5 Facts about Charcot Neuroarthropathy you need to know

1) With an unknown definitive mechanism of incidence, this disease process has many proposed hypothetical mechanisms currently in clinical practice. Some believe that increased inflammation and microfracturing of the bone secondary to sensory loss are key components, others believe glucose levels and specific traumatic events are responsible for this process which are compounded by inability to offload and protect the injured limb leading to progressive breakdown of the bone. We all agree that these elements are part of the problem, but do not necessarily occur in all cases. Especially in non diabetics with the disease of Charcot neuroarthropathy.

2) We know that many cases start with increased warmth, redness, and swelling. Unfortunately not ALL cases give us this "textbook" presentation.

3) We also know that characteristic radiographic changes may occur.  And when they do, differing mindsets and clinical approachs are valid and are practiced routinely in my practice. If an ulceration is present, or progressive radiographic changes are found, surgery is likely required for limb salvage.

4) We generally understand that patients with low or no protective sensory threshold on their feet tend to have a higher incidence of this process.  Also patients that have poor glucose control and are obese tend to have this same increase in incidence. Edema and general leg swelling in diabetic patients with Hemoglobin A1c levels higher than 8.0 tend to have increased risk of Charcot development in their feet. Usually all of these patients have good blood flow with regards to arterial circulation, but may have venous or lymphatic flow compromise.



5) Not all patients with Charcot neuroarthropathy are diabetic. I have treated many patients whom are not diagnosed with diabetes, and did not present with red swollen foot, who developed Charcot neuroarthopathy with radiographic bone degradation and resultant foot deformity. These patients do tend to have profound sensory polyneuropathy of unknown etiology (idiopathic) and are still at risk given the above listed requirements. I have had to reconstruct several patient's feet without diabetes as an underlying diagnosis, and it seems that they tend to have less overall complications but are still prone to the neuroarthropathy nonetheless.



The take away from this blog is that many of the "facts" about this disease process have some "grey area" information. You should seek the expert opinion with good experience in this disease process prior to any surgical intervention or decision for lower leg or foot amputation. The doctors at FFLC are well equipped to accommodate and treat this condition and are well versed in all avenues regarding limb salvage.

External fixation here in Naples Florida

External fixation may look very high-tech, and maybe even scary.  However, external fixation has been used in one way or another since almost 2400 years ago.  External fixation techniques were described by Hippocrates, and were used in treating tibia fractures.  External fixation is a minimally invasive technique to reduce displaced fractures and has become a very important part of deformity correction and nonunion and pseudo arthrosis repair as well.

Jean François Malgaigne was one of the many pioneers that made advancements with external fixation devices.  In 1846, Malgaigne used a device that consisted of a clamp and four metal prongs to reduce and stabilize a fracture of the patella, or kneecap.  Following this external fixation device many other similar inventions were used to treat fractures in various locations.  In 1938, Raoul Hoffman made advancements that made external fixation even more useful, and allowed surgeons to place pins into a fracture for stabilization with guidance, while being minimally invasive.  In 1951, Dr. Gavriil A. Ilizarov developed the external fixation device that is still in use today.  Ilizarov’s fixation device consists of a metal frame that encircles the limb, and is attached to underlying bone by pins.  Threaded rods and hinges allow movement of the bone to the correct alignment.  Ilizarov’s external fixator is great because adjustments can be made without opening the fracture site, and the device provides stability. Also it can be converted to internal fixation once the soft tissues have become less swollen. 

Modern day external fixation not only provides stability to a fracture, but can also be used for soft tissue deformities, as well as other bony deformities.  External fixation is preferred when slow correction is required, and even more useful in high risk patients with vascular disease and even open fractures with high risk of infection.  The chance of getting a blood clot is lessened because with external fixation patients can be partial weight bearing, or weight bearing as tolerated following the procedure due to the stability that the fixation provides.  External fixators have been used for other bony deformities, such as Charcot, ankle arthritis, and clubfoot.  External fixation can also be used to lengthen amputated foot and toe stumps.  External fixation has definitely helped many people, but there are still some cons.  Pain and infections are two issues associated with external fixation, and rates vary depending on the extent of the procedure, and the location of the device.  External fixation devices are used by specially trained physicians and all three of the doctors at FFLC are capable of utilizing these various techniques for patients that require such interventions.  

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

The Lover's Fracture

The calcaneus bone, or heel bone, is among the most commonly fractured tarsal bone in the foot.  Calcaneus fractures account for 1-2% of fractures in the body.  

Calcaneus fractures are also known as the Lover’s fracture.  

Calcaneal fractures often occur due to a jump from a height, which is how the term “Lover’s fracture” was coined because a lover may jump from great heights to escape from a lover’s spouse or boyfriend.

