Charcot reconstruction surgery: rebuilding a stable, walkable foot

What reconstruction fixes

In Charcot foot, nerve damage lets the bones and joints of the midfoot or ankle break down and shift, often with little or no pain. The deformity left behind makes ulcers and infection more likely, and studies link an ulcer over a Charcot deformity to a six to 12 times higher risk of major amputation compared with people with Charcot who have no ulcer.⁠^[1] Our Charcot foot page covers its early treatment.

Swipe sideways to see the whole drawing.

Reconstruction corrects the shape by removing a prominent bone (exostectomy), lengthening or transferring a tendon, or realigning the collapsed bones and fusing the joints (arthrodesis) so the foot sits flat.⁠^[1]

Dr. Efe Ozturk, a Foot and Ankle Surgeon who is board certified in wound care (FAPWH), performs Charcot reconstruction, from removing a single bony prominence to realigning the whole midfoot or ankle. He holds the correction with internal hardware or, for the feet that need it, an external frame, and he cares for the wound before and after surgery.

When it’s considered

Non-surgical care is the foundation of Charcot treatment and works in most cases; for severe deformity, surgery is now more widely accepted.⁠^[6] While Charcot is active, treatment starts with a total contact cast or a knee-high device that can’t be removed.⁠^[1] We fit both; see total contact casting.

For a foot that is still active but has intact skin, the international guideline suggests considering surgery when the joints are unstable or the shape puts the skin at high risk of breaking down inside the device. The same goes for pain that can’t be controlled in a cast or knee-high device. An ankle or heel tilted inward or outward is especially hard to manage in either one, because the ankle bones sit just under the skin.⁠^[1] Once Charcot has settled, removing a bony prominence can help an ulcer heal, or keep one from forming, when non-surgical care has not worked.⁠^[2]

If the foot is still inflamed, the guideline recommends immobilization and swelling control first. It also calls for a shared decision with a well-informed patient, and for a surgeon experienced with high-risk diabetic feet.⁠^[1]

Before surgery, we check your circulation with noninvasive testing at our practice and involve a vascular specialist when blood flow needs attention (see circulation tests for foot wounds). X-rays are taken on site; CT or MRI is arranged at an outside imaging center. See preparing for limb salvage surgery.

How the surgery is done

The operation depends on where the foot has collapsed and whether there is an open ulcer.⁠^[3]

• Removing a bony prominence. When the foot is stable but a bony bump sits under an ulcer, the bump is shaved down. In a review of 11 studies, the wound closed after the first operation in 60% of cases and in 90.7% once further treatment was counted. Operations under the outer side of the foot seemed to have more complications.⁠^[2] See exostectomy.
• Tendon procedures. Lengthening a tight Achilles tendon, or transferring a tendon, can be part of the reconstruction.⁠^[1,3] See surgery that takes pressure off ulcers.
• Realignment and fusion. Bone is removed or cut to restore the arch, and the joints are held until they fuse. Modern “superconstructs” extend the fusion beyond the damaged zone, remove enough bone to correct the shape without stretching the skin, and use stronger implants placed where they share the load.⁠^[6] In the midfoot, screws or beams that run through the length of the bones can hold the correction. For the ankle, one review recommends a rod from the heel up into the shinbone when there is no ulcer.⁠^[7,8,3]
• An external frame. Pins or wires connect the bones to a frame outside the leg. In one large series that used a frame on its own, it came off after six to eight weeks, leaving no screws or plates behind to break.⁠^[5] For an ankle with an ulcer or a complex deformity, the ankle review above recommends combining a frame with internal hardware.⁠^[3] See external fixation.

When the bone is infected. Surgeons differ on whether to clear the infection first and rebuild later, or to do both at once.⁠^[9] In one surgeon’s series, the infected bone was removed and the deformity corrected in a single operation, with an external frame holding the foot. Of 71 patients, 68 (95.7%) kept the limb and walked in off-the-shelf therapeutic shoes, though a few needed a second operation or a local flap to close the wound.⁠^[9] Dr. Ozturk removes infected bone and chooses antibiotics from bone cultures; see surgery for bone infection.

What the results show

• Many studies combined. In the review of 1,116 feet, the bones fused in 86.1%.⁠^[4]
• Midfoot beams. A review of 16 studies reported that 92% of limbs were saved at an average of 25 months, though complications were common whichever implant was used.⁠^[8]
• External frames. In a series of 292 feet, 23% had an ulcer that persisted or returned, and 12 of the 194 patients still being followed (6.2%) later needed an amputation. Activity levels improved.⁠^[5]

Recovery: months, not weeks

In one series of 22 midfoot fusions, the bones fully joined in 16 patients at an average of 5.8 months, and every patient was walking independently within 9.5 months.⁠^[7] In the frame series, a custom brace followed the frame for another 11 months, and custom shoes came after a year.⁠^[5] Expect regular checks of the skin, hardware and X-rays throughout.

Once Charcot is in remission, the guideline recommends shoes and inserts that fit and support the foot’s shape to help prevent a new flare. When deformity or instability remains, it recommends a custom below-knee brace, such as a Charcot restraint orthotic walker (CROW).⁠^[1] We provide therapeutic shoes and custom inserts; see offloading boots and footwear and recovery after limb salvage surgery.

Risks and limits

Charcot reconstruction is major surgery on a high-risk foot. Complications include wound infection, wound breakdown, bones that don’t fuse, hardware failure and the need for more treatment.⁠^[1] In the large review, 36% of people had a complication caused by the fixation technique.⁠^[4] Infection after foot and ankle surgery is more common with diabetes, nerve damage, Charcot and smoking,⁠^[10] and with an A1c of 8% or higher, so better blood sugar control is part of getting ready.⁠^[11]

The guideline’s review found no randomized trial comparing surgery with non-surgical care for active Charcot, and most results come from uncontrolled studies in carefully selected patients.⁠^[1,4] Not every foot is a good candidate, and a second opinion before amputation can help settle the choice. The Center for Lower Extremity Surgery also covers Charcot foot (external site) and joint fusion (external site).

Questions to ask before deciding

• Is my Charcot still active, or has it settled?
• Is my circulation good enough to heal after surgery?
• Is the bone infected, and will that be treated first or in the same operation?
• Will you use internal hardware, a frame or both, and why?
• How long will I keep weight off the foot, and what shoes or brace come after?

When to seek care

If you have diabetes or numb feet and one foot turns warm, red or swollen, or a foot with Charcot changes starts to change shape, call us the same day, even if it doesn’t hurt, and keep weight off it until you’re seen (see a red, hot, swollen foot). See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes.