Podiatry Today | March 2018

Supplement to March 2018

PodiatryToday

Emerging Concepts
In Surgical Management
Of The Charcot Foot
And Ankle

SUPPORTED BY

1
 Supplement

Supplement Authors
Peter A. Blume, DPM, FACFAS is an Assistant Clinical Professor of Surgery in the Department of Sur-
gery and an Assistant Clinical Professor of Orthopaedics and Rehabilitation in the Department of Ortho-
paedics, Section of Podiatric Surgery at the Yale University School of Medicine in New Haven, Ct.

Ryan J. Donegan, DPM, MS, AACFAS is in private practice in Enfield, Ct.

Philip Wrotslavsky, DPM, FACFAS is board-certified in foot and reconstructive rearfoot and ankle
surgery by the American Board of Foot and Ankle Surgery. He is in private practice in San Diego. He is
fellowship-trained in limb lengthening and reconstruction.

William Grant, DPM, FACFAS is board-certified by the American Board of Podiatric Surgery. He is
an instructor in the Department of Surgery at Eastern Virginia Medical School and is in private practice
in Virginia Beach,Va.

Bryan Barbato, MS, is a fourth-year student at the Barry University School of Podiatric Medicine.

Lisa Grant-McDonald, DPM is a Fellow with the CHI Franciscan Health Advanced Foot and Ankle
Reconstructive Surgery Fellowship in Lakewood, Wash.

Jeffrey Yates, BS is an applicant to Virginia Tech Medical School.

Alexander Webb, BS is a graduate of Norfolk State University and an incoming first-year student at the
Barry University School of Podiatric Medicine.

Byron Hutchinson, DPM, FACFAS is board-certified in foot and ankle surgery by the American
Board of Podiatric Surgery. He is the Director of Residency Training at St. Francis Medical Center in
Federal Way, Wash. Dr. Hutchinson is in private practice in Burien, Wash.

70 E. Swedesford Road, Suite 100, Malvern, PA 19355

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Table of Contents

When Patients Have Charcot Osteoarthropathy And Osteomyelitis

4
Given the challenges of treating this patient population, these authors discuss principles of diagnostic testing and
pertinent factors in formulating an effective treatment algorithm.
By Peter A. Blume, DPM, FACFAS, and Ryan J. Donegan, DPM, MS, AACFAS

Gradual Deformity Correction In The Charcot Foot

Citing the merits of gradual correction of Charcot deformities, this author emphasizes accurate assessment of the

8 deformity’s magnitude, a strong awareness of at-risk structures and appropriate ex fix selection to help achieve
optimal outcomes.
By Philip Wrotslavsky, DPM, FACFAS

Advanced Concepts In The Beaming Of The Charcot Foot

Discussing the inherent challenges with the etiology of the Charcot foot, these authors advocate the use of Root

13
biomechanical principles to facilitate a sound surgical plan and offer their recommendations for beaming in
reconstructive surgery.
By William P. Grant, DPM, FACFAS, Bryan Barbato, BS, Lisa Grant-McDonald,
DPM, Jeffrey Yates, BS, and Alexander Webb, BS

Key Principles On Frame Biomechanics And Application For Charcot Reconstruction

18
Recognizing the challenges of utilizing circular fixation in patients with diabetes and Charcot, this author dis-
cusses pertinent biomechanical factors and offers pearls on frame application to reduce complication risk.
By Byron Hutchinson, DPM, FACFAS

Current Insights On Charcot Ankle Reconstruction

20 When it comes to Charcot arthropathy of the ankle, this author emphasizes a strong awareness of the relevant
pathologic and metabolic processes, assessment and optimization of comorbidities, and keys to optimal fixation.
By Byron Hutchinson, DPM, FACFAS

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 Supplement

When Patients Have Charcot

Osteoarthropathy And Osteomyelitis
Given the challenges of treating this patient population, these authors discuss principles of diagnostic testing and
pertinent factors in formulating an effective treatment algorithm.
By Peter A. Blume , DPM, FACFAS, and Ryan J. Donegan, DPM, MS, AACFAS

C harcot osteoarthropathy was

first described in 1883 and re-
mains a poorly understood and
frequently overlooked complication of
diabetes.1 Recognition in the earliest
including hospitalists, vascular special-
ists and infectious disease physicians in
addition to foot and ankle surgeons, is
critical in providing the most successful
outcomes for this at-risk population.
However, differentiating between
acute Charcot osteoarthropathy and
osteomyelitis is difficult due to similar
signal intensity changes.16 Bone scintig-
raphy is highly sensitive but lacks speci-
stage is problematic as many cases are ficity in the diagnosis of Charcot osteo-
misdiagnosed. An estimated 7 percent Diagnosing Charcot arthropathy.17 Clinicians mainly use bone
of the United States population has di- Osteoarthropathy scintigraphy to rule out osteomyelitis in
abetes and along with the increased life Charcot osteoarthropathy is a diagnosis diabetic patients with open wounds and
expectancy of this population, diabe- by clinical examination. One should use the use of leukocyte-labeled bone scans
tes-associated complications such as foot imaging to stage and supplement evalua- offers a distinct advantage over MRI in
ulcerations, peripheral arterial disease, tion of the progression of the condition. patients with metal implants. With bone
infections and Charcot osteoarthropathy In practical clinical application, there are scans, there is no artifact generated from
are increasing in prevalence.2,3 acute and chronic stages of Charcot os- imaging of metal implants but this not
Charcot osteoarthropathy is a relative- teoarthropathy.10-14 In the patient with the case with MRI as the artifact can ob-
ly painless, progressive and degenerative acute-stage Charcot, osteoarthropathy scure imaging results.
arthropathy of a single or multiple joints and osteomyelitis are extremely difficult Although controversy has emerged
caused by underlying neurologic defi- to diagnose when they occur concur- concerning the accuracy of the “gold
cits, most commonly affecting peripheral rently as they appear to have similar pre- standard” bone biopsy, researchers still
joints. Current estimates of prevalence sentations both clinically and with im- recommend the modality and withhold-
range from .08 percent in the gener- aging modalities. As with any pathology, ing antibiotics for 48 hours prior to cul-
al diabetic population to 13 percent in clinicians would use a stepwise process to turing.18 Lavery and colleagues report
high-risk diabetic patients.4 Charcot os- obtain an accurate diagnosis, leading to 95 percent sensitivity and 99 percent
teoarthropathy usually occurs eight to correct treatment. specificity for osteomyelitis with a mean
12 years after the diagnosis of diabetes, While a history of infections and open of 1.6 isolates per patient, and Staphylo-
occurs more frequently in men during wounds can increase suspicion of osteo- coccus aureus (33 percent) and Enterococci
the fifth and sixth decades, and has recur- myelitis, this does not exclude a con- (12 percent) being the most common
rence rates between 12 to 33 percent.5-7 comitant Charcot osteoarthropathy pro- isolates.19 The table “A Closer Look At
Diabetic patients with Charcot osteo- cess just as unremarkable clinical tests do Diagnostic Imaging Studies” on page 5
arthropathy are complex patients with not exclude infection. One can employ offers a summary of relevant imaging
many comorbidities. When severe infec- laboratory testing for affirming as well as studies.
tion is concurrent, morbidity and mor- monitoring treatment. Advanced imag-
tality rates can be as high as 35 percent, ing also plays a role in the difficult task Addressing Perfusion,
even when there is appropriate manage- of differentiation between Charcot os- Osteomyelitis, Wound Coverage
ment of the infection.8 In contrast to teoarthropathy and osteomyelitis. Mag- And Reconstruction
Charcot osteoarthropathy, osteomyelitis netic resonance imaging (MRI) allows When formulating a treatment algo-
itself is an infection in the bone. People simultaneous evaluation of soft tissue and rithm for Charcot osteoarthropathy with
who have diabetes most often devel- osseous structures as well as defining the osteomyelitis, it is imperative to address
op osteomyelitis in their feet as a result anatomic location with good accuracy all factors that may have an effect on the
of foot ulcers.9 A team-based approach, and localization.15 outcome.The goal is as close to full erad-

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 Podiatry Today | March 2018