Calcaneal fractures are generally traumatic fractures occurring from motor vehicle accidents, muscular stress, or falls from a height.  We usually see these injuries in worker's injury claim cases, whereby someone has fallen off of a ladder or rooftop. 

Calcaneal fractures are categorized based on whether the fracture is displaced (greater than 2mm displacement), open (with soft tissue or bony structure exposed), closed (with skin and soft tissue intact), or comminuted (3 or more pieces).  Treatment for calcaneal fractures varies based on the type of fracture.  Standard radiographs and CT scan are used to diagnose calcaneal fractures, and determine the severity of the injury.  Pain over the heel, inability to walk, or a hematoma that extends to the sole of the foot are all signs of a calcaneal fracture.  

Presence of a hematoma on the sole is known as the “Mondor Sign”.  In a non-displaced fracture nonsurgical treatment may be sufficient.  Displaced or comminuted fractures typically require surgical treatment consisting of some type of fixation with metal plates or screws or more recently we have used multiplanar external fixation for restoration of height, the angle, and joint space of the posterior facet in the subtalar joint. 

In closed fractures surgical treatment is often postponed until swelling has subsided.  In open (exposed soft tissue or bone) or avulsion fractures (when a tendon pulls off a piece of bone), more urgent treatment is required.  Open fractures are exposed to the environment and need to be cleaned and then surgically corrected within a short time period to prevent infection which is another advantage of external fixation. 

 

Minor calcaneal fractures usually heal within a few months, and cause minimal long-term limitations.  More severe fractures may take years to heal, and never return to the previous condition.  

Long-term complications may include pain, limb length discrepancies, and changes in gait with chronic swelling, and reduced endurance and strength.  

Early treatment by the foot and ankle surgeon (ie Family Foot and Leg Center)  is the key to minimizing long-term complications. 

-Dr Timm

Limb Preservation: Total Contact Casting

Diabetics with neuropathic ulcers affect at least one quarter of all diabetics in the United States, and according to Wounds Research, approximately 1 in 5 of these individuals will eventually require an amputation of their foot. Total contact casting has recently become more popular as an option for foot protection, and to mediate the excessive wear and tear that some diabetic foot sores suffer.

What is total contact casting?

As the name suggests, this technique, which is used by many diabetic foot specialists, is a thin cast that is applied to the entire plantar surface area of the foot, as well as the lower leg. Based on its design, the cast can take up as much at 92 percent of the pressure from the ulcer site. Since ulcers often occur on parts of the foot or leg that are repeatedly impacted through daily movement, it is important that they receive as much padding as possible without affecting an individual’s normal walking patterns. Although total contact casting provides relief from certain pressures, the cast works with the natural human gait to make sure that no section of the foot or leg is required to take on excessive weight or pressure.

Does it always work?

Total contact casting has been shown to be effective in the healing of foot and lower leg ulcers, but only those that are noninfected. According to current research, the success rate is between 72 and 100 percent in most patients. A study conducted at the University Hospital Maastricht in the Netherlands examined how total contact casts would fare on infected patients, and of the 28 patients in the study group, only 36 percent showed signs of healing. The study group recommended that individuals with infected diabetic ulcers look toward alternative treatments for healing, according to the American Diabetes Association.

Surgery may become necessary in conjunction with acute infections.

Overview of the Charcot disease

What is it?

Charcot arthropathy, also known as Charcot foot and ankle, is a syndrome in patients who have neuropathy or loss of sensation. It includes fractures and dislocations of bones and joints that occur with minimal or no known trauma.​

Symptoms and Clinical Presentation

​Initially, there may be swelling, redness and increased warmth of the foot and ankle. Later, when fractures and dislocations occur, there may be severe deformities of the foot and ankle, including collapse of the midfoot arch (often called rocker bottom foot) or instability of the ankle and hindfoot. The syndrome progresses through three general stages:

•Stage 1 (acute, development-fragmentation): marked redness, swelling, warmth; early radiographs show soft tissue swelling, and bony fragmentation and joint dislocation may be noted several weeks after onset
•Stage 2 (subacute, coalescence): decreased redness, swelling and warmth; radiographs show early bony healing
•Stage 3 (chronic, reconstruction-consolidation): redness, swelling, warmth resolved; bony healing or nonunion and residual deformity are frequently present.

Cause (including risk factors) 

Charcot foot occurs in patients with peripheral neuropathy resulting from diverse conditions including diabetes mellitus, leprosy, syphilis, poliomyelitis, chronic alcoholism or syringomyelia. Repetitive microtrauma that exceeds the rate of healing may cause fractures and dislocations. Changes in circulation may cause resorption of bone, weakening the bone and increasing susceptibility to fracture and dislocation. 

Anatomy 

Charcot arthropathy may affect any part of the foot and ankle, including (in decreasing order of frequency) the midfoot, hindfoot, ankle, heel and forefoot.  Multiple regions may be involved concurrently.  Fractures and dislocations frequently involve several bones and joints, with extensive fragmentation and deformity. 

