SLR - October 2021 - Tomas A. Trevino
Reference: Sims, Michael, et al. “Bilateral Charcot Arthropathy Treated with Bolt-Beam Constructs in the Setting of Unilateral Foot Ulcers.” JBJS Case Connector, vol. 11, no. 3, 9 July 2021. Doi:10.2106/jbjs.cc.20.00661.Level of Evidence: 4
Scientific Literature Review
Reviewed By: Tomas A. Trevino, DPM
Residency Program: St. Joseph Medical Center – Houston, TX
Podiatric Relevance: Traditionally, Charcot Neuroarthopathy of the foot has been treated with internal fixation, external fixation or a hybrid model. However, in the presence of ulcerations this becomes complicated. Zgonis et al., stated that placement of internal fixation in the presence of plantar ulceration could be a nidus for future infection in the diabetic patient. Because of this, ulcerated Charcot has been treated historically with multiplanar osteotomies and concurrent external fixation, or by waiting for ulcer healing prior to correction with internal fixation. With the advent of medial column “beaming”, deformities can now be corrected with multiplanar osteotomies and the placement of intramedullary beams. This case report talks about two patients with bilateral Charcot arthropathy and unilateral foot ulcers that were treated with bolt-beam constructs and went on to heal uneventfully.
Methods: A report of two cases (one male, one female) in which patients developed bilateral Charcot Neuroarthropathy and presented with unilateral foot ulcerations. Patients underwent and failed conservative treatment consisting of Total Contact Casting (TCC), Charcot Restraint Orthotic Walker (CROW), and custom diabetic shoes. Both patients went on to needing multiple debridement, six-week courses of IV antibiotics, wound care as well as plantar ostectomy, application of external fixator with aggressive Achilles tendon lengthening. The wounds recurred, and the patients developed true rocker bottom deformities. Because of this, the senior surgeon chose to move forward with bolt-beam constructs with application of medial column plates.
Results: In one patient, the procedure was performed bilaterally and consisted of beams thrown down the first and third metatarsals proximally into the talus and calcaneus. In addition to this, a medial column plate with screws were placed as well. In the other patient, the procedure was performed in the left foot and consisted of having beams thrown down the first and second metatarsals into the talus. Like the first patient, a medial column plate with screws was placed along the medial column. Patient one went on to bony union with no recurrence of deformity or ulceration. At seven months post op, patient was pleased and was able to return to living a normal life. Patient two experienced some breakdown after transitioning to a boot. However, patient went on to heal and at 10 months was wound and deformity free.
Conclusions: Charcot Neuroarthropathy in the presence of plantar foot ulcerations has traditionally been treated by multiplanar osteotomies with external fixation or by waiting for ulcer healing prior to correction with internal fixation. In this article, the author reports two cases of bilateral Charcot Neuroarthropathy with unilateral foot ulcerations that were successfully treated with bolt-beam constructs and medial column plating. Although the literature does not support this, the senior author went on to add that this technique has been used in 18 patients over four years with all feet remaining plantigrade and ulcer free. More research with larger cohorts should be completed in the future, however this technique has the potential to be a solution for patients who present with plantar foot ulcers due to Charcot Neuroarthropathy.