Emerging Evidence On Treatment Of The Diabetic Charcot Foot

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Author(s): 
Lee C. Rogers, DPM, and Robert G. Frykberg, DPM, MPH

   Patients can use rolling walkers and wheelchairs but should exercise caution with the use of crutches. Many people with diabetes and Charcot foot are obese and all have peripheral neuropathy, which impairs proprioception and can lead to falls. Many don’t have the cardiovascular reserves to use crutches effectively. Additionally, the use of walkers for more than balance is not advisable since hopping on the unaffected foot can be a traumatic event and can lead to a Charcot process. Nearly 30 percent of patients with Charcot have bilateral Charcot foot so one must be cautious to avoid trauma.1

   There are some studies on pharmacologic therapies to arrest the active Charcot foot. Bisphosphonates such as pamidronate (Aredia, Novartis) and alendronate (Fosamax, Merck) have shown benefit in some small studies.7,8 Pamidronate is a single dose intravenous infusion. Alendronate is a once weekly oral therapy. A recent large population study from the United Kingdom showed no benefit for bisphosphonates.9

   Intranasal calcitonin is another option. Patients spray calcitonin in the nostril once daily, alternating nostrils. Advocates have theorized it is a better treatment than bisphosphonates because it has direct action on the RANKL/osteoprotegerin pathway.10 Others have discussed the use of potent anti-inflammatories, such as TNF-alpha inhibitors typically used in inflammatory arthritides.11

   In regard to medical treatment, the task force made the following recommendations.1,2
• Offloading the foot and immobilization are the most important treatment recommendations for active Charcot foot. These can prevent further destruction of the foot.
• There is little evidence to guide the utilization of available pharmacologic therapies to promote the healing of Charcot foot.
• Protected weightbearing is required after an active episode. This consists of prescription devices such as shoes, boots or braces.

What The Task Force Recommends On Surgical Treatment

The task force consisted mostly of Europeans of non-surgical specialties and Americans in surgical specialties. Naturally, there was division on the recommendations for surgery along those lines. The panelists agreed that one should reserve surgery for cases of severe instability, non-braceable deformity, infection or failed ulcer healing.1,2 Additionally, the panel agreed that surgery could be a primary treatment for Charcot arthropathy of the ankle since the outcomes with any medical treatments are poor.

   The surgical approach is based primarily on expert opinion as there are only a few larger retrospective studies. The task force agreed that there will likely never be high-quality surgical studies in the Charcot foot due to the rarity and difficulty in performing surgical studies. The goals of surgery should be to create a more stable plantigrade foot that one can brace with a shoe or Charcot restraint orthotic walker (CROW), and heal any ulcers.

   The approach differs based upon the joints affected, the severity of the condition and the surgeon’s experience or preference. Usually one would address the Achilles tendon surgically since equinus is known to be a deforming force at the midfoot, causing dislocation. Authors have described techniques using internal and external fixation.12 Surgical arthrodesis is generally effective and radiographic fusions are common, but fibrous pseudarthroses may produce the same positive outcome. Most experienced surgeons recommend more stable fixation, longer non-weightbearing time and longer follow-up times when correcting the Charcot foot. Complications are common and the surgeon should address them as they happen.13

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Dr.Jose Alberto Rivera Zenteno MD says: March 1, 2012 at 4:26 pm

Thanks for all of this information.
Now we can be up to date about it.

Sincerely,

Jose Alberto Rivera, MD
Mexican Geriatric Doctor

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Dr.Sunil V.Karisays: March 8, 2012 at 7:30 am

Charcot neuroarthropathy in DM has to be detected very early to prevent further disaster.
At our diabetic limb salvage center, Ihave a protocol for detecting Charcot early.

1. Every diabetic is advised on an exercise schedule only after confirming bone and joint deformities on AP/ LAT (dynamic) X-ray views of the feet. This is done every six months and three monthsfor low risk feet and high risk feet respectively. This costs about $4, which is economical and my patients can afford. This protocol has helped many patients to arrest the pathophysiology of active Charcot.

2. The task force has not considered the Charcot changes in DFI managed for a long duration. The prevention and treatment aspects of this condition are really challenging than the active / inactive Charcots. This is common in asian contries as DFI in PNP is common and management is poor.

We plan AP/LAT (dynamic) X-ray views of the feet every month for all DFI patients in whom we have planned release of tarsal tunnel. It concludes on radiological healing and helps me to detect Charcot changes.

3. Osteomyelitis of navicular bone or medial cuniform bone alone in diabetes has led to charcot changes. This issue has to be addressed .

4. I have been practicing medical management for Charcot and limb salvage is very satisfactory.

As we practice evidence-based medicine, we always take blood sugar as evidence for DM management, Similarly, every diabetic should be advised exercise only after having an evidence that his or her feet bone architecture is normal to walk, run, jog, etc.

Sincerely,

Dr. Sunil V.Kari, MS
Consultant Surgeon
Diabetic Foot Surgeon
Sou Mandakini Memorial Hospital
Diabetic Limb Salvage Center
HUBLI.Karnataka.INDIA

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