Charcot Foot/Ankle Reconstruction

What is Charcot Foot/Ankle Reconstruction?

Charcot foot/ankle reconstruction is a specialised surgical procedure designed to restore the stability, alignment, and functionality of the foot or ankle affected by Charcot neuroarthropathy, a condition primarily seen in individuals with diabetes or nerve damage (neuropathy). Charcot neuroarthropathy causes the bones, joints, and soft tissues in the foot or ankle to weaken and deteriorate, leading to deformities, instability, and chronic ulcers or infections in severe cases. Reconstruction involves correcting deformities, stabilising the bones, and promoting proper healing to enable patients to walk more comfortably and avoid complications like limb loss.

Who is Suitable for Charcot Foot/Ankle Reconstruction?

Charcot foot/ankle reconstruction is recommended for individuals with the following conditions:

• Severe Deformities: When the foot or ankle has significant deformities that impair mobility or lead to pressure sores and ulcers.
• Instability: For patients experiencing chronic instability due to weakened or fractured bones.
• Recurrent Infections: When infections persist due to open wounds caused by abnormal foot shapes or pressure points.
• Failed Conservative Management: For those who do not respond to non-surgical treatments such as immobilisation, offloading (e.g., custom orthotics or casts), or physical therapy.
• Good Overall Health: Candidates should be medically stable enough to undergo surgery, have realistic expectations for recovery and postoperative care, and be able to not bear weight for 8 weeks.

Benefits of Charcot Foot/Ankle Reconstruction

The primary benefits of Charcot foot/ankle reconstruction include:

• Improved Mobility: Correcting deformities allows patients to walk comfortably and use standard footwear.
• Reduced Risk of Amputation: Addressing structural issues and infections significantly lowers the risk of severe complications like amputation.
• Pain Relief: Stabilizing the bones and correcting misalignment reduces pain caused by abnormal pressure on joints or soft tissues.
• Prevention of Ulcers and Infections: Proper alignment reduces pressure points, preventing chronic wounds and infections.
• Enhanced Quality of Life: Patients can regain independence and confidence in daily activities.

Types of Charcot Foot/Ankle Reconstruction

The reconstruction type depends on the deformity's severity and location and the patient's overall health. Common types include:

• Realignment Osteotomy: Involves cutting and repositioning the bones to restore proper alignment.
• Internal Fixation: Plates, screws, or rods are used to stabilise fractures and correct deformities.
• External Fixation: A frame is placed outside the foot or ankle to hold bones correctly during healing. This method is often used in complex or severely infected cases (see circular frame).
• Arthrodesis (Joint Fusion): Fusing affected joints to provide stability and reduce pain, commonly performed on the midfoot or ankle.
• Bone Grafting: Used to fill gaps created by fractures or to support weakened bones, promoting proper healing.
• Debridement: Removal of infected or dead tissue facilitates wound healing and reduces the risk of complications.

Alternative Options to Charcot Foot/Ankle Reconstruction

For individuals who may not be suitable candidates for surgery or who prefer non-surgical interventions, several alternative options are available to manage Charcot foot/ankle:

• Immobilisation: Total contact casting (TCC) or a removable walker boot can stabilise the foot and prevent further damage during the active phase of Charcot neuroarthropathy.
• Offloading: Specialised footwear, braces, or orthotics designed to redistribute weight and reduce pressure on affected areas can help prevent ulcers and deformities.
• Physiotherapy: Therapy can help maintain mobility and strength while minimising stress on the foot or ankle.
• Custom Orthotics and Braces: Custom-made devices provide support and help correct minor deformities, improving stability and reducing the risk of pressure sores.
• Wound Care: Advanced wound care techniques (e.g., dressings and negative pressure therapy) can promote healing and prevent infection in patients with ulcers.
• Lifestyle Adjustments: Weight management, smoking cessation, good nutrition, and optimal blood sugar control are critical for reducing risks and improving outcomes in diabetic patients.

Preparation Before a Charcot Foot/Ankle Reconstruction

Preoperative preparation is essential for a successful Charcot foot/ankle reconstruction. Key steps include:

• Medical Evaluation: Comprehensive health assessments, including blood tests, imaging studies (X-rays, CT, and/or MRI), and vascular studies, to evaluate bone, joint, and circulatory health.  Dr Graff will refer you to a vascular surgeon pre-operatively.
• Infection Management: Treating active infections with antibiotics or debridement before surgery is critical to prevent complications.
• Blood Sugar Control: Maintaining optimal blood sugar levels is crucial for diabetic patients to reduce the risk of infection and promote healing.
• Smoking Cessation: Smoking impairs healing and increases the risk of complications; you would need to stop smoking to undergo the procedure.
• Nutrition Optimization: A diet rich in nutrients, particularly those that support bone and wound healing (e.g., calcium, vitamin D, vitamin C and protein), can improve recovery outcomes.
• Supportive Equipment: Preparing for postoperative needs, such as mobility aids (e.g., crutches and wheelchairs), is necessary to facilitate recovery.
• Pre-Surgery Planning:
• Discuss medications with Dr Graff, as some may need to be paused (e.g., blood thinners).
• Plan for mobility aids like crutches, a knee scooter, a wheelchair, or a walker for recovery.
• Arrange for help at home, as mobility will be limited after surgery.

