10/08/2025 George R Vito, DPM
Charcot Reconstruction Articles Should Have Good Long-Term (Steven Kravitz, DPM) Follow-Up (
I think the profession of foot and ankle surgeons
has learned a lot over the past 30 years in
reference to Charcot reconstruction. I was with
Dr. McGlamry and Banks when we first started
performing reconstructions with a two-team
approach; the surgery lasted 8 hours. With Dr.
McGlamry taking the first four-hour shift, with
Dr. Banks on the second 4-hour shift. Needless to
say, this may of not been the best approach, but
then again, who knew what the best approach was.
Then we dove into the external frame game. This my
friends, started in 1993, when the first ring
fixator was placed on the foot and ankle in Macon,
Georgia, not in Tucker GA. I taught the leaders in
the profession, i.e., Drs. Kalish, Laporta,
Jimenez, Hutchinson, Schuberth, who in turn taught
their residents, and in turn, their residents,
which has been about 33 years in the process.
We all tried every different way to deal with the
Charcot foot and ankle. From waiting to full
consolidation to performing surgery as soon as the
patient showed up to the emergency room with the
"hot Charcot foot". We tried open reduction with
external fixation, complete closed reduction with
external fixation, the use of internal fixation
with external fixation, the use of internal
fixation only, the use of blind reduction, with
small incisions, every type of bone enhancement
implantable possible. What have we learned.
Charcot is not what we thought. The process is
dynamic and ever changing, whatever we do to try
to control the deformity, recreate the deformity
to stabilize the deformity, or just hold the
position, there is no answer to the puzzle.
However, one of the major take home points of
Charcot reconstruction, is that there are no
complications of the surgery. There are expected
outcomes of the surgery. The word complication
should be banned from the consent form and from
any type of discussion with the patient. The
expected outcomes as we have learned over 35
years vary from patient to patient and from
surgeon to surgeon. But remember one thing, loss
of limb and death, is an expected outcome.
I am sorry to say, the direction of treatment is
now dictated by the economical challenges of the
health care systems across the county. When frame
cost skyrocketed, the usage was challenged by the
administrators of the hospitals, with the end
result of a drastic reduction of frame usage in
the Country. External fixation was not the answer
by no means, it was a tool, a very expensive tool,
as are most of the fixation methods.
The future direction of Charcot is simple, do the
most you can with the least amount of damage you
can. The process has gone full circle, we are back
to where we started 35 years ago. Let's not
recreate the wheel. There is not a simple
answer,,, nor a straight forward answer, there are
no studies that I know of, that can establish a
groundbreaking process to correct the Charcot foot
and ankle. This is due to the fact, that the
charcot foot and ankle is a dynamic process, we
never truly stabilize the foot and ankle, but only
chase the goal posts, which seem to keep moving
further and further away.
George R Vito, DPM, LeRoy, NY
