Charcot Arthropathy of the Diabetic Foot. Current Concepts and Review of 36 Cases

Abstract

A physician should always consider the Charcot neuroarthropathy when a diabetic patient has an inflamed foot. In the absence of fever, elevated CRP or ESR, infection is a highly unlikely diagnosis, and a Charcot process should primarily be considered. The initial treatment of an inflamed Charcot foot consists in sufficiently long non-weightbearing with a cast, which should start immediately after the diagnosis. The prerequisites of successful reconstructive surgery are correct timing, adequate fixation and a long postoperative non-weightbearing period. In the resolution stage most Charcot foot patients need custom-molded footwear.

Audit of acute Charcot’s disease in the UK: the CDUK study

“…In addition, the use of pamidronate was shown in an open-label study to reduce skin temperature and bone turnover markers [8], the latter effect being subsequently confirmed in a randomised controlled trial (RCT) [9]. Another small RCT demonstrated that weekly treatment with alendronate also led to a significant reduction in bone turnover markers, associated with reduced discomfort [10]. Despite these observations, the long-term clinical benefit of non-removable off-loading or bisphosphonate therapy has not yet been clearly established.…”

Should One Consider Primary Surgical Reconstruction in Charcot Arthropathy of the Feet?

“…First, knowing which degree of instability and deformity will be at high risk of failure with nonsurgical treatment relies on judgment [21,23] and the risk factors are not well understood. Expert assessment of these key parameters represents the basis for most treatment protocols from centers with wide experience in Charcot feet [18,19,21,23,24,29]. On the other hand, we believe decision making for surgery in Charcot feet on the basis of any given algorithm requires assessment by someone with considerable experience with Charcot feet and it should not be left to the inexperienced [21].…”

“…Limbs with open ulceration at the initial presentation and limbs with recurrent ulceration have decreased limb survival rate compared to feet without ulcers, adding to an annual limb amputation rate of approximately 1% to 5% [21,23,29]. The goals of treatment should not be merely to save the limb [10,[19][20][21][22]: Pinzur proposed the goal include a long-term infection-and ulcer-free plantigrade and stable foot that allows the patient to walk with commercially available depth-inlay therapeutic footwear [21].…”

“…Recurrence of ulceration means prolonged disability and the requirement for recasting, long-term use of ankle-foot orthoses, or possible secondary surgery [29]. In particular, unstable deformities in these frequently obese patients are difficult to brace with a high inherent risk of ulceration in the insensate feet [19,21]. Late institution of immobilization and unloading runs a high risk of permanent deformity after healing [6,14].…”

“…As such, more than 40% of the patients with midfoot disease who had been managed primarily nonoperatively may require surgery in the further clinical course [21,23]. While formerly corrective arthrodesis of nonplantigrade neuroarthropathic feet has been regarded as a salvage procedure and an alternative to amputation [20], more recent reports relying on biomechanically sound stabilization techniques have demonstrated maintenance of walking independence using commercially available therapeutic footwear and an infection-free foot [26] despite a high complication rate varying from 10% to more than 30% [3,19]. One study of 14 patients with Stage I Charcot arthropathy at the midfoot level reported successful healing of the primary corrective arthrodesis without immediate or long-term complications or any recurrent ulceration during a mean followup period of 41 months [35].…”