A Practical Approach to the Management of Charcot

APMA Annual Scientific Meeting 2018

Jacob Wynes DPM, MS, CWS, FACFAS

Assistant Professor, Department of Orthopaedics
University of Maryland School of Medicine
Co-Director UMMC Limb Preservation Clinic
“Charctose Intolerance”
 Agenda
 Interesting facts

 Principles of Charcot foot / ankle

reconstruction

 “EBM” considerations

 Tips and Tricks

 Case presentations
 Charcot Associations
• Diabetes
• Hemochromatosis
• Alcoholism
• Antiretroviral Therapy
• Spina bifida
• Lyme Disease
• Myelomeningocele
• Hansen’s Disease
• Syringomyelia
• Amyloidosis
• Syphilis
• Steroid Use
• Pernicious Anemia Rheumatoid Arthritis
• Spinal Cord Compression 20 patients (1986 – 2009)
Grear et al. FAI 2013
• Charcot Marie Tooth Syndrome
• Multiple Sclerosis
 Neurotrophic / Neurotraumatic

• Does it really matter?

Eichenholz Stages
1966
 *Schon 1998

Sanders / Frykberg
Consider the STJ
Brodsky / Rouse 1986
 Why is Charcot So Devastating?

 Charcot joints in ~ 0.16% of patients with DM (Glover et al. Adv

Wound Care 1997, Larson et al. Diabet Foot Ankle 2012)

 0.3% - 7.5% reported incidence

 40% Charcot develop ulceration

 Amputation in charcot patients (4.1%)

 Charcot + DM Ulceration (12x) vs. DM Ulceration alone (7x)

 Sohn et al Diabetes Care 2010

 35% higher mortality rate with Charcot + Foot Ulcer (w/ in 5 years)

 Sohn et al Diabetes Care 2009

 Charcot or Worse?
“Crush injury 5 days prior” to presentation

Recent hospital admission with WBC 20,000

(+) MSSA blood cultures

History of bilateral foot deformity bilateral

left foot years ago

11.8
14 219

HbA1c 8.9% ESR 97 / CRP 145 / Lactate 1.0

 Charcot: More Fun Facts…
Specialty referral centers have increased cases reported
59% increased risk for Charcot if obese and neuropathic
Stuck et al. Am J Med 2008

Quality of life poor (low SF 36 scores)

Better functional outcome when diagnosed within 3
months (Physical function + General health > Mental health)
Pakarinen et al. JFAS 2009
Wukich et al. Diabet Med 2011

Link btw neuropathy and CV disease

CV optimization decreased 5 year mortality in Charcot patients
Young et al. Diabetes Care 2008
Gazis et al. Diabet Med 2004
Pitocco et al. Acta Diabetolog 2014
 Charcot patients have “DM on the Brain”
• Subclinical albuminuria = Nephropathy AND Gray Matter Atrophy
– Impact on congnitive function
– Methta et al. Metabolism: Clin and Experimental 2014

• Pts with DFU decreased cognitive capacity without association of

smoking / depression
– Memory, exec function, reaction time, psychomotor, attention
– Natovich et al. Diabetes Care 2016

• Compliance (un-intentional vs. primary / secondary)

– Chatteree et al. J Med Ethics 2006

• Significantly decreased quality of life scores with presence of wound

(Validated Cardiff Wound Impact Scale)
– Goodridge et al. Foot and Ankle Int. 2006
– Price et al. International Wound Journal 2004
 Bone Quality in Charcot is Poor
• Marked increase in osteoclastic activity in DM
• Decreased collagen synthesis
• Decreased osteoid
• Impaired biomechanical strength of callus
(stiffness / tensile strength)
• Hyperglycemia impairs osteoblast response to
IGF 1 and increased AGE
• Loss of Bone Mineral Density
• Comorbidities
– Osteoporosis
– Renal Osteodystrophy
La Fontaine et al JFAS 2011
 Fracture vs. Dislocation
Herbst et al. JBJS (Br) 2004

