STABILISING A CHARCOT FOOT
- Method
- Rebuilding and fusing the collapsed skeleton of the foot
- Duration
- 90 to 180 minutes
- Recovery time
- 6 to 12 months
In the Charcot foot – in medical terms diabetic neuro-osteoarthropathy – the bones and joints of the foot collapse without it hurting. The arch sinks, and in severe cases the sole pushes through downwards. What was an arch becomes a rocker-bottom foot whose lowest point lies in the middle – exactly where no skin is made for that much pressure.
In the acute phase the foot is first taken out of loading consistently, usually for months in a total contact cast. Only once the bone has settled does the question of surgery arise – and it arises when the deformity is so pronounced that no shoe fits any more, when the foot stays unstable, or when wounds keep forming.
How the operation proceeds
The aim is a foot that stands plantigrade again – flat and evenly on the ground. The collapsed joints are cleared, the columns of the foot realigned and fused in the new position. The fusion deliberately reaches beyond the destroyed zone and takes hold in healthy bone; where the soft tissue would otherwise be under tension, the bone is shortened a little.
Lengthening the Achilles tendon is almost always part of it. A shortened calf pulls the heel up and presses the forefoot into the ground – the very force that made the arch collapse. Left alone, it works against the correction.
The foot is held from the inside. The stronger screw carries the inner column: it starts at the head of the first metatarsal and runs backwards through the cuneiform and the navicular into the talus. The long arch of the foot is effectively threaded back together. A slimmer screw holds the outer column.
We use the TWIN-CF system for this, developed specifically for the Charcot foot. These are not ordinary long screws: they carry two threads of different pitch. The leading thread bites faster than the one behind it, so the screw draws the bone ends together as it goes in. The threads are roughened so that bone grows onto them; the material is titanium.
Every screw is placed over a guide wire under fluoroscopy – so the path through the bones can be set out beforehand and checked while the screw goes in. If the destruction reaches the ankle, the hindfoot is fused as well.
When the operation is considered
The decision is never made on the X-ray alone. It depends on whether the foot still fits a shoe, whether it stays stable enough to walk on, whether recurring wounds are using up the skin – and whether circulation and any infection allow an operation of this size.
Where custom-made shoes and an orthosis keep the foot going, that is what we stay with. Where they no longer can, stabilisation is the way to preserve the ability to walk – and therefore the alternative to amputation.
Aftercare following stabilisation
The aftercare is long, and there is no way around it: the bone of a Charcot foot needs considerably more time than a healthy one. Loading it too early costs the correction.
Phase I (0–8 weeks): No weight-bearing
- No weight on the operated foot; crutches or a wheelchair
- Immobilisation in a cast or an orthosis
- Close checks on the wound and the soft tissue
- Thrombosis prophylaxis as prescribed
Phase II (8 weeks to 6 months): Building up weight-bearing
- Step-by-step increase in loading, guided by X-ray checks
- The metal stays in the foot – it comes out only if it causes trouble
- Fitting of a custom-made below-knee orthosis
- Physiotherapy: gait training, strengthening, balance
From month 6: Long-term care
- Transition into orthopaedic custom-made shoes, often with an inner shoe
- Carry on looking at the foot every day
- Regular follow-up – the Charcot foot remains a lifelong condition
- An MRI scan is possible with the screws in place – tell the radiology department beforehand
- Come back promptly if there is new swelling or redness
Our foot specialists
Experienced specialists in the Charcot foot and reconstructive foot surgery
