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The Charcot Foot: Treatment to Minimize Progression of Deformity

The Charcot Foot: Treatment to Minimize Progression of Deformity

Figure A

Acute stage Charcot foot is seen in a 55-year-old man with a significant past medical history of type 2 diabetes mellitus (A). He shows peripheral neuroarthropathy with a 1-week history of a hot, swollen right foot.

Charcot neuroarthropathy is a major cause of morbidity for patients with diabetes mellitus (DM). The foot of a 55-year-old man with a significant past medical history of type 2 DM is seen in the accompanying Figure. He has a history of peripheral neuroarthropathy with a 1-week history of a hot, swollen right foot. A radiograph of the foot revealed acute stage Charcot neuroarthropathy (Figures).

Charcot neuroarthropathy is progressive in nature. The longer the acute degenerative process persists, the greater the destruction, resultant deformity, and potential for other complications. Like any progressive disorder, Charcot neuroarthropathy requires more aggressive and invasive treatment the longer it goes unmanaged.

In this 2-part article, we discuss the signs of Charcot that affect the foot and ankle. The first part (“The Charcot Foot: A Missed Diagnosis Can Cost a Limb”) focused on identification and diagnosis of the disorder and how to distinguish it from other conditions. This second part describes management of this complex neuropathic condition, including the conservative options for treatment of acute Charcot foot and prevention of serious deformity, as well as the appropriate interventions for reconstruction.

Treatment Goals

The primary goal of treatment is to minimize the progression of foot deformity by achieving and maintaining structural stability of the foot and ankle. This includes preserving a functional plantigrade foot and ambulation while preventing ulcers from forming or recurring.

The choice of treatment for Charcot foot is based on the following 4 factors:

• Disease stage.

• Location of deformity.

• Presence of ulcerations.

• Existing comorbidities.

Conservative Treatment

During the acute stage, offloading the foot is crucial to arresting the progressive deformity. The mainstay of treatment is immobilization and reduction of stress on the foot.

Ideally, the foot should be immobilized in a total contact cast (TCC), or an instant TCC, which has been shown to be equivalent.1 To prevent skin abrasion, replace the TCC after 3 days and every week or two thereafter. This treatment typically lasts 8 to 12 weeks or until edema has resolved and the temperature of the affected foot is within 2°C (36°F) of that of the contralateral foot.2

Figure B

A foot radiograph (B) revealed acute stage Charcot neuroarthropathy. The primary goal of treatment is to minimize the progression of foot deformity.

Monitor progression by serial radiographs until fracture healing and bone remodeling are evident. At that point, the patient should be transitioned to a Charcot restraint orthotic walker. Eventually, to achieve a gradual return to full weight bearing, the patient should be provided with accommodative shoes and insoles. Keep in mind that the patient may need an ankle-foot orthosis with the accommodative shoes.

Medication with bisphosphonates may expedite conversion of an active Charcot foot to a more stable, chronic stage. This treatment was proposed because markers of bone turnover are excessively elevated in Charcot neuroarthropathy. However, although pamidronate has been reported to be effective,3 there is no conclusive evidence that bisphosphonates significantly minimize bone resorption in this patient population.

Electrical bone stimulation also has been proposed for treatment during the acute phase because of its ability to stimulate and promote rapid consolidation of fractures.4

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