A Closer Look At Diagnostic Imaging Studies

Study Results Conclusions

SPECT/CT coupled with Sensitivity and specificity Coupling of 67Ga SPECT/
bedside percutaneous bone for combined method 88.0 CT imaging and bedside
biopsy when positive scan percent and 93.6 percent percutaneous bone puncture
obtained.20 respectively. Positive predictive accurate for diagnosing dia-
value (PPV) and negative betic foot osteomyelitis
predictive value (NPV) of
Here one can see radical resection of 91.7 percent and 90.7 percent
infected bone. respectively.
Suspected osteomyelitis or Sensitivity, specificity and SPECT/CT significantly
exacerbation of known osteo- accuracy for CT of 77, 86, more accurate compared
ication of osteomyelitis before final re- myelitis investigated with CT and 79 percent. For SPECT/ with CT
construction takes place. During the ini- and SPECT/CT.21 CT, sensitivity, specificity and
tial treatment of osteomyelitis, assessment accuracy of 100, 86, and 98
of perfusion is critical as this is ultimately percent.
the most important factor for a success-
T1-weighted MRI features 93 percent of cases demon- Cases that did not demon-
ful outcome. One needs to close wounds, associated with diabetic strated T1-weighted imaging strate typical T1-weighted
manage tissue deficits and address osse- pedal osteomyelitis present features typical of pedal osteo- features predominantly
ous instabilities and areas prone to break- in histologically proven cases myelitis with confluent region secondary to hematologic
down. The overall strategy for surgically non-pedal osteomyelitis.22 of decreased signal intensity, mechanism of infection
managing a severe diabetic foot infection hypointense or isointense,
is infection control through aggressive relative to skeletal muscle in
and extensive surgical debridement, a a geographic pattern with
comprehensive vascular assessment with medullary distribution
possible vascular surgery and/or endo- Investigated FDG PET/CT FDG PET/CT sensitivity, Foci sites of acute infection
vascular intervention, and soft tissue and for diagnosis of osteomyelitis specificity and accuracy of precisely localized with PET/
skeletal reconstruction after the eradica- in the diabetic foot.23 100, 92, and 95 percent in CT allowing correct differ-
tion of infection to obtain wound clo- a patient-based analysis and entiation between osteomy-
sure and limb salvage. 100, 93, and 96 percent in elitis and soft-tissue infection
The need for adequate perfusion is ob- lesion-based analysis
vious. Many times, limb salvage requires Investigated bone scintigraphy Inflammatory lesions were MRI rather than plantar
a combination of infection management, to MRI for detecting osseous detected in 74.1 percent of bone scintigraphy for detec-
wound closure and surgical reconstruc- lesions.24 symptomatic regions by bone tion of chronic osteomyelitis
tion. All three of these factors are depen- scintigraphy and 98.1 percent
dent upon the perfusion of the lower of symptomatic regions by
extremity, allowing for adequate antibi- MRI. Sensitivity of MRI
otic delivery and osseous and skin heal- compared to bone scintigra-
ing. Perfusion should be greater than 30 phy was superior in detecting
mm Hg because lower values of arterial lesions in the long bones of
the thigh and the lower legs
perfusion are associated with impaired
(100 percent vs 78.4 percent
wound healing.25
respectively).
If the patient has inadequate perfusion,
you need to work closely with a vascu-
lar or interventional radiologist. Do not map of the arteries.8 Revascularization devascularized bone. Therefore, ade-
assume patients with Charcot osteoar- should be angiosome-directed and with quate surgical debridement, in addition
thropathy have proficient perfusion. The improved techniques such as retrograde to antimicrobial therapy, is necessary to
ankle-brachial index measurement is endovascular approaches, even small distal cure chronic osteomyelitis. The length
considered the most accurate noninvasive arteries are now accessible. of treatment for osteomyelitis depends
diagnostic method for evaluating periph- A severe diabetic foot infection car- upon clean margins as well as culture
eral arterial disease (PAD).26 This provides ries a 25 percent risk of major ampu- positive and culture negative specimens.
a quantitative evaluation of distal flow. In tation and one should involve infec- The standard recommendation for treat-
contrast, angiography can provide a defin- tious disease specialists as quickly as ing chronic osteomyelitis is six weeks of
itive diagnosis of PAD by showing a road possible.27 Antibiotics do not penetrate tailored parenteral antibiotic therapy.28

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 Supplement

The Reconstructive
Ladder For Wound
Closure
Free Flap

Tissue Expansion

Pedicle Flap

Local Flap

Skin Graft

Dermal Matrices

Negative-Pressure Wound Therapy

Closure by Secondary Intention

Primary Closure

Ascending the ladder, closure

becomes more technically difficult
and morbidities are increased. One
should choose a closure technique that Note the reconstruction of the deformity to prevent recurrent wounds. Resection
provides the least morbidity and most of bone, the exchange of bone cement, bone grafting, osteotomies and
durability, but this does not always arthrodesis are all options to achieve a stable foot.
involve starting at the lower steps.

However, oral antibiotics have now be- ces and other biologics, along with neg- comes reconstruction of the foot/ankle
come available that achieve adequate ative-pressure wound therapy (NPWT), in a stable plantigrade position. Resec-
levels in bone, achieving similar cure have played a large role in reducing the tion of bone, exchange of bone cement,
rates. Antibiotic-loaded bone cement need for more involved flaps. Still, large bone grafting, osteotomies and arthrode-
represents another antibiotic delivery deficits of tissue, exposed bone/tendon sis are all available to achieve a stable foot
vehicle, ideally providing antibiotic de- and plantar weightbearing wounds do not (see above radiograph). Surgeons can also
livery while simultaneously contributing have good outcomes with skin grafting. employ soft tissue balancing and gradu-
to the process of bone regeneration.29 Successful closure requires the removal al correction with Orthofix hexapod
Diabetic foot and ankle reconstruction of biofilm and a vascularized granular frames when long-standing deformities,
closure requires a thorough knowledge wound bed along with the prevention chronic soft tissue contractures and pe-
of flap and grafting techniques. One of seroma and sheer forces. Orthofix ripheral scarring of the neurovascular
must be vigilant with appropriate pa- flap frames with quick adjust struts ide- bundle are present.
tient selection and a thorough workup ally combine the rigidity and protection There are many different ways of main-
prior to surgery will assist in obtaining required while simultaneously allowing taining deformity correction in recon-
optimal results. If there is any question easy access. See “The Reconstructive struction. Surgeons may use Steinmann
about the patient’s vascular status, angio- Ladder For Wound Closure” above. pins to maintain position, achieve com-
gram and ankle-brachial index (ABI) are When Charcot osteoarthropathy is in pression with external fixation through
crucial, and one can utilize these findings the presence of an open wound, a step- midfoot, hindfoot and/or ankle joints,
with angiosome principles to plan flaps wise approach is required. The first step and achieve stabilization with beaming
and closures. The goal of wound heal- involves radical resection of clinically in- bolts and dual-purpose antibiotic-coated
ing is to obtain the best closure through fected bone (see photo on page 5).Tissue intramedullary nails (see left photo on
the least morbid means. The decision for cultures from the resected bone guide an- page 7). These are all viable options. One
wound closure depends on the location tibiotic therapy, involving any combina- would usually maintain fixation for a pe-
of the wound and host factors (i.e. tissue tion of intravenous, oral and implantable riod of eight weeks in foot deformities
extensibility and the individual’s healing bone cement/antibiotic-loaded beads/ and a minimum of 12 weeks when the
potential). bone void filler with antibiotics. After ankle is involved.
Adjunctive therapy with dermal matri- clearance of osteomyelitis, the focus be- The final outcome should be a limb

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 Podiatry Today | March 2018

pathic osteoarthropathy in the feet of diabetics.

Radiographics. 1996;16(6):1337–1348.
17. Schauwecker DS, Park HM, Burt RW, Mock
BH, Wellman HN. Combined bone scin-
tigraphy and indium-111 leukocyte scans
in neuropathic foot disease. J Nucl Med.
1988;29(10):1651–1655.
18. Crim BE, Wukich DK. Osteomyelitis of the
foot and ankle in the diabetic population:
diagnosis and treatment. J Diab Foot Comp.
2010;1(2):25–35.
19. Lavery LA, Sariaya M, Ashry H, Harkless LB.
Microbiology of osteomyelitis in diabetic foot
infections. J Foot Ankle Surg. 1995;34(1):61–64.
20. Aslangul E, M’bemba J, Caillat-Vigneron N,
et al. Diagnosing diabetic foot osteomyelitis in
patients without signs of soft tissue infection
The final outcome should be a limb with by coupling hybrid 67Ga SPECT/CT with
all biomechanical factors addressed bedside percutaneous bone puncture. Diabetes
Care. 2013;36(8):2203-10.
Note the use of external fixation to in order to provide a functional,
21. Bolouri C, Merwald M, Huellner MW, et al.
maintain reconstruction. plantigrade, wound-free limb.
Performance of orthopantomography, planar
scintigraphy, CT alone and SPECT/CT in pa-
tients with suspected osteomyelitis of the jaw.
with all biomechanical factors addressed Duration of off-loading and recurrence rate in Eur J Nucl Med Mol Imaging. 2013;40(3):411-7.
Charcot osteo-arthropathy treated with less re- 22. Howe BM, Wenger DE, Mandrekar J, Collins
to provide a functional, plantigrade, strictive regimen with removable walker. J Dia- MS. T1-weighted MRI imaging features of
wound-free limb done in an econom- betes Complications. 2012;26(5):430–434. pathologically proven non-pedal osteomyelitis.
ically responsible way (see right photo 6. Bates M, Petrova NL, Edmonds ME. How long Acad Radiol. 2013;20(1):108-14.
above). Using this protocol, Pinzur and does it take to progress from cast to shoes in 23. Kagna O, Srour S, Melamed E, Militianu D,
colleagues were able to achieve 95.7 the management of Charcot osteoarthropathy? Keidar Z. FDG PET/CT imaging in the diag-
Diabet Med. 2006;23(2 Suppl):27–A100. nosis of osteomyelitis in the diabetic foot. Eur J
percent limb salvage with ambulation 7. Fabrin J, Larsen K, Holstein PE. Long-term Nucl Med Mol Imaging. 2012;39(10);1545-50.
in commercially available therapeutic follow-up in diabetic Charcot feet with spon- 24. Morbach H, Schneider P, Schwarz T, et al.
footwear.30 taneous onset. Diabetes Care. 2000;23(6):796– Comparison of magnetic resonance imaging
800. and 99mTechnetium-labelled ethylene diphos-
Maximizing Outcomes 8. Kinlay S. Management of Critical Limb Isch- phonate bone scintigraphy in the initial assess-
emia. Circ Cardiovasc Interv. 2016;9(2):e001946. ment of chronic non-bacterial osteomyelitis of
Diabetic patients with Charcot osteo- 9. Khan NA, Rahim SA, Anand SS, Simel DL, childhood and adolesecents. Clin Exp Rheuma-
arthropathy are complex patients with Panju A. Does the clinical examination pre- tol. 2012;30(4):578-82.
many comorbidities other than osteomy- dict lower extremity peripheral arterial disease? 25. Saqib NU, Domenick N, Cho JS, et al. Predic-
elitis. A proactive, cooperative, co-man- JAMA. 2006;295(5):536–546. tors and outcomes of restenosis following tibial
agement model for the perioperative 10. Shem KL. Neuroarthropathy of the wrist in artery endovascular interventions for critical
paraplegia: A case report. J Spinal Cord Med. limb ischemia. J Vasc Surg. 2013;57(3):692–699.
management of high-risk patients un- 2006;29(4):436–439. 26. Faglia E. Characteristics of peripheral arterial
dergoing complex surgery can improve 11. Brown C, Jones B, Donaldson DH, Akmakjian disease and its relevance to the diabetic popula-
the quality and efficiency metrics associ- J, Brugman JL. Neuropathic (Charcot) arthrop- tion. Int J Low Extrem Wounds. 2011;10(3):152–
ated with the delivery of service to these athy of the spine after traumatic spinal paraple- 166.
complicated patients.31 n gia. Spine. 1992;17(6 Suppl):S103–S108. 27. Zgonis T, Stapleton JJ, Roukis TS. A stepwise
12. Smith DG, Barnes BC, Sands AK, Boyko EJ, approach to the surgical management of se-
Ahroni JH. Prevalence of radiographic foot ab- vere diabetic foot infections. Foot Ankle Spec.
References
normalities in patients with diabetes. Foot Ankle 2008;1(1):46–53.
1. Chisholm KA, Gilchrist JM.The Charcot joint:
Int. 1997;18(6):342–346. 28. Spellberg B, Lipsky BA. Systemic antibiotic
a modern neurologic perspective. J Clin Neuro-
13. Stuck RM, Sohn MW, Budiman-Mak E, Lee therapy for chronic osteomyelitis in adults. Clin
muscul Dis. 2011;13(1):1–13.
TA, Weiss KB. Charcot arthropathy risk ele- Infect Dis. 2012;54(3):393–407.
2. Wild S, Roglic G, Green A, Sicree R, King H.
vation in the obese diabetic population. Am J 29. Hanssen AD. Local antibiotic delivery vehicles
Global prevalence of diabetes: estimates for the
Med. 2008;121(11):1008–1014. in the treatment of musculoskeletal infection.
year 2000 and projections for 2030. Diabetes
14. Jones CW, Agolley D, Burns K, Gupta S, Hors- Clin Orthop Relat Res. 2005;437:91–96.
Care. 2004;27(5):1047–1053.
ley M. Charcot arthropathy presenting with 30. Pinzur MS, Gil J, Belmares J. Treatment of os-
3. Frykberg RG, Zgonis T, Armstrong DG, et
primary bone resorption. Foot. 2012;22(3):258– teomyelitis in charcot foot with single-stage
al. Diabetic foot disorders. A clinical practice
263. resection of infection, correction of deformity,
guideline (2006 revision). J Foot Ankle Surg.
15. Tan PL, Teh J. MRI of the diabetic foot: differ- and maintenance with ring fixation. Foot Ankle
2006;45(5 Suppl):S1–S66.
entiation of infection from neuropathic change. Int. 2012;33(12):1069–1074.
4. Suder NC, Wukich DK. Prevalence of diabetic
Br J Radiol. 2007;80(959):939–948. 31. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospi-
neuropathy in patients undergoing foot and an-
16. Marcus CD, Ladam-Marcus VJ, Leone J, Mal- talist-orthopedic co-management of high-risk
kle surgery. Foot Ankle Spec. 2012;5(2):97–101.
grange D, Bonnet-Gausserand FM, Menanteau patients undergoing lower extremity recon-
5. Christensen TM, Gade-Rasmussen B, Peders-
BP. MR imaging of osteomyelitis and neuro- struction surgery. Orthopedics. 2009;32(7):495.
en LW, Hommel E, Holstein PE, Svendsen OL.

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 Supplement

Gradual Deformity Correction

In The Charcot Foot
Citing the merits of gradual correction of Charcot deformities, this author emphasizes accurate assessment of the
deformity’s magnitude, a strong awareness of at-risk structures and appropriate ex fix selection to help achieve
optimal outcomes.
By Philip Wrotslavsky, DPM, FACFAS

G radual correction of foot and

ankle deformities is a topic that
is not often discussed. The de-
cision of when to perform gradual cor-
rection in the foot requires a thorough
with a neuropathic foot) into consider-
ation. One can make an analogy to the
field of orthodontics and braces. No one
would find it acceptable to acutely cor-
rect misaligned teeth. That is why braces
understanding of deformity correction. are applied and the teeth are gradually
When the surgeon is faced with a com- corrected. Similarly, with the Charcot
plex disease process such as Charcot foot, a combination of equinus, shorten-
foot in addition to a multiplanar defor- ing, translation, angular deformities and
mity, one can appreciate the difficulty rotation of the foot will more often than
in choosing the appropriate procedure. not add up to a much larger deformity
Once one becomes aware of the mag- than originally perceived by the surgeon.
nitude of deformity associated with the
Charcot foot and the actual amount of Magnitude Of Deformity In
correction needed to obtain a stable foot, The Charcot Foot: How Much
then the decision regarding acute versus Correction Is Necessary?
gradual correction can be appreciated. These are the basic principles to keep
There is controversy about when to in mind when surgically correcting de-
proceed with surgery, the type of correc- formities that are present in the Char-
tion and fixation constructs. In the liter- cot foot. First, one must recognize the
ature, researchers have reported a failure Achilles is contracted and in equinus
rate of as much as 50 to 80 percent for (see photo at the left).6 One must always
Charcot foot reconstructions.1 While it surgically address the equinus deformity.
was previously believed that the Charcot Then the surgeon would need to cor-
foot had “bounding pulses” and more rect and fuse the medial column in or-
than adequate blood flow, Wukich and der to create a stable foot.The increased
colleagues recently noted a 40 percent When surgically correcting the glycosylation will change the biology
prevalence of peripheral arterial disease deformity present in a Charcot foot, of the fibers in the Achilles, causing it
(PAD) in patients with diabetic Charcot there are some basic principles. First, to contract and the plantar ligaments of
neuroarthropathy.2 one must recognize the Achilles is the foot to weaken, thus causing a break-
Previous authors have postulated that contracted and in equinus. down of the midfoot.7,8 The main lever
an acute deformity correction of the arm of the foot will stress the talonavic-
Charcot foot may lead to complications deformity correction while providing ular joint, naviculocuneiform joint and
of ischemia. To prevent ischemia in the less risk to neurovascular structures. In the cuneiforms to metatarsal joints. Ra-
Charcot limb, multiple authors have de- my opinion, not only does there need to diographically, one will more often see
scribed a two-stage approach to Charcot be a concern during an acute correction a large break in the Meary’s angle than
reconstruction involving gradual correc- for arterial structure compromise but the a drop in the calcaneal inclination angle
tion of the deformity followed by inter- physician should also take venous con- (see top photo on page 9). Lamm reports
nal fixation.3-5 The authors believe that gestion, skin stretching and even nerve the normal Meary’s angle is 4 degrees in
gradual correction allows for accurate structures (even though we are dealing a cavus position.9 I see an average of 25

8
 Podiatry Today | March 2018

Acute Versus Gradual

Correction: Advantages And
Disadvantages

Acute Gradual
Correction Correction

Best for small- to

Large deformities
medium-sized
can be corrected
deformities

Can use comput-

Better in the fe- er-assisted software
mur and humerus to attain exact
correction

If surgeon is not
Internal or exter- satisfied with the po-
nal fixation sition, he or she can
run a new program

Works well in tibia/

ankle region, where
Lengthening is not
there is high risk
typically possible
of nerve issue with
acute deformity

No ability to make Works well if patient

adjustments has poor soft tissue

Requires external
fixation and patient
to adjust frame

Slow correction
gives skin and
Radiographically, one will more often see a large break in the Meary’s angle than neurovasculature the
a drop in the calcaneal inclination angle (top). The author has treated patients ability to stretch
that had as large as 52.5 degrees of Meary’s angle break (bottom).

subluxed onto the hindfoot, one needs

degree Meary’s angle deformity, which other legs are located under the first and to measure the amount of subluxation to
puts the foot in a rocker bottom position, fifth metatarsal heads. In order to create see how many centimeters one will need
thus making the medial column break 29 that tripod, one must stabilize the medial to pull out to lengthen the foot. Usual-
degrees. I have treated patients that had column, which will subsequently drive ly by the time the surgeon gets the pa-
as large as 52.5 degrees of Meary’s break the lateral column into a more optimal tient to the OR, the overlapping bones
(see bottom image above). position. become stuck in the shortened position,
A way to simplify the correction goals After evaluating the equinus compo- which prohibits acute correction.
in the Charcot foot is by trying to cre- nent and the medial column, the surgeon Transverse deformities can contrib-
ate a tripod stand with the foot. The cal- needs to consider any shortening of the ute heavily to the overall magnitude as
caneus is one leg of the tripod and the foot. In cases in which the forefoot is an adducted or abducted foot can cause

9
 Supplement

The percutaneous Gigli saw osteotomy allows for a through-and-through midfoot, hindfoot or ankle osteotomy without
having large skin incisions.

