Elsevier

Foot and Ankle Clinics

Volume 11, Issue 4, December 2006, Pages 825-835
Foot and Ankle Clinics

Charcot of the Calcaneus

https://doi.org/10.1016/j.fcl.2006.06.010Get rights and content

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Pathophysiology

The pathophysiology of Charcot calcaneus includes both mechanical and physiologic factors. The Charcot foot has autonomic neuropathy of vasoregulation leading to increased blood flow and bony resorption in affected feet [9]. Not all patients demonstrate peripheral vascular disease. Impaired sensitivity combined with traumatic events regardless of magnitude are the hallmarks of this disorder. Mechanically, the neuropathic ankle offers significantly greater biomechanical challenges because of the

Diagnosis

Charcot of the calcaneus is similar to that in other joints in that early diagnosis is imperative. The time to initial treatment is essential. Unfortunately, commonly there is a delay in recognition. The diagnosis is delayed or missed in as many as 25% of patients [12]. The clinical findings will vary depending on the stage of presentation. As noted in early stages, the swelling and skin changes can be quite striking. Distinguishing this stage from an infectious process can be challenging;

Classification

Classification of Charcot arthropathy, as with any system, is designed to suggest appropriate treatment options. Brodsky's classification describes three patterns for the Charcot foot: type 1 involves the midfoot, type 2 involves the hindfoot, and type 3A involves the ankle. Type 3B includes fracture of the calcaneus in his classification. A type 3B involves the calcaneal tuberosity. The primary problem was thought to be mechanical with joint involvement being secondary. The loss of calcaneal

Patterns of injury

Calcaneus injury occurs in three main patterns: posterior avulsion, joint depression, or anterior process fracture. Each has a different natural history. El-Khoury and Kathol [18] described four patients with avulsion fracture of the posterior tubercle of the calcaneus [19]. This finding was unusual in that the patients had no or minimal prior trauma, and all were diabetics with neuropathy. Biehl and coauthors [19] in 1993 presented cases of tuberosity fractures in neuropathic diabetics. This

Management

The goals of treatment of Charcot arthropathy are to decrease the inflammation, encourage bone healing, and prevent further deformity [21]. Prolonged immobilization via total contact casting and bracing are used commonly to stabilize the foot in an as anatomic position as possible while reducing edema until the foot reaches the resolution phase [22]. When a patient has deformity of the foot or ankle that is severe to the point at which management with a custom brace or footwear is not feasible,

Debridement and exostectomy

Surgical treatment with ulcers present has been attempted with dismal results. Thompson and Clohisy performed surgery on patients with open plantar ulcerations. These procedures resulted in a 25% incidence of deep infections. This is compared with a zero incidence of deep infections when the procedure was performed on a patient with intact skin [15]. As the deformities of the calcaneus increase, total contact casting becomes less of a viable option.

Farber and coauthors [8] realized the

Arthrodesis

When total contact casting, debridement, and exostectomy fail, the surgeon must consider arthrodesis. Arthrodesis historically has been considered a salvage procedure. Thompson and Clohisy [26] looked at deformity owing to Charcot arthropathy in the region of the ankle or tarsal bones. Each of the five extremities that had deformity in the region of the ankle and hindfoot had substantial loss of bone that resulted in instability and severe malalignment. They found that the frequency of failed

Summary

Charcot of the calcaneus, although not as prolific as midfoot deformation, still results in significant morbidity. Current treatment centers on methods proven effective for other joints in the foot. Most neuropathic conditions of the calcaneus can be managed reasonably nonoperatively. In cases of severe deformity or ulceration, surgical management may be the more conservative approach. The surgical principles of proper soft tissue balancing and handling are critical. As the diabetic population

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