ADVANCED FOOT AND ANKLE SPECIALISTS, PA
Jay S. Weingarten, DPM, FACFAS, FACFAOM
Podiatric Physician and Surgeon
Board Certified Physician – Treating Pediatrics to Geriatrics
Surgical Management of Diabetic Charcot Foot
The Charcot foot is a non-infective, destructive type of arthritis that affects
between 1-2.5% of diabetics. The incidence of this arthritic process has
increased recently due to patients with diabetes mellitus living longer. There is
an equal distribution among males and females. The average age of patients
developing a Charcot foot is 40 years. 30% of patients develop a Charcot foot
in both feet and/or ankles. This form of arthritis can develop suddenly and
without pain. In a very short period of time the bones in the foot and/or ankle
can spontaneously fracture and fragment.
The final result in the development of a diabetic Charcot foot is severe foot
deformity. These deformities may result in difficulty wearing standard footgear.
As the deformity progresses the foot takes on the appearance of a "rocker
bottom". As the arch of the foot collapses areas of pressure develop on the
bottom of the foot that are prone to developing open sores or ulcerations. Loss
of ankle stability may occur to such an extent that the patient may not be able
to walk without the use of a brace. The vast majority of these deformities can
be treated with non-operative care. New advances in technology and the
development of new forms of lower extremity braces and splints have provided
a wider range of treatment alternatives that are very effective in managing the
Charcot foot.
There are situations where non-operative therapy is ineffective in managing a
Charcot foot. Surgical management of the Charcot foot may be required to
resolve some of the problems associated with the condition. Indications for
surgery include: 1) chronic deformity with significant instability that is not
amenable to brace treatment, 2) chronic deformity with increased plantar
pressures and risk of ulceration, 3) a significant deformity with secondary
ulceration that has failed to heal despite non-operative therapy and 4)
recurrent ulcers that have initially healed with non-operative care.
Surgical Intervention
Various types of surgery are available and may be required to manage a
Charcot foot. The type of surgery that may be necessary depends on 1) the
anatomic location of the Charcot deformity (i.e. the midfoot, the ankle. etc.) 2)
the stage of the Charcot process (there are three specific stages of the Charcot
process) 3) whether or not an ulcer is present. 4) whether or not the deformity
is unstable and 5) overall health status of the patient.
The types of surgical procedures include the following:
 Ostectomy - Ostectomy is a surgical procedure where a portion of bone
is removed from the bottom of the foot. This procedure is usually
performed for a wound on the bottom of the foot that is secondary to
pressure from a bony prominence. An ulcer may or may not be present.
The goal of the surgery is to remove the bone causing increased pressure
and thereby allowing the ulcer to resolve or prevent the area from
ulcerating. This procedure is usually performed as an outpatient or may
require a one-night stay in the hospital. The type of anesthesia selected
depends upon the health status of the patient and the preference of the
surgeon. Recovery time includes 3-4 weeks in a weight-bearing brace or
cast. A patient can usually return to extra depth footgear with a diabetic
insert following complete healing.

Midfoot Realignment Arthrodesis - This procedure is usually indicated
when there is significant instability of the middle portion of the foot.
Usually the foot has collapsed and there is significant bony prominence
along the bottom of the foot. Surgery is indicated when a simple
ostectomy will not be sufficient. The goal of surgery is to provide stability
and a relatively normal arch to the foot. This procedure usually requires
a one or two night stay in the hospital. This is usually performed under
general anesthesia and requires various types of internal fixation to be
placed within the foot. This may include screws and plates. The
convalescence associated with midfoot realignment arthrodesis is
approximately three months in a non-weight-bearing cast. A patient may
then progress to a weight-bearing brace for approximately 1-2 months.
The patient will then return to an extra depth shoe with a diabetic insert
at 5-6 months following surgery.

Hindfoot and Ankle Realignment Arthrodesis - Hindfoot and ankle
realignment arthrodesis is usually indicated when there is significant
instability resulting in a patient being unable to walk. These types of
procedures are recommended when bracing has failed. Patients are
basically non-ambulatory and many times amputation of the limb is the
only other alternative. Realignment arthrodesis of the hindfoot and ankle
is a limb salvage surgery. The ultimate goals of the procedure are to
maintain a functional limb such that one can transfer within their home
and possibly do some walking with the use of a brace or ambulatory
assistive device. This procedure usually requires a 1-2 night stay in the
hospital. The procedure is performed under general anesthesia and
requires the use of various types of internal and external fixation
devices. This may include the use of screws, plates, intramedullary nails
and external fixators. The postoperative course includes approximately
four months in a non-weight-bearing cast followed by a 2-3 month period
of walking in a protective rocker bottom brace. A patient will then
progress to a custom made brace that may be required throughout the
course of their lifetime.
Possible Complications
Surgery in the diabetic patient always has significant risks. People with
diabetes mellitus are more susceptible to infection due to their disease
process. Therefore, these operations have a high complication rate. The
arthrodesis procedures have a greater failure rate, increased risk of
complications and longer convalescence relative to simple procedures such as
ostectomy. It is recommended that a patient and their family have an
extensive consultation with the surgeon to understand all potential risks
including limb loss. A patient must be medically fit since this does require a
general inhalation anesthesia and an extensive postoperative course.
Preoperative work-up should include assessment of cardiac status and must be
performed prior to surgical intervention.
Summary
Surgical management of the Charcot foot can be challenging and at times
risky, but often the only alternative for limb-salvage. Many of the patients who
undergo this type of surgery would otherwise go on to a below-the-knee
amputation. Therefore, surgical management of the Charcot foot can be quite
gratifying to the patient, the patient's family and the surgeon. The patient and
the family should thoroughly understand the risks and benefits of the
procedure and have an extensive preoperative consultation with the surgeon.
It is recommended that surgery be performed by an experienced practitioner
who has a thorough understanding of the disease process and experience with
this type of surgery. It may be advantageous to have this type of surgery
performed at a tertiary care facility to handle the potential complications that
one might incur with these types of patients.
1233 SE Indian St., Suite 102, Stuart, FL 34997
tel. 772-223-8313, fax 772-223-8675
1106 W Indiantown Rd, Suite 4, Jupiter, FL 33458 tel. 561-744-6683, fax 561-744-7033