal arthrodesis

5) Indications for surgery for Char-cot foot:

A) Uncontrolled painB) Unresponsive ulcerationC) Unshoeable deformityD) Any of the above

6) Optimization of reconstruc-tive outcomes in neuroarthropa-

11) Complications associatedwith external fixators in Charcotreconstructions include:

A) Pin tract infectionsB) Pin failure/fractureC) DehiscenceD) All of the above

12) Options that should be dis-cussed with each patient con-templating a Charcot reconstruc-tion are:

A) Elective amputationB) Palliative careC) ReconstructionD) All of the above

13) A patient suffering from re-current ulcerations under a sub-luxed medial cuneiform withouta rockerbottom deformity. Theulcers recur despite shoegearand bracing modifications. Thepatient should be offered:

A) Midfoot osteotomyB) Local exostectomyC) Tibiocalcaneal fusionD) An isolated achilles ten-don lengthening with boneremoval

14) Recent research has shownthat patients with neu-roarthropathy treated withoutsurgery have an ulcer recurrencerate of roughly:

A) 0%B) 50%C) 100%D) No one has performedthis research

15) The following can be utilizedto enhance bone healing in sur-gical fusions of Charcot patients:

A) bone growth stimulatorsB) Pridie’s perforationsC) bone morphogenic pro-teinD) all of the above

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See answer sheet on page 193.


192 PODIATRY MANAGEMENT

16) Complications that should be discussed withpatients prior to considering reconstruction in-clude:

A) Acute neuroarthropathyB) Worsening of lower extremity peripheralneuropathyC) InfectionD) 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 de-formity, obesity, nicotine use and an open ulcera-tion should 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 and with-out ulceration) presenting with Stage 2 neu-roarthropathy of the ankle with severe valgus de-formity, and limited activities of daily living due toinability 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

E X A M I N A T I O N

(cont’d)

See answer sheet on page 193.

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LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

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 #3/08Developing a Comprehensive Diagnostic

and Treatment Plan for CharcotNeuroarthropathy—Part 2

(Bernstein and Motko)

medical education continuing developing a objectives ...uing medical education by the council on...

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