The butt frame (left) allows for the correction of forefoot deformities in any direction. The miter frame (middle) and the 6+6
construct (right) allow for simlutaneous correction of a combination of forefoot and hindfoot deformity.

foot shortening. When performing an With the goal of fusing the medial col- the mechanical axis of the foot will en-
adduction to rectus correction, one must umn, the surgeon must attain alignment able better fixation and function.
be careful of the medial skin structures. in the dorsal/plantar view as well as in The other subtle deformity is a frontal
The skin on the lateral aspect of the foot the lateral view. The surgeon must be plane rotation. Too often with an acute
is the concern when correcting a large able to bisect the first metatarsal all the correction, the surgeon does a great job
abductus deformity. way through the talus in both views, es- correcting the equinus, transverse, lateral
The next two deformities are more pecially if one is to beam the foot. Oth- and translational deformities. However, if
subtle but do not be fooled because they erwise, the beaming screw will miss. If one does not address the frontal plane,
are still part of the overall magnitude of one is plating and the first metatarsal is the patient will end up walking on the
deformity. I will first discuss translation. too medial, the plate will not fit. Aligning outside or inside of the foot, causing a

10
 Podiatry Today | March 2018

Here is pre-op AP view showing a 25 degree talo-first metatarsal angle with 2 cm medial translational shift of the first
metatarsal (left) and a post-op AP view (right) showing reduction of the talo-first metatarsal angle to 1.6 degrees with
reduction of translation.

new set of ulcers. other terms, one will need to calculate to decide if acute or gradual correction
Grant and coworkers caution against how much to shorten the foot in order is the proper method of correcting the
the rote use of medial-based wedges.10-12 to avoid compromising any at-risk struc- Charcot foot. Using Herzenberg and
These wedges have limited indications tures. If the surgeon corrects the defor- Paley’s planning techniques, the surgeon
and may accentuate deformity in patients mity too quickly, the skin and vascula- can apply either the law of concentric
who have been selected inappropriately. ture are at risk for necrosis.While no two circles or the law of similar triangles to
Their results show that medial-based deformities are the same, in the Charcot decide on the rate of correction.13,14 One
wedges in patients with even small de- foot, the structures typically at risk are will also need to apply the formula de-
grees of hindfoot varus produced signifi- the dorsal and medial skin, and the dorsal scribed by Paley using the law of sines
cant accentuation of hindfoot varus. vasculature so a rocker to rectus correc- to see how much lengthening is ob-
Forefoot to hindfoot position is crit- tion will put the dorsalis pedis and dorsal tained when derotating the forefoot out
ical when preparing for medial column skin at risk. An adductus to rectus cor- of a supinatus position. Without adding
fusion as any misalignment can create rection will compromise the medial skin. up all the deformity parameters before
varus deformities and compromise one’s A large equinus correction can risk the performing an acute correction, the sur-
fixation. posterior tibial vasculature and a varus to geon is just guessing as to how much of
valgus ankle correction compromises the a bone wedge to remove without risk-
Being Aware Of The Structures medial skin and posterior tibial artery. ing the neurovascular structures and skin.
At Risk This is similar to a surgeon measuring
Ultimately, if performing an acute cor- Weighing Acute Versus Gradual the intermetatarsal angle prior to a bun-
rection, the surgeon needs to add up Correction ion surgery to decide where to perform
all these deformities and calculate how Once the surgeon has measured all the the osteotomy.Therefore, it is incumbent
much he or she is stretching the foot. In deformity parameters, the next step is upon the surgeon to do the same when

11
 Supplement

performing a Charcot correction. deformities in any direction. There are 2016;39(4):e595-e601.

2. Wukich DK, Raspovic KM, Suder NC. Prev-
The beauty of using a hexapod com- two other constructs that allow for sim-
alence of peripheral arterial disease in pa-
puter-assisted external fixator is that one lutaneous correction of a combination of tients With diabetic Charcot neuroarthropa-
has more flexibility when correcting the forefoot and hindfoot deformity. These thy. J Foot Ankle Surg. 2016;55(4):727–731.
multiplanar deformities that are present constructs are the miter frame (see bot- 3. Lamm B, Gottlieb H, Paley D. A two-stage
in the Charcot foot. The surgeon does tom middle photo on page 10) and the percutaneous approach to charcot diabet-
ic foot reconstruction. J Foot Ankle Surg.
not need to perform the aforementioned 6+6 (see bottom right photo on page
2010;49(6):517–522.
complex math equations because the 10).The 6+6 construct is a variant of the 4. Smith D,Wrotslavsky P.Two stage reconstruc-
computer software does that for you. Butt frame that places a ring anterior and tion of the diabetic Charcot foot: a review of
Using a gradual approach can be a safer, posterior to the butt joint, creating two 4 cases. Podiatry Institute Update 2016, Ch. 12,
more accurate and reproducible method separate frames on one. The miter frame Podiatry Insitute, Tucker, Ga., 2016, pp. 57-
60. http://www.podiatryinstitute.com/pdfs/
in correcting the Charcot foot.You have is based off the concept of a miter joint
Update_2016/2016_12.pdf. Accessed on De-
the ability to slowly correct the defor- in carpentry in which there is a 45-de- cember 7, 2017.
mities so the at-risk structures can adapt. gree angle connecting two straight items 5. Malay DS. Staged surgical management of the
The capability to run residual program that are going at a 90-degree angle. Charcot foot. Podiatry Institute Update 2012,
corrections allows for the surgeon to ad- In the case of the Charcot foot, the Podiatry Institute, Tucker, Ga., 2012, pp. 209-
213. Available at http://www.podiatryinsti-
dress any new deformities that were un- posterior portion of the miter frame can
tute.com/pdfs/Update_2012/2012_41.pdf.
masked during the correction. One can address hindfoot and ankle deformities, Accessed December 7, 2017.
correct large deformities without having and the distal portion can separately and 6. Lavery LA, Armstrong DG, Boulton AJ;
to perform shortening osteotomies. simultaneously address forefoot defor- Diabetex Research Group. Ankle equi-
External fixation can have minor mities. It is not within the scope of this nus deformity and its relationship to high
plantar pressure in a large population with
drawbacks that have simple solutions. article to delve into the nuances of six
diabetes mellitus. J Am Podiatr Med Assoc.
Proper education of the patient about axis computer-assisted deformity correc- 2002;92(9):479–482.
why gradual correction is of the utmost tion and all its intricacies. However, I do 7. Grant WP, Sullivan R, Sonenshine DE, et al.
importance. Patients who cannot per- need to note a major point. The advan- Electron microscopic investigation of the ef-
form the turns of the struts for various tages of using gradual correction with a fects of diabetes mellitus on the Achilles ten-
don. J Foot Ankle Surg. 1997;36(4):272–278.
reasons can have the assistance of a home hexapod fixator is that one has the ability
8. Batista F, Nery C, Pinzur M, et al. Achilles
nursing organization to help. Weekly fol- to make adjustments during the correc- tendinopathy in diabetes mellitus. Foot Ankle
low-ups with X-rays are essential to see tion process, unlike an acute correction, Int. 2008;29(5):498–501.
if the program is going accordingly. A which locks you into the original posi- 9. Standard SC. The Art of Limb Alignment. 5th
second procedure to remove the frame tion of correction.With computer-assist- ed. Baltimore, MD: Rubin Institute for Ad-
vanced Orthopedics, Sinai Hospital of Balti-
with the insertion of an internal fixation ed hexapod correction, if you unmask a
more; 2012: 163.
is part of the protocol. deformity during the correction process, 10. Grant-McDonald LM, Grant WP, Yates J.
you have the ability to run residual pro- Emerging concepts in beaming for Charcot.
Choosing The Right External grams that allow the surgeon to correct Podiatry Today. 2017;30(3):56–59.
Fixation any deformity in any direction. 11. Grant WP, Garcia-Lavin S, Sabo R. Beaming
the columns for Charcot diabetic foot recon-
Now that the surgeon has calculated the
struction: a retrospective analysis. J Foot Ankle
magnitude and center of rotation of an- In Conclusion Surg. 2011;50(2):182–189.
gulation (CORA) of the deformity, there Correcting the Charcot foot is not a 12. Grant LM, Catanzariti AR, Grant WP. Long-
are the decisions of where and how to simple surgery that involves randomly term outcomes of Charcot reconstruction:
perform the osteotomy. taking out wedges of bone to realign the a 20-year follow-up study. Presented at the
American College of Foot and Ankle Sur-
I prefer to perform a percutaneous foot. One must be aware that the Char-
geons 2017 Annual Scientific Meeting Feb-
Gigli saw osteotomy (see top photo on cot foot is a much larger deformity than ruary 27-March 2, 2017; Las Vegas, Nevada.
page 10). This technique allows for a what we see on X-ray. It is imperative 13. Paley D. Principles of Deformity Correction. Ch.
through-and-through midfoot, hindfoot to measure all appropriate angles and as- 11, Springer-Verlag Berlin Heidelberg, 2002,
or ankle osteotomy without having large certain the magnitude of the deformity pp. 363-365.
14. Herzenberg JE, Waanders NA. Calculating
skin incisions.15,16 prior to deciding upon what procedure
rate and duration of distraction for deformity
Prior to performing the osteotomy, to use. In my opinion, gradual deformity correction with the Ilizarov technique. Or-
the surgeon needs to decide on the type correction of the Charcot foot is the pre- thop Clin North Am. 1991;22(4):601–611.
of external fixator. With the Charcot ferred method of obtaining correction in 15. Lamm BM, Gourdine-Shaw MC,Thabet AM,
foot, there are two constructs that will the foot with a large deformity. It is safe, et al. Distraction osteogenesis for complex
foot deformities: Gigli saw midfoot osteoto-
correct the usual deformities associated reproducible and accurate. n
my with external fixation. J Foot Ankle Surg.
with Charcot. First is the butt frame (see 2014;53(5):567-76.
bottom left photo on page 10), which References 16. Mendicino RW, Catanzariti AR. Emerging
is based upon a butt joint in carpentry. 1. Lee DJ, Schaffer J, Chen T, Oh I. Internal concepts with percutaneous osteotomies. Po-
versus external fixation of Charcot mid- diatry Today. 2014;27(5):44-48.
It allows for the correction of forefoot foot deformity realignment. Orthopedics.