Charcot Foot/Ankle Reconstruction Procedure

• Charcot neuroarthropathy causes catastrophic destruction and dislocation of bones and joints.
• Surgery for Charcot neuroarthropathy must be performed with strict diabetic control and good nutrition. 
• The surgery often involves reconstruction of the bones and joints into the correct alignment, which can involve gradual correction with a circular frame (see Circular Frame)
• Sometimes, the surgery is staged. The first stage involves correcting the deformity using the frame, which can take 6-12 weeks.
• The second stage is fusing the bones in the correct position, using a bone graft from the bone above the hip or the fibula, and held still using rods, plates and screws internally or a circular frame. 
• In theatre, X-rays ensure the bones are aligned correctly, and a tourniquet is placed around the thigh to help with bleeding.
• This is a major surgery and can take several hours. 
• The surgery aims to improve the foot's shape to prevent ulceration and aid mobilisation, but it will not return the foot to normal.

The Hospital Stay

• Your foot will be elevated overnight, and you will have antibiotics through a drip. 
• You will need blood-thinning medications or injections to prevent DVT. 
• You will stay in the hospital for 2-5 days with antibiotics, blood thinners, regular paracetamol, regular laxatives, regular vitamin C and stronger painkillers to take if and when required. 
• You will not be allowed to weight bear for 8 weeks
• Depending on your balance and strength, you may need rehabilitation postoperatively
• Buying a second-hand knee scooter pre-operatively and practising at home before the surgery can be helpful; please bring it into the hospital with you. It is easier to use a knee scooter than crutches.

When You Go Home

• You will need medications for pain relief; regular paracetamol (2 tablets four times a day) is recommended, as well as strong painkillers, especially at night before bed. These can have side effects of drowsiness, nausea and constipation, and other tablets to help with these side effects may be required. 
• You will need blood-thinning medications or injections and vitamin C for 8 weeks. 
• You will need a shower chair and bags to keep the plaster dry 
• You will need to attend your post-op appointment in 2-3 weeks, where the wounds will be checked 
• On the same day as the wound check, you will need to be placed into a bivalved total contact cast for a further 6 weeks by orthotics (Dr Graff will give you information regarding an orthotics company)

Charcot Foot/Ankle Reconstruction Rehabilitation

All patients are different, and these timelines are only guides; some may progress faster or slower than others.

0-3 weeks

• You will be in a backslab or boot for 2-3 weeks
• You will not be allowed to weight bear on the affected side.
• Please keep your foot elevated and out of bed for toilet only
• You will need to bag the leg for showers.
• Pain relief: Please take regular Panadol with meals before bed; you will need stronger painkillers in the first few weeks, especially at night.
• Please take blood-thinning medications/injections and vitamin C as prescribed

2-3 weeks

• You will have an appointment with Dr Graff and an x-ray.
• On the same day, please organise an appointment with the orthotist to have a bivalved total contact cast placed after the appointment
• Elevate the foot at rest
• You can shower in a shower chair and pat the wounds dry. Please check your foot at this time to ensure there is no redness or signs of infection.
• You must wear the cast at all times except for showering.

8 weeks

• You will have an appointment with Dr Graff and an x-ray
• The cast will be removed, and you can start weightbearing in a diabetic air walker boot for a further 6 weeks with physiotherapy
• You can take the boot off for sleeping and showering

4 months

• You will have an appointment with Dr Graff and an x-ray.
• You will still have swelling and may be unable to fit into normal shoes. Post-operatively, it would be best if you could fit into supportive sneakers with rocker-bottom shoes or supportive custom-made boots.
• Please consult your podiatrist for ongoing shoe wear and/or orthotics.

When Can I Return To Work?

• ‍Seated work at 3 months
• Prolonged standing 6 months
• Heavy labour work 12 months‍

When Can I Drive?

• Left foot 2 months
• Right foot 4 months

Charcot Foot/Ankle Reconstruction Risks

Surgery for Charcot foot is at high risk for complications, including amputation. It is imperative to have strict diabetic control and good nutrition.

Potential complications include:

• Anaesthetic problems
• Nerve injury
• Blood clots
• Infection
• The fusion does not heal (non-union)
• The fusion heals in the wrong position
• (malunion)
• Ongoing pain
• The need for further surgery
• Amputation
• Charcot neuroarthropathy of other joints

Charcot Foot/Ankle Reconstruction Prognosis

Key aspects of the prognosis include:

• Functional Improvement: Most patients experience significant improvement in mobility, stability, and the ability to use regular footwear.
• Risk Reduction: The surgery lowers the risk of complications such as ulcers, infections, and amputations.
• Recovery Time: Recovery can take several months. It involves a period of immobilisation followed by gradual weight-bearing and physical therapy.
• Long-Term Outcome: Properly managed and regular follow-ups allow reconstructed feet/ankles to remain functional for years.
• Challenges: Some patients may experience complications like infection, hardware failure, or recurrence of deformities, necessitating additional interventions.

Success depends on the patient’s commitment to follow the prescribed recovery plan and manage underlying health conditions.

What if Charcot Foot/Ankle Reconstruction is Delayed?

Delaying Charcot foot/ankle reconstruction can lead to several complications, including:

• Progressive Deformity: Without intervention, the bones may continue to collapse and shift, worsening the deformity and making future surgery more complex.
• Ulcers and Infections: Persistent pressure points from deformities increase the risk of chronic wounds and infections, which can progress to life-threatening conditions like sepsis.
• Loss of Mobility: Severe deformities can lead to reduced mobility and dependence on assistive devices.
• Increased Risk of Amputation: Untreated Charcot neuroarthropathy significantly raises the likelihood of requiring partial or complete amputation due to unmanageable infections or bone destruction.
• Worsened Quality of Life: Chronic pain, instability, and difficulty walking can negatively impact the patient’s health and well-being.

Addressing the condition promptly with surgical or non-surgical management is crucial to prevent these complications and improve outcomes.

Contact Us

If you want more information or have any questions or problems, please contact Dr Graff at admin@christygraff.com or call the rooms at 0493 461 133.

Charcot Foot/Ankle Reconstruction Information Sheet