Dislocation in Charcot = Normal BMD

Fracture in Charcot = Decreased BMD

 How Bone is Affected in Charcot
• Pleiotropic cytokines

• Bone resorption

– TNFα, IL -1 , IL-6
• Baumhauer et al. FAI 2006

• Protection from Bone resorption

– Offloading
• Folestad et al. J Foot Ankle Res 2015

– Increased IGF-1, IGF-2, IL 6

• Millet et al. J Bone Min Res 2004

– CGRP, VIP, Substance P

• Kaishihara et al. J Neuroci 1989
Cost comparison: Charcot Limb Salvage vs.
Trans-tibial Amputation
Gil et al FAI 2013

Level III retro-cohort study

n = 67 patients
Cost reviewed over 12 months
50% with OM

17/67 DM with BKA $49,251

82% in Rehab Facility

50/67 DM with Reconstruction $56,712

70% in Rehab Facility
 Charcot Treatment Options
Conservative Surgical
Saltzman et al. CORR 2005: review of non-operative
tx of Charcot (large tertiary center) • Plantar
Lowery et al. FAI 2012
ostectomy
• Immobilization
2.7% annual rate of amputation • TAL
95 articles reviewed (Level
23% rate of brace wear for more 4/5 clinicaldebridement
 Osseous evidence)
• than 18 months
Strict NWB
49% rate of recurrent ulceration • Realignment
Inconclusive: fixation /
osteotomy
timing arthrodesis
 Selective
Smith et al. Int J Evid Based Health 2007 (Southern
• Reduction maintained by
Australia)
 Internal fixation
cast/brace*decrease temperature /
Bisphosphates
disease activity vs. controls  External fixation
No evidence with reduction ulcerations,  Orthobiologics
hospital admissions, rate of surgical
• Bisphosphonates
intervention, QOL
 Can I WB these patients at all?
Parisi et al. Diabet Foot Ankle 2013

• N=22
– DM 2, Mean age 56 years, BMI 23 - 34

• Eicenholtz 1 / 2 walker boot / immediate WB good

functional outcomes
• No stat sig differences in lateral Meary’s angle
Goals of Charcot Reconstruction

• Plantigrade

• Stable

• Shoeable / braceable foot

• Decrease risk for further

breakdown / ulceration or
infection
 Charcot Reconstruction:
Key Points
• Heel under mechanical axis of lower leg

• Metatarsal heads perpendicular to heel

– weight evenly distributed

• Adjacent joints stabilized

• Passive dorsiflexion 5° past neutral

• Minimally invasive techniques

• Use of orthobiologics

• Supplemental external ring fixation

N = 15 Charcot
(7) Lisfranc
(4) Midtarsal
(2) NC
(1) Perinavicular
(1) Multiple

N = 19 DM / Neuropathy

N=16 unimparied

Level 2; NIH Funded Study

 Radiographic Measures as a Predictor of Ulcer
Formation in DM Charcot Midfoot
Bevan et al. FAI 2008

• Retrocohort investigation

• Non surgical charcot patients

• n = 24 feet (25% ulceration) when

Lateral Meary’s angle > - 27 degrees
Catanzaritiet al JFAS 2000
Wukichet al. FAI 2014 Schonet al FAI 1998

Medial column charcot: Lisfranc

Schon et al FAI 2002

 Cuboid Height as a Sole Predictor
for Ulceration

• No direct correlation
with plantar ulceration
(34.6% vs. 45.2%)

• Negative correlation
with Meary’s angle
– Meyr et al. JFAS 2017
Meary’s 15 degrees
Talar / 1st Met Angle Improvement

> 2 degree loss of correction correlates with non union

75% of nonunions – remained plantigrade

Calcaneal / 5th Met Angle Improvement

3-6 months duration for osseous union (73%)

No ulcer recurrence
• Sammarco (GJ) et al JBJS 2003
– Osseous union 83% @ 35 months
– Must span the Charcot segment

• Sammarco (VJ, GJ) et al JBJS 2009

– 73% union @ 52 months
– 8/22 broken screws

• Grant JFAS 2011

– +/- STJ fusion, 31.00 ± 22.97 months maintenance of radiographic correction

• Wiewiorski et al. JFAS 2012

– No failure @ 27 months (6.5mm fusion bolt)
– Medial column and CCJ

• Cullen et al. JFAS 2013

– No failure @ 18.5 months
 21 Patients (4 year follow up)