12
 Podiatry Today | March 2018

Advanced Concepts In The Beaming

Of The Charcot Foot
Discussing the inherent challenges with the etiology of the Charcot foot, these authors advocate the use of Root
biomechanical principles to facilitate a sound surgical plan and offer their recommendations for beaming in recon-
structive surgery.
By William P. Grant, DPM, FACFAS, Bryan Barbato, BS, Lisa Grant-McDonald, DPM,
Jeffrey Yates, BS, and Alexander Webb, BS

C harcot is a disease characterized

by increased local bone resorp-
tion by osteoclasts. The recep-
tor activator of nuclear factor-kappa-B
ligand (RANKL) is an integral compo-
nent in the regulation of osteoclast dif-
ferentiation and activation. The RANKL
induces the activation and differenti-
ation of osteoclasts by binding to the
osteoclasts’ RANK.1 Both RANK and
RANKL are expressed constitutively.
The RANKL overproduction is a char-
acteristic of Charcot but it is not limited Here is a preoperative 3D CT showing a Charcot midfoot with a plantar ulcer
to Charcot. It also occurs in many bone beneath the cuboid. Note that the navicular sits superior to the talus with
complete dislocation but no fracture. Also note the severe stacking of the
diseases such as psoriatic arthritis, rheu-
metatarsals.
matoid arthritis and osteoporosis.2
In a study involving three patient
groups, Mabilleau and colleagues com- neuroarthropathy group and was four occurs by non-enzymatic glycosylation,
pared monocyte formation into os- times greater than the osteoclastic activ- termed glycation. This primarily occurs
teoclasts and osteoclastic activity in vi- ity in the healthy group. Osteoclasts in in tissues with a slow turnover rate, ex-
tro with and without the addition of patients with Charcot neuroarthropathy posing collagen proteins to the extracel-
RANKL.3 The groups included patients differentiate to become highly active.4 lular environment where non-enzymatic
with diabetic Charcot neuroarthropathy, glycosylation takes place.4
healthy patients and patients with dia- A Closer Look At How AGE And Advanced glycation end products
betes. Without the addition of RANKL, RAGE Affect The Formation Of crosslink within and around collagen fi-
researchers noted a significant increase Charcot bers, and compromise their functional-
in osteoclast formation in the Charcot The formation of advanced glycation ity.6 Type 1 collagen’s main function is to
group in comparison with the healthy end products (AGEs) is a common con- resist tension and accounts for the rigidity
and control groups. There was also in- sequence of aging. Increased AGE pro- in bone. The primary locations of type 1
creased osteoclastic activity in the Char- duction occurs in patients with pro- collagen are skin, tendon, bone and den-
cot group in comparison with the others. longed elevated blood glucose levels, tin.6 Collagen crosslinking within bone is
With the presence of RANKL, the frequently termed hyperglycemia. Ad- known to affect bone stiffness andYoung’s
study authors noted an increase in osteo- vanced glycation end products modify modulus independent of the bones’ min-
clastic activity in all three of the groups.3 N-carboxymethyl-lysine of type I colla- eralization and microarchitecture. This
However, osteoclastic activity was con- gen (CML collagen).5 The post-transla- leads to weakening of bone strength
siderably more aggressive in the Charcot tional modification of the CML collagen without evidence of demineralization.7

13
 Supplement

Advanced glycation end product ac-

cumulation recruits the increased for-
mation of the pattern recognition re-
ceptor for AGE, known as RAGE,
which expresses constitutively and
causes increased downstream activation
of RANKL when bound. According
to Macaione and colleagues, increased
RANKL activation causes osteoclasto-
genesis.8 The soluble receptor (sRAGE)
competes with RAGE to bind RANKL.
The sRAGE also inhibits RAGE by
binding to RAGE.9
Witzke and colleagues assessed the loss
Again note the dislocation of the intact talus and the 3D CT AP view of RAGE defense as a cause of Charcot
demonstrating stacking of the metatarsals with the rolling down of the lateral neuroarthropathy by focusing on three
side away from the viewer. groups of patients.7 The three groups
included healthy control patients, pa-
tients with type 2 diabetes and patients
with diabetic Charcot neuroarthropathy.
Researchers recorded circulating levels
of sRAGE and bone stiffness for each
group. The study authors noted an 86
percent decrease in sRAGE values for
patients with Charcot neuroarthropathy
in comparison to the healthy control
population. Bone stiffness was marked-
ly reduced in the Charcot group. The
study authors concluded that RAGE did
in fact increase RANKL activation and
RANKL is responsible for increased os-
teoclastic activity. Additionally, a reduc-
tion in bone stiffness with a concomitant
increase in bone density may suggest a
Here one can see preliminary correction with removal of the external fixator and pathologic proliferation of cross-linked
the use of Steinmann pins due to the open wound plantarly. The surgeon has collagen.
corrected the metatarsal stacking and there is now anatomical realignment of Another potentially deleterious ef-
the foot with the talus and navicular articulating. fect of reduction in circulating sRAGE
is AGE-induced osteoblast apoptosis,
which authors have implicated in al-
terations to bone repair in the face of
elevated osteocalcin.9 This may explain
why Charcot fusion sites remain weak
even after consolidation.

Key Insights On The Forces

Acting On The Charcot Foot
For the foot and ankle surgeon, the
most important part of these cell bi-
ology studies is the finding that bone
stiffness was markedly reduced in pa-
tients with Charcot neuroarthropathy.10
These findings correlate directly with
studies that demonstrate a decreased
This 3D CT AP view confirms realignment of the talus and navicular as well as
normal width of the foot with correction of the metatarsal stacking. Young’s modulus of elasticity and tensile
strength in the Achilles tendon in pa-

14
 Podiatry Today | March 2018

tients with Charcot neuroarthropathy.11

Carboxymethyl-lysine of type I colla-
gen is a major constituent of bone, ten-
don and the ligaments that hold bones
together. There is a combination of bio-
chemical evidence and laboratory testing
evidence that shows that AGE radically
alters bone and tendon.12 The best clin-
ical treatment solution for this process
would be a reversal of AGEs or a replace-
ment of sRAGE, but these options are
not feasible at this time.
This altered cellular biology that re-
sults in a diabetic Charcot foot requires
an approach to surgical reconstruction
that compensates for:
1) glycosylation of collagen resulting
in failure of ligaments of the hind-
foot and bone stiffness reduction;
and
2) RANK-L-mediated and increased
osteoclastic activity downregulating
bone repair.
This demands a reconstruction plan
that includes arthrodesis of the affected
foot joints to negate abnormal ligaments
from their normal role and selection of
hardware strong enough to load share
with the weakened bones.
As the foot moves throughout the gait
cycle, the bones move relative to each
other and Root and colleagues describe
that the direction of forces acting upon
the rearfoot or more proximal bone
will react and angle with the direction
of the forces acting on the forefoot or
more distal bone.13 As the joints in the
foot move during the gait cycle, the ra-
tio of compressive forces and rotational
movement forces alternates. As the an-
gle between joints becomes larger, the Note the placement of a medial column beam for Charcot. One can perform
rotational movement forces are greater beaming percutaneously.
and compressive forces are lesser. During
the period of great rotational movement
forces, muscles and ligaments must func- The majority of the forces at that joint the skeleton to resist the rotational forces
tion to resist excessive rotational motion are developed from compression rather on its own. Diabetes targets the intrin-
at joints. than rotational moment forces. However, sic muscles of the foot and glycosylates
Root and coworkers theorized that if the angle between a joint increases the tendon and ligament, creating a higher
when the foot is in a neutral or supi- rotational moment forces, deformation propensity for them to become fatigued
nated position, the bone and joints of is likely. It is the job of the muscles and and fail.
the medial column are at a lesser angle ligaments to maintain sufficient tension Peripheral neuropathy and polyneu-
with each other, and are able to provide force to resist any undesirable rotational ropathy are common findings in the
greater compressive forces in compari- motion at the joints in order to prevent diabetic population. Neuropathy affects
son to a pronated foot.13 With the foot disruption of joint integrity. sensation and proprioception. Dimin-
in a neutral or supinated position, there As muscles become overworked and ished sensation and proprioception in-
are reduced forces interacting at a joint. ligaments become fatigued, this leaves hibits one’s ability to react to uneven

