Multidisciplinary approach to soft-tissue reconstruction of the diabetic charcot foot

Background: Diabetics are prone to foot ulceration as a result of local tissue ischemia, immune impairment, and biomechanical derangement in the setting of neuropathy. Healing ulcers in the setting of Charcot neuroarthropathy is challenging, as the skeletal changes usually signify advanced disease. Methods: Records were reviewed for all patients with the diagnosis of Charcot neuroarthropathy and ulceration treated over a 7-year period. Demographic data, anatomical wound location, therapeutic interventions, and wound healing rates were recorded. Results: Three hundred fourteen wounds in 259 patients were examined. One hundred ninety-three wounds with documented follow-up data were analyzed. Fifty wounds (25.9 percent) were on the forefoot, 73 (37.8 percent) were on the midfoot, 28 (14.5 percent) were on the hindfoot, and 42 (21.8 percent) were about the ankle. Wounds were débrided surgically an average of four times. Primary closure was attempted in 29 wounds (15.0 percent). Delayed primary closure was attempted in 35 wounds (18.1 percent). Bioengineered alternative tissues were used in 61 wounds (31.6 percent). Autologous skin grafting was performed on 41 wounds (21.2 percent). Fifteen local flaps (7.8 percent) and five free flaps (2.6 percent) were performed. Forty-eight patients (31.6 percent) required a major amputation. Excluding patients who underwent major amputation, 95 wounds (65.1 percent) were healed at the time of final follow-up. Conclusions: The majority of ulcers on Charcot feet required multiple débridements to achieve a clean wound. Multiple therapeutic modalities were used to achieve a 65 percent rate of healing. Despite those efforts, many patients required partial foot or major amputations, with more proximal wounds being at highest risk of the latter.