October 2011

Task Force Establishes Diabetic Charcot Foot Guidelines

By Brian McCurdy, Senior Editor

Offloading and immobilization are key in the initial treatment for diabetic Charcot foot but the current staging for the deformity may not be effective, according to new recommendations from the International Task Force on the Charcot Foot that were jointly published in Diabetes Care and the Journal of the American Podiatric Medical Association.

   The task force noted that the existing Charcot classifications are insufficient to provide adequate prognoses or treatment for the condition, according to Lee C. Rogers, DPM, a co-chairman of the task force. He and his colleagues recommended establishing a classification of “active” or “inactive” Charcot, which describes an inflamed or not inflamed foot respectively. The guidelines note that physicians often use definitions of Charcot, such as acute and chronic, although there is no accepted point to describe the transition between the two.

   Task Force Co-Chairman Robert Frykberg, DPM, emphasizes the importance of making an early diagnosis at the onset of inflammation and before deformity occurs. Dr. Frykberg urges clinicians to have a high index of suspicion. For example, when one is faced with any fracture to the neuropathic foot, Dr. Frykberg suggests treating such a fracture as if the patient had a Charcot foot even in the absence of deformity.

   Radiographs are an important initial exam and one should look for subtle fractures and subluxations in the absence of visible pathology, according to the recommendations. The task force notes that if radiographs appear normal, magnetic resonance imaging or nuclear imaging can confirm clinical suspicions.

   “Offloading and immobilization is first and foremost the most accepted conservative treatment. All else is adjunctive,” adds Dr. Frykberg, the Chief of Podiatry and Residency Director at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix. The guidelines suggest protective weightbearing after an active Charcot episode as well as lifetime surveillance for new or recurrent Charcot and other diabetic foot complications.

   The task force finds little evidence guiding the use of pharmacologic therapies to promote the healing of Charcot foot. Likewise, although bone stimulation for Charcot is promising, the task force finds limited evidence supporting this treatment.

   Although offloading is important initially, one might consider surgery as a primary treatment for acute fractures and dislocations, just as one would treat a non-neuropathic patient, notes Dr. Rogers, the Co-Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. Furthermore, the authors say surgery can be a primary treatment for severe Charcot neuroarthropathy of the ankle.

   Specifically, the task force finds that exostectomy may be beneficial in relieving bony pressures that cannot be accommodated otherwise. The authors also say lengthening of the Achilles tendon or gastrocnemius tendon may improve alignment and reduce forefoot tension. The guidelines note that arthrodesis may help patients with pain or instability.

   When treating Charcot, there are several common “myths” that physicians should be aware of, according to Dr. Frykberg. He dispels the idea that Charcot is a “vascular” disease due to insufficiency, noting that the opposite is true and Charcot is characterized by an abundance of blood flow. He also clarifies that there is usually some modest degree of pain present in the active stage of Charcot.

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