Worse complications when > 2/5 high risk criteria observed:

1) Substantial bone deformity

2) Ulcer over infected bone
3) Osteopenia
4) Obesity
5) Immunocompromise

Eschler et al. Journal Diabetes Research 2015

Pinzur MS. FAI 2007

Wound healing 21% ; Recurrent ulceration in 13% Average of 2.8 complications per patient
Richter et al. Foot Ankle Surg 2015 Lamm et al. JFAS 2010
 Can We Predict Who Will do Poorly?
Rettedal et al. JFAS 2018

• Charcot Reconstruction Preoperative

Prognostic Score (CRPPS)
• Poor prognosis = wound / major amputation
at last follow up [4.33 ± 1.07]
• Score of [2.96 ± 1.23] consistent with better
prognosis
• Score > 4 consistent with poor outcome
• Regression: anatomic location (ANKLE) /
CRPPS
• Sensitivity of 75% ; Specificity of 71%
Lamm et al. JFAS 2016
Lamm et al. JFAS 2010
 Anterograde?
Assal et al JBJS 2009 / 2010 Technique Guide

n=15 DM / Charcot

Average 42 Month Follow up

6.5mm - 8mm X 150mm screw

Recommendations:

-TAL / GR +/- STJ Fusion

- Autograft

- Thread purchase > 50% of 1st met

Ulceration NOT Contraindicated

• 2 Ring Pedal Block
• 2 Ring Tibial Block
• 2 Half pins proximal tibia ring
• 1 Half pin distal tibia ring
• Axial wire distal tibia
• Axial wire proximal tibia
• Axial wire calcaneus
• Oblique calcaneal wire
• Axial wire talus (+/- additional oblique
wire)
• 2 metatarsal wires
External fixation with greater odds of success (systematic review of 616
procedures) (Dayton et al. JFAS 2015)
8x more nonunion with ex fix ; 1.5 X amputation with internal fixation with higher
rate of overall complications (Lee et al. Orthopaedics 2016)
13 Steps
• Immediately after procedure
– Hibbiclens soaked gauze or sponge
– Bolster tight against the skin

• No change for 1 week

• Perioperatively until removal

– Q3 day change with chlorhexidine wipes
– 4x4 gazue ABD and ACE

• Treat PRN with dicloxicillin, cephalexin, or doxycyline

• Recognition of the CONTINUUM:

– Pin site irritation
– Pin site infection
– Pin tract infection
 No two feet are created equal

25 degrees varus / 8 degrees varus

6 weeks

Camasta 2010 PI Update

Post Operative Clinical 8 months
Development of neuropathic ankle after midfoot charcot:
5 / 171 feet

Pinzur MS. FAI 2012

7/28/2016
Post op
11/2014 - 11/2015
Intra Op: 3/2016
• Reduction of exuberant scar tissue and
promoting neurogenic support to bone
growth (Wei et al. J. Biol Chem 2009,
Kassemm et al. Acta Opthalmol 2013)

• Downregulation of TNF-alpha and IL-1 (He

et al. J Biol Chem 2013, Romero et al. J.
Obstet Gynecol 1994)
8/2016
Post op Clinical
1/21/2016
3/2016
Intra Operative Fluoroscopy
5/5/2016
6/2/2016
6/2016
6/21/2016
3 Months Post op
5/9/2017
CT Scan 11/2017
Presentation to UMOA: 12/21/2017
 Pre Op Ceretec Scan

• No evidence of osteomyelitis
Surgery #1: 1/30/2018
3/29/2018
5/10/2018
Surgery #2: STJ Arthrodesis / ROH / Exchange HW
DOS: 5/30/2018
Last Follow Up: 6/14/2018
 Summary
• Prognostic influence: Lateral Talar First Met alignment +
Tibiocalcaneal alignment

• Assessment of physiology preoperatively and preservation

perioperatively

• Influence of hindfoot alignment on midtarsal joint

• Influence of bone mineral density on deformity

• Potential for cascade of HW failure in midfoot

– (serial radiographs important)

• Hindfoot stability >> Midfoot

• Obtain then Maintain

Thank You