Charcot
Dr. Mroczek has extensive experience in treating Charcot Neuroarthropathy (Charcot) for more than 20 years and over 1000 cases. While some Charcot patients can be treated without surgery, he utilizes the latest techniques for reconstruction including both internal fixation with plate and screws and external fixation utilizing a “cage” when necessary. Internal fixation is the method of choice since it provides superior fixation and correction compared to external fixation. The internal fixation techniques must be very strong since Charcot bone is soft. As a recognized expert, he was part of a design team that engineered a plating system specifically to reconstruct complex Charcot deformities in this weak bone. If there is a wound and/or active infection, then external fixation is utilized since metal cannot be implanted in this scenario.
All patients with Charcot have sensory neuropathy, which is loss of protective nerve sensation. This can be measured in the office with a simple monofilament device or a more complex work-up by neurology. Not all patients with sensory neuropathy are aware of subtle changes in the sensation. Some patients however have classic “pins and needles” in the hands and feet with decreased sensation. The most common cause of sensory neuropathy is diabetes, however, there are other causes.
Charcot frequently occurs without any specific trauma. The initial signs are swelling, warmth and redness, but a patient may not present with all three of these classic signs. The x-rays can be negative in the early stage. When there is a strong clinical suspicion, a MRI may be helpful in diagnosing the condition. The process can lead to a series of “microfractures”, progressive fragmentation and destruction of the bone and joint architecture. At this stage, the x-rays will be diagnostic. This progressive fragmentation and collapse can result in deformity, loss of function, ulceration, infection and amputation. Charcot can occur in the foot or ankle.
The initial treatment is a combination of nonweightbearing, activity modification and immobilization in a cast or boot. The goal of this treatment is to prevent a deformity or progression. If this leads to consolidation of the bones/joints in a generally acceptable position, then the next phase of treatment would be custom bracing and gradual restoration of activity.
Some cases will consolidate to a stable position, but have a bony prominence or spur leading to a ulceration an infection. When this occurs, a simple shaving or removal of this prominence with or without lengthening the Achilles tendon or calf muscles, can enable the ulcer to heal. The patient will then transition into a custom brace or orthotic/insert.
In cases with severe deformities or failure to consolidate to a stable position, then a reconstruction is indicated with internal fixation to correct the deformity and provide stability. If there is an associated wound and/or infection, then the foot/ankle is corrected in a similar fashion, but the correction is held not with internal fixation but external fixation. The next phase would include transition to a custom brace and gradual restoration of activity.
While Dr. Mroczek will work with the patients to provide an opportunity for limb salvage, some patients have such a severe deformity, bony destruction and/or infection, that a below knee amputation is the best or even only option. This is particularly true in patients with significant medical comorbidities such as cardiac and renal disease. Dr. Mroczek is straightforward with his patients in these cases since it is more important to save the patient’s life over their limb.
