Charcot neuroosteoarthropathy of the feet is a major risk factor for foot deformity and ulceration with a subsequent rate of lower extremity amputation [3
]. Nonoperative measures such as total contact casting are regarded as treatment of choice for a majority of patients if the treatment is likely to provide a plantigrade foot without major bony destruction and deformities [6
]. According to some series, however, 40% to 50% of these patients may have secondary surgery due to recurrent ulcers or residual deformity [3
]. This two-step approach may be associated with prolonged immobilization and increased morbidity, diminished quality of life, and increased costs [3
]. We therefore asked whether primary surgery would (1) provide a stable plantigrade ulcer-free and infection-free foot in patients with advanced mechanical instability of the foot and/or the ankle and at high risk for secondary surgery; (2) allow increased physical activity level; and (3) do so at complication rates not higher than those reported for secondary surgery.
We note several limitations of our study. First, knowing which degree of instability and deformity will be at high risk of failure with nonsurgical treatment relies on judgment [21
] and the risk factors are not well understood. Expert assessment of these key parameters represents the basis for most treatment protocols from centers with wide experience in Charcot feet [18
]. On the other hand, we believe decision making for surgery in Charcot feet on the basis of any given algorithm requires assessment by someone with considerable experience with Charcot feet and it should not be left to the inexperienced [21
]. Second, our single cohort was heterogeneous, making generalizations more difficult. All major studies on the topic published during the last 15 years (Tables , ) are retrospective with limited numbers of patients [27
]. The authors are not aware of any prospective comparative study or any high-quality randomized controlled trial of primary nonoperative versus primary surgical treatment of Charcot feet. The need for such studies has been repeatedly mentioned [21
] as has the difficulty in conducting such a trial owing to the heterogeneity of the deformities and instability [21
]. Nevertheless, our data suggest a subset of patients with advanced instability and deformity benefit from primary surgical reconstruction comparable to patients who have secondary surgical reconstruction.
Retrospective clinical series on corrective arthrodesis in Charcot feet (last two series refer to primary surgical intervention)
Retrospective clinical series on corrective arthrodesis in Charcot feet (Last 2 series refer to primary surgical intervention. Display of the essential outcome parameters (NS not specified, AFO ankle-foot-orthosis)
As such, in the present study with two-thirds of the feet having hindfoot manifestation of neuroosteoarthropathy and a high risk for a potential failure of nonoperative treatment none of the patients was assigned to primary nonoperative treatment. All our patients, whether they achieved bony or fibrous union, achieved a plantigrade and stable foot that remained ulcer-free during the observation period (Table ). This compares quite favorably with the results after secondary surgery, where the recurrence rate of ulceration varied between 0% and 20% (Tables , ).
Our patients accomplished full weight bearing within a mean of 3.5 months after surgery, which is longer than in nondiabetic patients but compares well with the only series of primary arthrodesis in Eichenholtz Stage I patients [35
] and shorter than reported following secondary arthrodesis (4–7 months, Table ). The high rate of patients being mobilized in accommodative shoewear after primary arthrodesis favorably compared to that of other series after secondary reconstruction where a substantial number of patients permanently use ankle-foot orthoses (Table ). Functional outcome has rarely been analyzed in patients after surgical reconstruction of Charcot feet employing the AOFAS scores while most authors have expressed the functional result in a more descriptive manner (Table ). A substantial increase in AOFAS scores occurred in our cohort within a relatively short time mainly due to functional improvement and better realignment both in our midfoot and hindfoot groups. The results exceed the AOFAS scores given for a limited series of 10 patients with mostly hindfoot involvement [36
The deep infection rate after primary arthrodesis was also low compared with secondary arthrodesis where the infection rate ranged from 0% to more than 30% (Table ). While almost one-third of our patients had preoperative ulcers in combination with instability or deformity (eight of 26 feet, Table ), none of our patients had progressive deformity or subsequent amputation. All of these ulcers in our study healed uneventfully following corrective arthrodesis. In contrast, a number of authors advocate postponing surgery until a concomitant ulcer has definitely healed [8
] or rely on alternative techniques of fixation as external fixators [24
]. Despite the fact that an open wound may increase the risk for complications [4
], we observed no major infectious complications. Other complications in our series were high when compared to studies with secondary intervention strategy [3
]. Hardware failure often coincides with the nonunion rate which was substantially high in our (23%) as in other series (0–30%, Table ). Despite this, a stable fibrous nonunion in good position does not necessarily require surgery. Choice of implants or implant combinations was adapted to the underlying biomechanical requirements preferably using large-size internal implants. We believed none of the observed implant failures could directly be related to improper selection of implants. This even holds true for the single patient with chronic fistula who denied revision as she was satisfied with the functional level achieved.
In the light of the recent literature our outcomes fulfill the definition of a favorable outcome that includes “the ability to remain free of ulcer and infection and to maintain walking independence using commercially available depth-inlay shoes and custom accommodative orthoses” [24
]. Early surgical intervention in high-risk patients may allow shorter periods of treatment at lower costs with an improved quality of life. We believe surgical reconstruction in Charcot feet should not be limited to a salvage procedure and an alternative to amputation in failed nonoperative care [20
]. Amputation may be the more expensive option compared with reorientation arthrodesis [4
]. Selected patients with nonplantigrade feet, instability, and manifest or impending ulcers may benefit from early surgical reconstruction with long-lasting functional improvement and without recurrence of instability or ulceration. Based on former reports [35
] and our data a prospective randomized study should be performed to further elucidate the role of primary surgical versus nonsurgical treatment in patients with early diabetic Charcot feet.