15
 Supplement

pavement, fatigued ligaments or any

excessive or prolonged rotational move-
ment forces that continually act upon
the foot during the gait cycle.
Producing a foot which will be fixed
in a neutral or slightly supinated position
allows the bones and joints to function at
a lesser angle with each other.This facili-
tates higher compressive forces and picks
up some of the slack from the weakened
intrinsic muscles, and fatigued ligaments
and tendons. The foot will be capable of
maintaining its own skeletal integrity.
The purpose of this article is to describe
a biomechanical surgical approach based
on Root biomechanics to reconstruct a
Charcot foot. This results in a Charcot
foot that does not rely on glycosylated
soft tissues for stability but relies on the
principles of proximal osseous stability.

Here is an intraoperative radiograph showing the use of guide pins for placement What You Should Know About
of the beams within the first and second metatarsal segments to beam the The Surgical Goals And
medial column. Technique
The bones of the reconstructed Charcot
foot should be neutral or slightly supi-
nated. Glycosylation causes weakness in
the ligaments that likely fail when the
proximal stable bones and distal reactive
bones are at increased angle during the
propulsive stage of gait. Alternately, a
neutral or slightly supinated foot posi-
tion allows joint compression and syner-
gy with arthrodesis hardware.
A neutral to slightly supinated foot has
the following characteristics:
* A Meary’s angle near 0 degrees
* Positive calcaneal inclination angle
* Slightly adducted forefoot
* Stable hindfoot
In light of the accumulating evidence
that Charcot diabetic foot is most likely
associated with AGE-RAGE glycosyla-
tion of collagen and ligamentous failure,
arthrodesis of the displaced joints is the
recommended surgical treatment. When
performing arthrodesis, the positions of
the foot should be as follows: adducted, a
Meary’s angle of 0 degrees, no supinatus
and no stacking of metatarsals.
Since Charcot bone of the foot is in-
trinsically altered, its tensile strength,
elasticity and porosity are abnormal.
Here is a lateral view of Charcot reconstruction. All three metatarsal beams Therefore, any internal fixation the sur-
load share together because the subtalar joint is locked. geon chooses should ideally function to
supplement the weightbearing duties of

16
 Podiatry Today | March 2018

attendant ligaments, tarsal and metatar- and lateral columns. Achilles tendons with diabetic neuroarthrop-
athy. J Am Podiatr Med Assoc. 2005; 95(3):42-
sal bones. This introduces the concept of 8) Use an external fixator in Charcot
246.
load sharing between implants that sur- reconstruction with beaming. Au- 12. Grant W, Rubin L, Pupp G,Vito G, Jacobus D,
geons use for the Charcot diabetic foot. thors have demonstrated that bent Jerlin E, Tam H. Mechanical testing of seven
Practically speaking, however, no cur- wire Ilizarov fixation has synergy of fixation methods for generation of compres-
rent implants are designed as weight- compression with screws that sur- sion across a midtarsal osteotomy: a compari-
son of internal and external fixation devices. J
bearing or load sharing for Charcot foot. geons use as beams.14
Foot Ankle Surg. 2007; 46(5):325-335.
This includes orthopedic screws and 13. Root ML, Orien WP, Weed JH. Normal and
locking plates as well. Therefore, the re- In Summary Abnormal Function of the Foot, Vol. 2, Clinical
sponsibility to select the strongest fixa- Beaming is a biologically-based biome- Biomechanics Corp., Los Angeles, 1977.
tion type and method currently falls to chanical treatment for a metabolic dis- 14. Grant WP, Rubin LG, Pupp GR, et al. Me-
chanical testing of seven fixation methods for
the surgeon. ease. Its goal is to load share with met-
generation of compression across a midtar-
abolically altered ligaments, tendons and sal osteotomy: a comparison of internal and
Recommendations For Beaming bone, and restore shape and function to external fixation devices. J Foot Ankle Surg.
As A Reconstruction Strategy the diseased diabetic foot. n 2007;46(5):325-35.
With this in mind, we can currently
Additional References
make the following recommendations: References
1. Jeffcoate W. Vascular calcification and osteol- 15. Pinzur MS, Gil J, Belmares J. Treatment of os-
1) Select the strongest hardware pos- teomyelitis in Charcot foot with single stage
ysis in diabetic neuropathy- is RANKL the
sible to load share since bone pa- missing link? Diabetologia. 2003; 47(9):1488- resection of infection, correction of deformi-
thology does not favor normal ar- 1492. ty and maintenance with ring fixation. Foot
throdesis. Bear in mind that stainless 2. Larson S, Burns P. The pathogenesis of Char- Ankle Int. 2012; 33(12):1069-1074.
cot neuroarthropathy: current concepts. Dia- 16. Pinzur MS, Gurza E, Kristopaitis T, et al.
steel’s load to failure is 240,000 PSI
betic Foot Ankle. 2012; epub Jan. 10. Hospitalist – orthopaedic co-management of
versus 180,000 PSI for titanium. high risk patients undergoing lower extrem-
3. Mabilleau G, Petrova N, Edmonds M, Sabok-
2) When it comes to realignment, sta- bar A. Increased osteoclastic activity in acute ity reconstruction surgery. Orthopedics. 2009;
bilization and hopeful arthrodesis, Charcot’s osteoarthropathy: the role of recep- 32(7):1-7.
ensure the foot is in a position of tor activator of nuclear factor-kappaB ligand. 17. Pinzur MS. Neutral ring fixation for high risk
Diabetologia. 2008; 51(6):1035-1040. non-plantigrade Charcot midfoot deformity.
adductus with a positive Meary’s
4. Vashishth D. Advanced glycation end-prod- Foot Ankle Int. 2007; 28(9):961–966
angle and corrected cuboid height. 18. Lamm BM, Siddiqui NA, Nair AK, LaPorta
ucts and bone fractures. Int Bone Mineral Soci-
3) Use bent-wire external fixation in ety. 2009; 6(8):268-278. G. Intramedullary foot fixation for midfoot
combination with internal fixation 5. Alikhani M, Alikhani Z, Boyd C, et al. Ad- Charcot neuroarthropathy. J Foot Ankle Surg.
as it is synergistic with Steinmann vanced glycation endproducts stimulate os- 2012; 51(4):531–536.
teoblast apoptosis via the MAP kinase and 19. Sammarco VJ, Sammarco GJ, Walker EW Jr,
pins or large diameter “beams.”
cytosolic apoptotic pathways. Bone. 2007; Guiao RP. Midtarsal arthrodesis in the treat-
4) Strategies to minimize failure of ment of Charcot midfoot arthropathy. J Bone
40(2):345-353.
beaming hardware include using 6. Alikhani Z, Alikhani M, Boyd C, et al. Ad- Joint Surg Am. 2010 92(Suppl 1 Pt 1):1–19.
stainless steel instruments with the vanced glycation end products enhance ex- 20. Wiewiorski M, Yasui T, Miska M, Frigg A,
largest core diameter available. pression of pro-apoptotic genes and stimulate Valderrabano V. Solid bolt fixation of the me-
fibroblast apoptosis through cytoplasmic and dial column in Charcot midfoot arthropathy. J
5) Insert two beams into the medi-
mitochondrial pathwayss. J Bio Chem. 2004; Foot Ankle Surg. 2013; 52(1):88–94.
al column in the talus. These two 21. Sohn M, Stuck R, Pinzur M, Lee T, Budi-
280(13):12087-12095.
beams share the load of the medial 7. Witzke KA, Vinik AI, Grant LM, et al. Loss man-Mak E. Lower-extremity amputation
column with the pathologic liga- of RAGE defense: A cause of Charcot neuro- risk after Charcot arthropathy and diabetic
ments and bones. arthropathy? Diabetes Care. 2011; 34(7):1617- foot ulcer. Diabetes Care. 2009; 33(1):98-100.
1621. 22. Christensen T, Bulow J, Simonsen L, Holstein
6) Lateral column stabilization ar-
8. Macaione V, Aguennouz M, Rodolico C, et E, Svendsen O. Bone mineral density in di-
throdesis fuses the metatarsal bases abetes mellitus patients with and without a
al. RAGE-NF-kB pathway activation in re-
to the cuboid and cuboid to the sponse to oxidative stress in facioscapulohu- Charcot foot. Clin Physiol Functional Imaging.
calcaneus in an anatomic position. meral muscular dystrophy. Acta Neurologica 2009; 30(2):130-134.
By rotating the lateral column Scandinavica. 2005; 115(2):115-120. 23. McCarthy A, Etcheverry S, Bruzzone L, et
9. Lindsey J, Cippollone F, Adullah S, Mcguire D. al. Non-enzymatic glycosylation of a type I
metatarsal bases and cuboid superi-
Receptor for advanced glycation end-prod- collagen matrix: effects on osteoblastic devel-
orly, the surgeon can limit supinatus opment and oxidative stress. BMC Central Cell
ucts (RAGE) and soluble RAGE (sRAGE):
created by Charcot medial column cardiovascular implications. Diabetes Vasc Dis Biology. 2001; 2:16, epub Aug. 2.
failure. This decreases pressure on Res. 2009; 6(1):7-14. 24. Grant W, Lavin S, Sabo R. Beaming the col-
the lateral column. 10. Saito M, Marumo K. Collagen cross-links as a umns for Charcot diabetic foot reconstruc-
determinant of bone quality: a possible expla- tion: a retrospective analysis. J Foot Ankle Surg.
7) Locking the most proximal foot
nation for bone fragility in aging, osteoporo- 2011; 50(2):182-189.
joint, the subtalar joint, serves two 25. Sammarco J. Superconstructs in the treatment
sis and diabetes mellitus. Osteoporosis Int. 2010;
purposes: It adheres to Root’s prin- 21(2):195-214. of Charcot foot deformity: plantar plating,
ciples of proximal osseous stability 11. Grant W, Foreman E, Wilson A, Jacobus D, locked plating, and axial screw fixation. Foot
and permits load sharing of medial Kukla R. Evaluation of Young’s Modulus in Ankle Clin N Am. 2009; 14(3):393-407.