Diagnosis 

Time between onset of symptoms and diagnosis may be several weeks or months. Delay in diagnosis may or may not affect the end result because gross instability may occur even if prompt diagnosis is made. Diagnosis is based on a high index of suspicion for this problem in patients with neuropathy. Increased redness, swelling and warmth may be the only early signs. Some patients have pain. Early radiographs may show soft tissue swelling with no bony changes, but repeat radiographs several weeks later may show bone and joint changes.

Treatment Options 

Non-Surgical: Non-operative treatment includes a protective splint, walking brace, orthosis or cast. Early weightbearing is allowed in stage 1 by 41 percent of specialists and in stage 2 by 49 percent of specialists, and other specialists recommend non-weightbearing. After stable healing is noted in stage 3, treatment includes accommodative footwear with protective orthoses.Surgical: Selected patients with instability in the early stages may be treated with open reduction and internal fixation and fusion. In the later stages, surgical options may include realignment osteotomy and fusion (correction of deformity) or ostectomy (removal of bony prominence that could cause an ulcer ). 

* Sometimes the surgery can fail, and this is commonly because of improper or inadequate fixation, poor glucose management, obesity, noncompliance, and even infection. 

Credentials you can trust.

Often times patients will ask me what my credentials actually mean. Below is a summary directly from the website of the American Board of Podiatric Surgery (which will change the name to American Board of Foot and Ankle Surgery this year) which delineates the prerequisites necessary to be deemed "Board Certified" by this particular surgical board. 

-Dr Timm

Diplomate American Board of Podiatric Surgery

Certification in Foot Surgery

Certification in Foot Surgery              indicates that a podiatrist has demonstrated a cognitive knowledge of podiatric surgery, including the diagnosis of general medical problems and surgical management of foot diseases, deformities, and/or trauma, and those structures which affect the foot and ankle.                                                       THE CURRENT QUALIFICATIONS INCLUDE:                                           

Completion of a four-year doctoral training at a CPME-accredited podiatric medical school.                         

Completion of residency training program approved by the Council on Podiatric Medical Education (CPME).                                                                                                                                                                            

Submission of a list of procedures through Podiatry Logging Service for Surgery demonstrating a diversity of surgical experience in foot surgery.    

Approval by the ABPS Credentials Committee of complete foot surgery case documentation of procedures selected by ABPS from the list of procedures.       

Passing Part I and Part II of the Certification in Foot Surgery Examination.Diplomates certified in Foot Surgery must recertify every ten years.

Myths about wound care

1) Wound Care Centers are the gold standard for healing all wounds.

All too often we see a wound such as the one pictured above, and as a second or third opinion we need to manage this patient because the wound is not healing. Wound care centers are usually very good at treating superficial wounds, but in the foot and especially in the area of the digits, we find that even a "small superficial dry ulceration of the hallux" can be a surgical emergency because of the proximity of bone and tendon in this area and are often not treated entirely well in a wound care center which is filled with nonsurgical wound care doctors. 

2) Diabetics don't heal well.

This is not always the case in a patient who has a dopplar examination of the lower extremities, and is found to not have any significant vascular disease. If you are eating 3 meals a day, and are not on dialysis chances are you have healing potential and just need better offloading, aggressive surgical debridement, and possibly a localized bone debridement or tendon procedure. We often team up with vascular surgeons, infectious disease doctors, and endocrinology doctors to help achieve optimal conditions to prevent amputations. 

If your foot and ankle wounds are not improved after 4 weeks of care, you need to see a wound care specialist board certified in foot and ankle surgery.



Brian Timm, DPM, FACFAS

Secrets of Chronic Achilles Pain

1) NOT all posterior heel pains are tendon problems.

We will provide a thorough examination, which includes diagnostic ultrasound, radio graphs, and clinical exam with history taking to provide the best possible outcome for your pain. There are several other structures which are present and could be treated in a different manner than any straight forward Achilles tendinitis.  Noted above, there is a bursa which is present here and can often be the root cause of pain secondary to bursitis. This is treated differently than Achilles tendinitis. This may also require MRI to determine how much of the inflammation is related to bone versus soft tissue. Additionally, and more rarely, a stress fracture can cause this pain in the calcaneus. This is not common but we check for this as well.

2) Tendon tears do NOT always require surgery.

After clinical examination and proper staging/grading of the extent of the tear, we have had success in treating Achilles partial tears and even ruptures non-surgically in select patient populations. We have a variety of techniques at our disposal in order to facilitate the healing process if surgery is not indicated. In the case of chronic tears there are several nonsurgical treatments that work, particularly PRP injections, High energy shock-wave treatments, and even physical therapy with anti inflammatory ultrasound.

