Emerging Evidence On Treatment Of The Diabetic Charcot Foot
• 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.
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.
1. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. J Am Podiatr Med Assoc. 2011;101(5):437-446.
2. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129.
3. Rogers LC, Bevilacqua NJ. The diagnosis of Charcot foot. Clin Podiatr Med Surg. 2008;25(1):43-51.
4. Armstrong DG, Lavery LA. Monitoring healing of acute Charcot’s arthropathy with infrared dermal thermometry. J Rehabil Res Dev. 1997;34(3):317-321.
5. Rogers LC, Bevilacqua NJ. Imaging of the Charcot foot. Clin Podiatr Med Surg. 2008;25(2):263-274.
6. Frykberg RG, Mendeszoon E. Management of the diabetic Charcot foot. Diabetes Metab Res Rev. 2000;16(Suppl 1):S59-65.
7. Jude EB, Selby PL, Burgess J, et al. Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetologia. 2001;44(11):2032–2037.
8. Pitocco D, Ruotolo V, Caputo S, et al. Six-month treatment with alendronate in acute Charcot neuroarthropathy: a randomized controlled trial. Diabetes Care. 2005;28(5):1214–1215
9. Game FL, Catlow R, Jones GR, et al. Audit of acute Charcot’s disease in the UK: the CDUK study. Diabetologia. 2012;55(1):32-35.
10. Bem R, Jirkovska A, Fejfarova V, et al. Intranasal calcitonin in the treatment of acute Charcot neuroosteoarthropathy. Diabetes Care. 2006;29(6):1392-4.
11. Khanna D, Arnold EL, Pencharz JN, et al. Measuring process of arthritis care: the Arthritis Foundation’s quality indicator set for rheumatoid arthritis. Semin Arthritis Rheum. 2006;35(4):211-237.
12. Bevilacqua NJ, Rogers LC. Surgical management of Charcot midfoot deformities. Clin Podiatr Med Surg. 2008;25(1):81-94.
13. Rogers LC, Bevilacqua NJ, Frykberg RG, Armstrong DG. Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle. J Foot Ankle Surg. 2007;46(5):372-375.