17
 Supplement

Key Principles On Frame

Biomechanics And Application
For Charcot Reconstruction
Recognizing the challenges of utilizing circular fixation in patients with diabetes and Charcot, this author dis-
cusses pertinent biomechanical factors and offers pearls on frame application to reduce complication risk.
By Byron Hutchinson, DPM, FACFAS

S urgeons have utilized circular fixa-

tion for Charcot reconstruction ef-
fectively for several years.1-3 The di-
abetic patient poses unique challenges for
the surgeon when considering the use of
self–stiffening and the more force applied,
the greater resistance to force.5
The surgeon should ensure simultane-
ous tensioning of the skinny wires on the
ring to maintain appropriate tension with
circular fixation. For the application to be one wire above the ring and one wire be-
successful, the surgeon needs to be familiar low the ring (see top photo on page 19). Si-
with certain aspects of frame biomechanics. multaneous tensioning of the wires avoids
While a detailed discussion of frame the inherent problems with having to
biomechanics is beyond the scope of this consider the angle of the wires on the ring
article, Bronson and colleagues reviewed with single tensioning. For example, any
important aspects of frame stability and angle that is not 45 degrees will result in
offered biomechanical analysis.4 They em- increased or decreased tension on the first
phasized having a strong understanding of wire when the second wire is tensioned.
the relative effect of the individual frame For most patients with diabetes Opposing olive wires will help to pre-
components and specific parameters of undergoing Charcot reconstruction, vent translation and drop wires should
bone segment fixation on axial compres- this requires funneling or coning of the be avoided. One can often use half pins
sion, torsional stiffness, anteroposterior and tibial block. This allows for the tibial along the tibial face and 4 mm half pins
medial-lateral bending stability. Consider- block to be close to the bone segment are the same as two tensioned wires at 90
ation of ring and wire diameter along with and helps provide stability of the ring kg as far as axial loading is concerned.6
construct.
wire tension and wire angle,and their effects When it comes to patients with diabetes,
on bone segment stabilization is of critical more fixation units on a ring are recom-
importance as well. One needs to consider that the tibial block is high enough to pro- mended because of the frequency of pin
all of these variables when making rec- vide additional stabilization to the block site irritation or infection.
ommendations for the use of circular ex- and to avoid vulnerable areas in the tibia. The double row footplate provides ad-
ternal fixation in Charcot reconstruction. This tibial block is recommended for both ditional fixation options and has more sta-
The basic frame construct for Charcot ankle and midfoot Charcot reconstruction. bility than the single row footplate. Several
deformity starts with the tibial block. The The basic fixation units are skinny wires options are available to close the footplate
rings need to be close enough to the bone and half pins. Understanding the relevant depending on the situation. Studies have
segment but wide enough to allow for biomechanics and application of these fix- shown that closure with two threaded
swelling. For most patients with diabetes ation units is the most important aspect of rods is the most stable.7 Placement of all
undergoing Charcot reconstruction, this a successful frame. A common mistake is the wires in the footplate is recommended
requires funneling or coning of the tibi- bringing the wires down to the ring rather before tensioning. Clifford and colleagues
al block (see above photo). This allows for than building up to the wires with fixation demonstrated a more effective tension se-
the tibial block to be close to the bone elements. This places stress and tension on quence with simultaneous tensioning of
segment and helps provide stability of the the wires resulting in wire failure or wire the forefoot wires first followed by the
ring construct. In addition, it is important irritation/infection. Tensioned wires are calcaneal wires.7 One may employ bent

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 Podiatry Today | March 2018

The surgeon should ensure simultaneous tensioning of the skinny wires on the ring to maintain appropriate tension with one
wire above the ring and one wire below the ring.

wire fixation along the footplate to work

synergistically with the midfoot intramed-
ullary beams (see photo at the right).
Limb salvage in diabetic patients un-
dergoing Charcot reconstruction can be a
considerable challenge for even the most
experienced surgeon. Optimizing these
patients is critical for a successful outcome
and eliminating biomechanical failures
in circular frame design will enhance the
possibility for limb preservation. n

References
1. Cooper PS. Application of external fixators for
management of Charcot deformities of the foot
and ankle. Foot Ankle Clin. 2002;7(1):207-54.
2. Roukis TS, Zgonis T.The management of acute
Charcot fracture dislocations with the Taylor’s
spatial fixation system. Clin Podiatr Med Surg.
2006;23(2):467-83.
3. Herbst SA. External fixation of the Charcot ar-
thropathy. Foot Ankle Clin. 2004;9(3):595-609.
4. Bronson DG, Samchukov ML, Birch JG, Brown
RH, Ashman RB. Stability of external circular
fixation: A multi-variable biomechanical analy-
sis. Clin Biomech. 1998:13(6):441-448.
5. Aronson J, Harp JH Jr. Mechanical consider-
ations in using tensioned wires in a transosseous
external fixation system. Clin Orthop Relat Res.
1992;280:23-9.
6. Calhoun JH, Li F, Bauford WL, et al. Rigidity
of half-pins for the Ilizarov external fixator. Bull
Hosp Jt Dis. 1992;52(1):21-6.
7. Clifford C, McCann K, Samchukov M. Factors
influencing smootn wire tension on external
fixator foot suppor: a multivariate study. Texas This radiograph demonstrates the use of a bent wire fixation technique in a
Scottish Rite Hospital for Children. Dallas,Tex- midfoot Charcot reconstruction.
as. 2010. Unpublished.

19
 Supplement

Current Insights On Charcot

Ankle Reconstruction
When it comes to Charcot arthropathy of the ankle, this author emphasizes a strong awareness of the relevant
pathologic and metabolic processes, assessment and optimization of comorbidities, and keys to optimal fixation.
By Byron Hutchinson, DPM, FACFAS

C harcot arthropathy of the ankle

is a very complex, limb-threat-
ening and life-altering deformi-
ty. Historically, surgeons avoided fusion
because of a high incidence of non-
union or failure.1 With improving meth-
ods of fusion and a better understanding
of the neuropathic process in the ankle,
limb salvage has become a much more
viable option.
Surgical options in the ankle are typi-
cally reserved for the severe, unstable de-
formity when conservative care has failed.2
The primary goals in ankle reconstruction
are to achieve better alignment and stabil-
ity of the ankle to allow for better bracing.
In addition, those patients who are at high Here is a clinical view of active ankle Charcot.
risk for ulceration or have had previous ul-
cerations can benefit from reconstruction.
It is paramount that the surgeon has a
good understanding of the pathologic
and metabolic processes at work in an-
kle Charcot. We know that Charcot is a
non-infectious destruction of the joints
and bone in patients with peripheral neu-
ropathy. There is typically some trauma in
the neuropathic patient that leads to two
distinct pathways of destruction. Those
with autonomic neuropathy and increased
arteriovenous (AV) shunting develop sub-
chondral collapse and fragmentation.
Those without autonomic neuropathy
and no AV shunting develop neuropath-
ic dislocation.3 Interestingly, bone miner-
al density plays a role in the type of de-
struction. In 2004, Herbst and colleagues
looked at dual-energy X-ray absorptiom-
Note the anteromedial incision for hindfoot fusion along with a tibiotalocalcaneal
etry (DEXA) scans on affected limbs in
(TTC) fusion.
55 patients with diabetes to determine the

