What is the best treatment approach for a patient with Charcot foot?

Treatment Approach for Charcot Foot

The best treatment for Charcot foot is a non-removable knee-high device, with a total contact cast being the first choice, to immobilize and offload the foot to promote disease remission and prevent deformity progression. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is crucial:

1. Clinical Assessment:

   • Look for increased temperature, edema, and/or redness of the foot compared to the contralateral foot 1
   • Use infrared thermometry to measure skin temperature differences between affected and unaffected limbs 1

2. Imaging:

   • Perform plain X-rays (standing/weight-bearing when possible) including anteroposterior, medial oblique, and lateral projections 1
   • If X-rays appear normal but clinical suspicion remains high, perform MRI to confirm diagnosis 1
   • When MRI is unavailable or contraindicated, consider nuclear imaging scan, CT scan, or SPECT-CT 1

3. Laboratory Tests:

   • Blood tests like CRP, ESR, white blood count, or alkaline phosphatase are not recommended for diagnosis 1

Treatment Algorithm

1. Immediate Offloading and Immobilization

• Initiate knee-high immobilization/offloading immediately once Charcot foot is suspected, even while diagnostic studies are being performed 1

• Treatment options in order of preference:

  1. Total contact cast (TCC) - first choice 1
  2. Non-removable knee-high walker - second choice 1
  3. Removable knee-high device (only when non-removable options are contraindicated or not tolerated) 1

• Do not use below-ankle offloading devices (surgical shoes, postoperative sandals, custom molded shoes, or slipper casts) as they provide inadequate immobilization 1

2. Weight-Bearing Considerations

• Use assistive devices (crutches, walker) to reduce weight-bearing on the affected limb 1
• Continue offloading until remission is confirmed

3. Monitoring Disease Activity

• Perform serial temperature measurements between affected and unaffected limbs 1
• Consider all of the following to determine remission:
  • Temperature measurements
  • Clinical edema
  • Imaging findings 1
• Schedule follow-up appointments based on:
  • Fluctuation in edema volume
  • Co-morbidities
  • Treatment risks
  • Patient's progress and recovery 1

4. Pharmacological Management

• Do not use the following medications for Charcot foot treatment:

  • Bisphosphonates (alendronate, pamidronate, zoledronate)
  • Calcitonin
  • PTH
  • Methylprednisolone
  • Denosumab 1

• Consider vitamin D and calcium supplementation during fracture healing phase, following national guidelines for supplementation in persons at risk of deficiency 1

5. Surgical Intervention

Consider surgery when:

• Foot/ankle joint instability is present
• Deformity with high risk of developing ulcers exists
• Pain cannot be adequately managed with conservative measures 1

6. Prevention of Re-activation

• Provide footwear/orthoses that accommodate and support foot shape 1
• Consider below-knee customized devices for additional protection in patients with deformity or joint instability 1

Important Considerations and Pitfalls

1. Delayed Treatment Risks:

   • Immediate offloading is critical - delays can lead to worsening deformity and complications 1
   • Recent research shows that follow-up MRI monitoring may be associated with longer treatment durations without necessarily improving outcomes 2

2. Treatment Duration:

   • Treatment should continue until remission is confirmed through multiple parameters (temperature, edema, imaging) 1
   • Do not rely on soft tissue edema alone to determine remission 1

3. Compliance Challenges:

   • Non-removable devices ensure compliance but may be less comfortable
   • If using removable devices (third choice), emphasize the importance of wearing them at all times 1

4. Monitoring for Complications:

   • Regularly inspect for pressure points and potential ulceration
   • Be vigilant about signs of infection, especially in patients with sensory loss 3

By following this structured approach with emphasis on immediate offloading using a non-removable knee-high device, particularly a total contact cast, patients with Charcot foot can achieve disease remission and prevent serious complications like foot deformities, ulceration, and potential amputation.