Treating the Complicated Neuropathic Charcot Foot

Dear Readers,

Have you treated a patient with a diabetic foot ulcer and a neuropathic (Charcot) foot lately? If you have, you are already aware of how complicated and difficult it is to treat them. Many eminent surgeons will recommend primary amputation with no thought given to treating the ulcer. British surgeon Sir Astley Cooper said, “He is a good surgeon who can amputate a limb, but he is a better surgeon who can save a limb.” This is a philosophy to which we all should adhere.
Two of my wound care heroes, Dr. Grace Warren and Dr. Paul Brand, spent their entire lives treating patients with neuropathic limbs. Dr. Warren and Dr. Brand have provided more guidance for care of neuropathic limbs than any other surgeons in history. Dr. Warren started her medical career in obstetrics and gynecology but was drawn to neuropathic limb care when one of her patients with peripheral neuropathy suffered an ankle fracture. Her attending physician thought treatment was hopeless but suggested she try to cast the fracture if she desired. Despite the ominous prediction, the fracture healed and the ankle remained functional despite a prolonged healing time. This stimulated Dr. Warren’s interest in learning more about this seemingly hopeless problem and helping the many patients she was seeing with neuropathic limbs. In order to find out all she could, she turned to the only authority on the subject at the time, Dr. Paul Brand.
Dr. Brand, born in 1914, was the son of missionaries and grew up in India. He returned to England for his formal education and decided to pursue a medical career after seeing the “magic” of a blood transfusion on a dying patient. During his training he encountered a patient who was bleeding to death from a neck wound. With the calm demeanor of a practiced surgeon, he controlled the bleeding with the best instrument available, his thumb, and repaired the venous injury. On completion of his training he returned to India where he was exposed to neuropathic patients with horrible deformities of hands and feet, and foul-smelling ulcers that made them outcasts. He worked to find ways to help these often ignored people. His methods of treating and reconstructing neuropathic limbs affected with ulcers and deformities have given new life to countless patients suffering with these problems.
Dr. Warren devised diagnostic techniques to facilitate early diagnosis of neuropathic arthropathy (Charcot foot). She was instrumental in perfecting reconstructive techniques for seemingly destroyed ankles. A surgeon who knew Dr. Warren confirmed with me that she was one of the most amazing surgeons with whom he had ever worked.
I encourage you to read their publications and learn more about these remarkable heroes of wound care and how their work can assist us in saving even an apparently “hopeless” extremity.

Terry Treadwell, MD, FACS
Clinical Editor, WOUNDS

Warren G, Nade S. The Care of Neuropathic Limbs: A Practical Manual. New York, NY, London, UK: The Parthenon Publishing Group; 1999.
Yancey P, Brand P. The Gift of Pain: Why We Hurt & What We Can Do About It. Grand Rapids, Michigan: Zondervan Publishing House; 1993, 1997.