20
 Podiatry Today | March 2018

bone mineral density changes in midfoot

and ankle Charcot.4 They found that the
fracture pattern predominated in the an-
kle and bone mineral density changes were
pronounced in comparison to near normal
values in the dislocation pattern. In 2011,
LaFontaine and coworkers sought to an-
alyze the histologic structure of Charcot
bone in comparison to other patients with
diabetes and healthy controls.5 Their con-
clusion was that Charcot bone appeared
to be woven bone.These studies and more
have led many (including myself) to believe
that diminished bone mineral density and
a predominant fracture pattern is present in
Charcot of the ankle.6-8 In addition, woven
bone has inferior integrity and these factors
need to be taken into consideration during
reconstruction in the Charcot ankle.
The basic surgical tenets are determin- Here one can see the use of a distal femoral locking plate in a reconstruction
ing the planes of deformity and realign- case involving ankle Charcot.
ment. Control of infection is important as
well as assessment of talar integrity and the
viability of the soft tissue envelope.
The most favorable method for recon-
struction of the ankle is not known but I
favor a superconstruct involving a combi-
nation of internal and external fixation.9
This superconstruct in the ankle takes into
consideration the unique aforementioned
metabolic situation when it comes to the
ankle.
The primary goals of surgery are to
provide bony stabilization and have an an-
kle that one can brace. In my experience,
the best outcomes have been in those pa-
tients that commit to a Charcot restraint
orthotic walker (CROW) boot for life. I
have also found that the patients need to
understand that this is limb salvage and in
most circumstances, it is a “one and done”
type of surgery. In addition, it is important
to consider whether the surgery will im-
prove their quality of life.
The vast majority of interventions I have
performed have been in patients with in-
active Charcot deformities in which they
had a previous ulceration or were not able
to wear a brace. In certain circumstances,
this is ideal.
When patients have active Charcot,
it is important for the surgeon to weigh
the benefit of reconstruction versus the
risk of limb loss in this setting. It has been The ideal external fixation construct for ankle Charcot is a circular fixator, which
my experience that patients with diabetes includes a tibial block and a foot plate. The author utilizes a double row foot plate
who present with a dislocation pathway and an extended tibial ring for more stability.

21
 Supplement

An extended tibial block avoids placing wires or half pins in the middle of the tibia where fractures can occur. In the left photo,
note the mid-tibial fixation that can place the tibia at risk. In the right radiograph, there is a mid-tibial fracture due to fixation
elements and premature weightbearing.

It is extremely important to funnel the frame based on the anatomy of the leg to keep the frame more stable.

22
 Podiatry Today | March 2018

and ankle deformity do much better with 3. Herbert SA, Jones KB, Saltzman CL. Pattern
of diabetic neuropathic arthropathy associated
active Charcot reconstruction than those
patients who have active fragmentation. If Patients with Charcot with the peripheral bone mineral density. J
Bone Joint Surg Br. 2004;86(3):378-83.
there is no deformity present, offloading is 4. Herbst SA. External fixation of Charcot ar-
most appropriate. ankle deformity can thropathy. Foot Ankle Clin. 2004;9(3):595-609.
5. LaFontaine J, Shibuya N, Sampson HW,
Ensuring Preoperative be very challenging. Valderrama P. Trabecular quality and cellular
characteristics of normal, diabetic, and Char-
Optimization Of Patients
Optimization of patients with Charcot With proper cot bone. J Foot Ankle Surg. 2011;50(6):648-
53.
deformity of the ankle is extremely im- 6. Petrova NL, Edmonds ME. A prospective
portant. This begins with evaluation and optimization, limb study of calcaneal mineral density in acute
Charcot osteoarthropathy. Diabetes Care.
stabilization of the patient’s comorbidi-
ties. One should obtain a metabolic bone salvage is attainable. 2010;33(10):2254-2256.
7. Jung RH, Greenhagen RM, Wukich DK,
profile prior to surgery.10-12 The patient Vardaxis V,Yoho RM. Charcot neuroarthropa-
should have optimal glycemic control. thy and bone mineral density. Lower Extremity
Although there is no consensus on ide- Review. November 2012.
8. Rogers LC, Frykberg RG, Armstong DG, et
al HbA1c values, the closer one is to 8
al. The Charcot foot in diabetes. Diabetes Care.
percent, the more predictable the out- The ideal external fixation construct for 2011;34(9):2123-2129.
come. The surgeon should also consider ankle Charcot is a circular fixator, which 9. Hegewald KW, Wilder ML, Chappell TM,
end-stage renal disease. Dialysis patients includes a tibial block and a foot plate. I Hutchinson BH. Combined internal and
generally do well if the surgery is timed utilize a double row foot plate and an ex- external fixation for diabetic Charcot recon-
struction: A retrospective case series. J Foot
around their dialysis schedule. In my tended tibial ring for more stability (see
Ankle Surg. 2016;55(3):619-27.
opinion, renal transplant patients do not bottom photo on page 21). In addition, 10. Jehoon L,Vasikaran, S. Current recommenda-
do well with reconstruction and are bet- the extended tibial block avoids placing tions for laboratory testing and use of bone
ter served with a definitive amputation. wires or half pins in the middle of the turnover markers in management of osteopo-
Psychosocial issues are also important tibia where fractures can occur. It is also rosis. Ann Lab Med. 2012;32(2):105-112.
11. Seibel MJ. Biochemical markers of bone
to address. There are some recent studies extremely important to funnel the frame
turnover Part I: Biochemistry and variability.
to suggest that cognitive dysfunction oc- based on the anatomy of the leg to keep Clin Biochem Rev. 2005;26(4):97-122.
curs along with neuropathy.13-15 The pa- the frame more stable (see bottom photo 12. Seibel MJ. Biochemical markers of bone
tient needs to have an appropriate support on page 22). The surgeon may use wires turnover Part II: Clinical applications in the
group and if that is not available, one has to and/or half pins to complete the construct management of osteoporosis. Clin Biochem
Rev. 2005;26(4):97-122.
consider a skilled nursing facility or home and should apply these using standard
13. Kodl CT, Seaquist ER. Cognitive dys-
health at a minimum. frame biomechanical principles. function and diabetes mellitus. Endocr Rev.
It is important to have several fixation 2008;29(4):494-511.
Pertinent Surgical Pearls units on each ring with the understand- 14. Munshi M, Capelson R, Grande L, et al.
The surgical procedure centers around ing that some will have to be removed Cognitive dysfunction is associated with poor
diabetes control in older adults. Diabetes Care.
optimum alignment of the foot under the due to pin irritation or infection, which is
2006;29(8):1794-1799.
leg. Typically, one can do this through a higher in the diabetic population than the 15. Strachan MW, Deary IJ, Ewing FM. Et al. Is
lateral utility incision over the fibula and, non-diabetic population. It is ideal to leave type II diabetes associated with an increased
at times, an ancillary anterior medial inci- the frame on for 10 to 12 weeks. risk of cognitive dysfunction? A critical
sion over the ankle joint, especially when review of published studies. Diabetes Care.
1997;20(3): 438-445.
midfoot correction is necessary. The vast In Conclusion 16. Pinzur MS, Noonan T. Ankle arthrodesis with
majority of the Charcot ankles I see are To summarize, patients with Charcot an- a retrograde femoral nail for Charcot ankle
in valgus as opposed to varus. Removing kle deformity can be very challenging. arthropathy. Foot Ankle Int. 2005;26(7):545-9.
the fibula allows direct access to the ankle With proper optimization, limb salvage 17. Caravaggi C, Cimmino M, Caruso S, Dalla
joint and facilitates removal of bone nec- is attainable. A combination of internal Noce S. Intramedullary compressive nail
fixation for the treatment of severe Charcot
essary to relocate the foot under the tibia. fixation and external fixation provides an
deformity of the ankle and rear foot. J Foot
The internal fixation platform that is excellent superconstruct to achieve suc- Ankle Surg. 2006;45(1):20-4.
most popular is an intermedullary (IM) cessful limb salvage. n 18. Dalla Paola L,Volpe A,Varotto D, et al. Use
nail.16-18 When there is fairly good talar in- of a retrograde nail for ankle arthrodesis in
tegrity and the deformity is varus or mild References Charcot neuroarthropathy: a limb salvage
1. Stuart MJ, Morrey BF. Arthrodesis of the procedure. Foot Ankle Int. 2007;28(9):967-70.
valgus, I prefer to use an IM nail. When
diabetic neuropathic ankle joint. Clin Orthop 19. Shogren S, Zelinskas S, Hutchinson B,
there is a fracture dislocation pathway, the Relat Res. 1990;(253):209-11 Kamboj V. Distal femoral locking plates for ti-
IM nail is preferable as well.When there is 2. Burns PR, Wukich DK. Surgical reconstruc- biotalocalcaneal fusions in the Charcot ankle:
severe valgus or no talus, I recommend a tion of the Charcot rearfoot and ankle. Clin A retrospective study. Foot and Ankle Online
lateral plate.19 Podiatr Med Surg. 2008;25(1):95-120. Journal. 2011;4(8):3.

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