Prominences on the bottom and inside parts of the foot are at especially high risk of causing ulcers. Removal of bony prominences (exostectomy). The simplest way to prevent a bony prominence from causing an ulcer is to remove that piece of bone. Casting may be used after debridement to keep pressure off of the ulcer as it heals. Bone graft material may also be used to help bones heal if any of these operations are performed. Unstable fractures and dislocations also require surgery to heal. Charcot deformity correction. When fractures and dislocations are unstable and/or the bones are significantly out of place, plates, screws, and/or rods may be required to correct the deformities and get the bones to heal in an appropriate position. Debridement of ulcers. Ulcers may require surgical help to get them to heal. Therefore, operations to fix them generally require more hardware (plates and screws) than would be needed in patients without diabetes. For those conditions that require surgery a detailed understanding of anatomy is critical to ensure that the procedure is performed efficiently and without injuring any important structures.

For acute fractures without major joint dislocations, simply repairing the broken bones (open reduction and internal fixation) may be sufficient. When the above goals of Charcot treatment cannot be achieved by casting and custom footwear alone, surgery may be the best option. Joint fusions are powerful operations for correcting deformity and improving stability and are therefore a mainstay of Charcot treatment. For significant deformities, particularly of the heel or ankle, a large rod may need to be inserted in the ankle to maintain stability. Though not caused directly by an injury, the calf muscle or Achilles tendon may be tight. Keep blood sugar under control (complication rates are directly related to the patient's hemoglobin A1C level). Amputation. In severe cases of Charcot arthropathy, such as those complicated by severe deformity, deep bone infection, or loss of blood supply to the foot, it may not be possible to save part or all of the foot. The following are just some of the surgical options for the various problems that Charcot may present. For instance, Charcot patients with an ulcer have a 50% chance of ending up with an amputaiton, so if surgery is necessary to correct deformities and prevent ulcers, it is often worth the risk.

Debridement simply means cleaning the ulcer and removing any dead skin that is unlikely to heal. Deformities can lead to prominent bones under the skin, and the pressure on the skin caused by those bones can lead to ulcers. This tightness can create pressure points on the sole, specifically toward the forehead, or ball, of the foot, that may lead to ulcers. In these situations, the doctor may recommend amputation above the level of the disease, followed by fitting of a prosthetic device to help the patient remain mobile. Because of the underlying diabetes and the significant deformities that are often present, surgery in a Charcot foot carries a higher risk of wound complications, infections, and amputation compared to routine foot and ankle fracture surgery. Although the risk of a complication from surgery is high, the risk of poor outcomes from untreated Charcot foot is often even higher. This patient developed an infection of the bone 9 months after an ankle joint fusion to reconstruct a Charcot deformity. After attempts to cure the infection were unsuccessful, it was necessary to amputate his foot and ankle. Because of the wide range of problems and deformities being treated, specific success or complication rates vary.

If surgery is done before the development of an ulcer, success rates are actually quite good (typically greater than 80%). The presence of an ulcer, however, makes surgery significantly more challenging, mostly because of the increased risk of infection. Anatomical structures (tendons, bones, joints, etc) tend to hurt exactly where they are injured or inflamed. Due to poor bone quality, fractures that occur in diabetics are typically more complex. A complex realignment and fusion was performed to prevent the patient from developing a prominence and ulceration. Each day, the baby's foot must be stretched and manipulated, then tapped to maintain the range of motion gained by the manipulation. This method requires approximately three visits to the physical therapist each week. The risks and benefits of surgery should be carefully weighed in each case. Most structures in the foot are fairly superficial and can be easily palpated. After 3 months, most babies have significant improvement in foot position, and visits to the physical therapist are required less often. A solid understanding of anatomy is essential to effectively diagnose and treat patients with foot and ankle problems. Anatomy is a road map. Therefore a basic understanding of surface anatomy allows the clinician to quickly establish the diagnosis or at least narrow the differential diagnosis.

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