3) Bone spurs are NOT always relevant. 

Often times patients will state that they "Have had a spur in the past but it went away". Usually any bone protuberance which is either palpable or visible on a plan radio-graph or MRI will NOT go away spontaneously ever and always if indicated will need resection if it is the root cause of the symptoms. In most cases the spur is not the root cause of the symptoms, and is not required to remove it, but there are far too often very large spurs which are not even symptomatic that are visible on X-ray examinations in many of our patients, therefore backing up further the concept that bone spurs are not always the real problem.

Bio-mechanically a bone spur will exist in areas of either repeated chronic trauma, or areas of chronic taut insertions. Rarely is this an isolated tumor of bone, and that being said, it is often not necessary to remove the bone spur.


Dr Timm

Board Certified by the American Board of Podiatric Surgery

Hammer Toes

Hammer toe
Hammertoes occur when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.
Normally, these bones and joints are straight. A hammertoe occurs when the toes become bent at the first interphalangeal joint, making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.

What causes hammertoes?
There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.
In some instances trauma (either direct injury or overuse from walking or sport) can predispose to hammertoes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?
It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem. In a study we have performed, 95% of patients were in the wrong size shoes.
Will it get worse?
At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the common symptoms?
Deformity / prominence of toe
Pain
Redness around the joints
Swelling around the joints
Corn / Callous
Difficulty in shoes with deformity of the shoe upper
Difficulty in walking
Stiffness in the joints of the toe

How is it identified?

Clinical examination and a detailed history allow diagnosis. X-rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

What can I do to reduce the pain?
There are several things that you can do to try and relieve your symptoms:
Wear good fitting shoes with a deep toe box
Avoid high heels
Use a toe prop to straighten the toe if it is still mobile
Wear a protective pad over the toe
See a doctor at the Family Foot and Leg Center.

What can we as a specialist do to correct or reduce your symptoms?
If simple measures do not reduce your symptoms, there are other options:
Advise appropriate shoes
Advise exercises if the toes are still mobile
Show you how to strap the toe in a corrected position
Provide a splint or protection
Consider orthotics

Advise on surgery
The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthoses) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?
If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

What will happen if I leave this alone?
Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes. The position of the toe places increased stress on the ball of the foot and this can become painful. Corn and callous formation on the ball of the foot is not uncommon. In some cases, the metatarsophalangeal joint capsule ruptures, causing the toe to sit up in the air.

Can the deformity be reversed or cured?
The only effective way of correcting the deformity is to have an operation.

How does the operation correct the deformity?
There are a number of different operations. However, the most common operations are:
Tendon transfer
Digital arthroplasty
Digital arthrodesis
Tendon transfers involve taking the tendon from under your toe and re-routing it to the top of the toe so that the toe is pulled down. This can be used alone if the toe is mobile or in combination with the other two procedures. This can leave the toe a bit swollen and stiff.
Digital arthroplasty and arthrodesis involve the removal of bone from the bent joint to allow correction. An arthroplasty removes half the joint and leaves some mobility whilst an arthrodesis removes the whole joint and, following a period of time with a wire/pin protruding from the end of the toe, leaves the toe rigid.
In more severe cases, the tendon on the top of the toe and the joint at the ball of the foot need to be released to allow the toe to straighten. If there is severe stiffness at this joint, then the base of the bone at the bottom of the toe (phalanx) may need removing (basal phalangectomy) or the metatarsal shortened (Weil osteotomy).

Patients will often tell me this: "I have heard it is very painful."
The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.

Will I have to have a general anaesthetic (be asleep)?
Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case. We often perform these procedures at our surgical suite over at the Gridley Building location, where often times these procedures are done within 30 minutes, and you leave right then in a surgical shoe with the dressing applied immediately after the procedure is completed.

Will I have to stay in hospital?
No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Will I have to have a plaster cast?
Plaster casts are generally not required for this type of surgery.

Are there a lot of complications?
There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimised.
Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with toe surgery:
Persistent swelling which may be permanent
Recurrence of deformity / corn (this tends to be more of a problem with the little toe)
Regrowth of removed bone
Residual pain
Stiffness or flail (floppy) toe
The toe may not sit on the ground – floating toe (there is an increased risk of this with arthrodesis)
You may get discomfort in other parts of your foot during the recovery period. This generally settles.
There is always a possibility that the deformity may return in later life.

When will I be able to walk again and wear shoes?
In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.
Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks. This period is longer for arthrodesis as shoes cannot be worn until the wire/pin has been removed (generally 3-6 weeks).
Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1 year.

When will I be able to drive again?
When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.
When will I be able to return to work?
If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.
When will I be able to return to sport?
Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 3 months. This will depend on the type of operation you have and how you respond to surgery.

Hopefully this is an effective run down of various questions commonly asked by my patients here, and if you come up with more please comment and the questions will be answered.

DT