Challenges of Charcot Reconstruction Surgery

Article by Dr. Misako McLeod, DPM 

I’m one of the few foot and ankle surgeons in Hawaii who perform Charcot Foot and Ankle reconstructive surgery. Let me tell you, its not easy dealing with insurances, hospitals. anesthesia groups, and


Last year, I was calle dinto a Me

I toght to myself”this must be the one who

A pit bull of a nurse looked at lmd strigh tin the eye and


Most doctors DO NOT take on these surgeries for several reasons:

1. They are difficult, complex surgeries with severe issues and high risk for complications and non-compliant patients.

2. Nobody seems to understand what its about. There is little public knowledge on Charcot foot. Often times, I see a severe non-neurpathic foot with nora anatomy being labeled as as “Cahrcot foot” simply because it loos collapsed. This is a serious midusndetsanding of the diease process.


Charcot foot was first described by Jacque _______. in the France, the misery of the______




3. The hospitals dislike surgeries because their not a simple one-hour surgery that maxmizeds financial return. Its much moreprofiatble to a hospital to have your leg amputated than have several limb salvage suegrries,


4, The surgeries require long OR times and expensive implants and equipment.


5. It is usual an common that a patient will often thane to ben taken back to the OR to have their frame readjusted, tightened, or worse re-redirected you rewire.


5. Patients typically are noncompliant and lack understanding of the degree of


6. PAtients gets frustrated. arterials and lack of blod flow, open wounds, bad lungs, bad bone; smoking

In this world, we want to have things died and fixed quickly, unfortunately, mother nature doesn’t agree with this and will raise her wrath upon anyone who demands otherwise,

1. arteial – no


2. smoking and bone

3. bad lungs.


6. Patients are sick


7. Its not profitable


Why the insurance companies don’t like it:

1. Its expensive. It’s cheeper to cut off the patient’s leg than to perform a Charcot reconstructive surgery.



Why the hospitals don’t like you as a surgeon?

1. They don’t understand what you’re doing. Doesn’t matter that you save most of your patients form a below-knee-ampuation. That downs tmatter. Instead, they hire one year trained (thats ess than internship) to evaluate your most compacted case that they likely have never even seen or reform. When you ask for their case laid tonsure that they in fact are experienced and perform on a ruglr basis these toy e complex cases.




Its unfortunate that medicine has digressed to define itself merely by financial measures, and employing nonclinical bean counters wh lack understanding of the

I have always respected and admired the true interdisciplinary approach to medicine where doctors crate a think-tank and evaluate each patient as as individual – for all their persanol challenges, socioeconomic,a nd as wells the technical challenges of surgery.


Medicine is a a challengin uniue field that should deb entered for the . They will always be unites surgical cases and – these need to be and learned form to better educate the medical. What is happening is that







Article by Dr. Misako McLeod, DPM

The peroneal tendons run along the side of your leg and insert into the side and bottom of the foot. They control your ability to evert your foot and press your foot downward. These movements are necessary for walking and the gait cycle.

Peroneal tendons issues are very common and usually there is an underlying biomechanical issue that caused the problem. Peroneal tendons problems usually occur in athletes and people with high arches (pes cavus).  Basic types of peroenal injuries include: tendoniitis, tears, and subluxation.

Peroneal tendoniitis

The most common problem, Peroneal tendoniitis,  involves inflammation of the tendons, pain, and warmth. It can cause difficult walking and an aggravating chronic pain.

Peroneal Tears

Common problem that involves pain, warmth, swelling and weakness or and instability of the foot and ankle. The patient may complain of the foot and ankle feeling as if it’s going to “give way.”

Degenerative changes or tendonosis

Chronic inflammation over the years can lead to degeneration of the tendons, over stretching, and fraying of the tendons. This causes weakness, intermittent pain and swelling, and difficulty walking.


The peroneal tendons run under a fibrous band called the retinaculum. When this retinaculum ruptures, the tendons may slip out of their normal position. The patient can often reproduce the symptoms by everting their foot. At that time, you can feel the tendons moving out of their normal position, and a snapping feeling around the ankle bone.

Although every condition has a different treatment regimen, most issues can be treated by immobilization, physical therapy, and anti-inflammatories. When these measures fail, surgery may be indicated and each condition requires a different surgical procedure.


During your examination, I will usually evaluate the course of the tendon with an ultrasound to check for large tears. Although an ultrasound cannot detect smaller intra substance tears, it provides a good overview of the tendons in general. Sometimes, I will then proceed with ordering an MRI to get a much more detailed evaluation of the tendons. However, keep in mind, that although MRIs may pickup larger, more obvious tears, the smaller longitudinal tears may not be detected. Technology has not advanced to the point where the smallest tears can be picked up by MRI at this point.


Each condition above has a different treatment regimen. This treatment protocol is individualized and depends upon the severity of the patient’s issue. Treatment may involve: casting, bracing, physical therapy, steroid injections, anti-inflammatories, and orthotics. If these conservative measures fail, surgery may be indicated.


If the peroneal tendons are torn or frayed, surgery will consist of removed all dead or weakened tendon, possible Topaz coblation to facilitate healing, and primary repair. Sometimes, stem call grafts are wrapped around the tendon to facilitate healing.

If the peroneal retinaculum is weakened or ruptured, the retinaculum will be reattached to the fibula bone with small tendon anchors to provide additional stability. A small groove may be created in the back of the fibula to allow the peroneal tendons to remain in place.

The patient will be immobilized and non-weightbearing for 4-6 weeks to allow the tendons to heal. Then, the patient will be placed in a removable cast boot and started on a program of gentle range-of-motion exercises, contrast soaks to reduce swelling, and physical therapy.

Once the patient is fully walking, I usually cast for orthotics to correct any pre-existing biomechanical issues which may have contributed to the issue.








Man surgeon and woman assistant in protective uniform preparing for operation looking at camera on background of surgical lamp. Focus in woman assistant

A foot and ankle specialist is a medical specialist in the foot and ankle, and must complete 4 years of graduate school and then a residency.

Currently, residency graduates are required to complete AT LEAST  2 years of surgical training in foot and ankle.  During residency, one must complete various rotations which may include: Plastic Surgery, Trauma Surgery, Orthopedics Surgery, General Surgery, Emergency Room Medicine, Internal Medicine, Pathology, Radiology, Infectious Disease, Neurology, Rheumatology.

After completion of these general rotations, the resident moves forward to to complete various foot and ankle rotations with emphasis in limb salvage and preservation, advanced wound care, elective surgery, biomechanics, Pediatrics, as well as other various sub-specialities.

Today, unfortunately, there is currently much misinformation about foot and ankle specialists being presented to the public by their economic and political competitors.

These competitors are typical foot and ankle orthopedic surgeons who imply that foot and ankle specialists are “not qualified” and “lack surgical training.” These statements are unprofessional, biased, and deserve to be challenged and questioned.

As one can see from the above review, the facts speak for themselves.

If you would like more information about Podiatrists and their services, a good website to reference is:

www.American College of Foot and Ankle Surgeons. com

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