Charcot Neuroarthropathy in Patients with Diabetes: An Updated Systematic Review of Surgical Management

Charcot Neuroarthropathy (CN) of the foot and ankle is a demanding clinical dilemma and surgical management can be very complicated. Historically, the evidence guiding the surgical management of CN is comprised of small retrospective case series and expert opinions. The purpose of this manuscript is to provide a systematic review of papers and the indications for surgery.

Materials and Methods

A Medline search was performed using the key terms of Charcot, arthropathy, neuroarthropathy, neuro-osteoarthropathy, and surgery. The abstracts of all articles cited were reviewed, and articles that reported on surgical management of CN were included for further review.

Inclusion Criteria

Included in the study group was any manuscript written in English that discussed the surgical management of CN of the foot and ankle secondary to DM, including review articles and retrospective case series.

Exclusion Criteria

Excluded from the study group was any manuscript that was not written in English as well as any articles that did not discuss surgical management of CN. Articles that discussed patients with non-diabetic causes of CN (i.e. leprosy, syringomyelia, syphilis, and alcohol, etc.) were also excluded as well as manuscripts describing CN in other areas of the body outside of the foot and ankle.

For the purpose of this study, the terms Charcot arthropathy, neuroarthropathy, and neuropathic arthropathy were used interchangeably. 

Results

There were 209 articles cited over a 5-year period. Of these articles, 30 met the criteria for inclusion in this review. Two of the thirty articles (6.6%) were level two prospective comparative studies. Four of the studies (13.3%) were level three retrospective case controlled studies. The remaining 24 articles (80%) were level 4 case series. Level 5 studies were not included for statistical interpretation in this study, however, some expert opinions were used for discussion purposes.

There were 330 of 860 surgeries involving the ankle (38.4%), 358 surgeries involved the hindfoot (41.6%), 231 involved the midfoot (26.9%) and there were 2 surgeries specifically involving the forefoot (0.2%). These procedures do not add up to 100% because some patients required surgery at more than one anatomic region.

In addition, 196 of 860 (22.8%) also had a tendoachilles lengthening. Twenty-two of the 30 studies included joint arthrodesis as a treatment option, either alone or in addition to another surgery.

There were a total of 77 amputations, resulting in an overall amputation rate of 8.9%.

Although midfoot and hindfoot CN is far more common than ankle CN according to anatomic classification, the midfoot may be more amenable to bracing and other nonoperative treatment methods than cases in which the ankle is affected.

The addition of the circular external fixation device did not affect the overall limb salvation rate or complication rate.

While it is encouraging to see this literature, overall there continues to be inconclusive data to recommend one form of fixation over another.

Key Points

There have been no direct comparisons over the past five years comparing early versus late surgery; therefore, evidence for the performance of surgery during the acute phase is inconclusive at this time.

There has been an increasing trend over the past 5 years for tibiotalocalcaneal (TTC) arthrodesis. This may indicate that the TTC arthrodesis is becoming a more common procedure with more surgeons utilizing this technique for CN involving the ankle and hindfoot.

Indications for Surgery and Options

Surgical Indications:

•       Nonhealing foot ulcer or impending ulceration

•       Osteomyelitis

•       Unbraceable deformity/Instability with the collapse of the lateral column

•       Pain

Surgical Options:

•       Exostectomy

•       Realignment Arthrodesis

•       Internal/External Fixation

•       Amputation

Conclusion

The current review suggests that the surgical literature for CN is improving, evidenced by higher-level studies over the last 5 years. Also encouraging is the fact that literature now exists that compares fixation techniques, reconstruction vs. amputation, and cost evaluations of limb salvage. Arthrodesis, specifically TTC, seems to be gaining popularity as a surgical treatment option for CN. There are still no randomized, prospective, multicenter trials regarding this topic, and the proper timing of surgery is still undefined.

The goal of treatment, whether it be nonoperative or operative, is to achieve a plantigrade, stable foot that remains ulcer-free. As CN deformity involves more proximal anatomic regions (ankle and hindfoot), the need for surgical intervention becomes more likely.

Despite modern techniques utilizing improved methods of fixation and improved patient selection, approximately nine percent of patients with CN who undergo surgery will require a major amputation.

From: B.J. Schneekloth et al. Charcot Neuroarthropathy in Patients with Diabetes: An Updated Systematic Review of Surgical Management. Journal of Foot and Ankle Surgery, 2016.