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

   The task force made the following recommendations about surgical management.1,2

• Surgical treatment is beneficial in Charcot foot or ankle cases refractory to offloading and immobilization. Surgery is also beneficial in the case of recalcitrant ulcers.
• The initial management of acute neuropathic fractures and dislocations should not differ from initial management techniques for other fractures.
• Exostectomy is useful in relieving any bony pressure that orthotics and prosthetics cannot accommodate.
• Lengthening of the Achilles tendon or gastrocnemius tendon reduces forefoot pressure. It also improves the alignment of the ankle and hindfoot to the midfoot and forefoot.
• Arthrodesis can be useful in patients with instability, pain or recurrent ulcerations who fail non-operative treatment, despite a higher rate of incomplete bony union.
• For severe Charcot arthropathy of the ankle, one could consider surgical management as a primary treatment.

In Conclusion

The Charcot foot syndrome is a complex complication of diabetes and neuropathy, but physicians can prevent major deformity associated with this syndrome. We should have a high index of suspicion when examining a neuropathic patient with a hot, swollen foot. If one implements existing treatments early, they are effective at preventing ulceration and bony destruction.

   Offloading is the most important initial treatment and given the risk benefit ratio, offloading should begin even during the diagnostic period. Other pharmacologic treatments have not shown conclusive benefits. Surgical treatments can be effective when experienced surgeons perform them. However, one should reserve surgical treatment for cases in which offloading and bracing fail, or in cases of severe instability.

   Jean-Martin Charcot, MD, concluded his seminal paper on tabetic arthropathies, which now bear his name, with the statement “sera continue,” which means “to be continued.” More than 130 years later, his statement remains true. There is much we have to learn about the pathophysiology of this condition, which will generate future therapies.

   Dr. Rogers is the Co-Director of the Amputation Prevention Center at the Valley Presbyterian Hospital in Los Angeles.

   Dr. Frykberg is the Chief of the Podiatry Section and the Podiatric Residency Director at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix.

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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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