What is the treatment for Charcot foot?

Treatment of Charcot Foot

The primary treatment for Charcot foot is immediate knee-high immobilization/offloading with a non-removable device to prevent progression of deformity, promote disease remission, and reduce the risk of complications. 1

Diagnosis and Initial Management

Clinical Presentation

• Red, hot, swollen foot in a patient with diabetes and neuropathy
• Temperature difference between affected and unaffected foot
• Potential foot deformity (in later stages)
• May occur with or without ulceration

Diagnostic Approach

1. Imaging:

   • Plain X-rays (bilateral if possible) including:
     • Anteroposterior (AP), medial oblique, and lateral projections
     • Standing (weight-bearing) radiographs preferred when possible 1
   • MRI if plain X-rays are normal but clinical suspicion remains high 1
   • Alternative imaging if MRI unavailable/contraindicated: nuclear imaging scan, CT, or SPECT-CT 1

2. Temperature Assessment:

   • Measure skin temperature using infrared thermometry
   • Compare with same anatomic point on contralateral extremity 1

Treatment Algorithm

Acute Phase (Active Charcot)

1. Immediate Offloading:

   • First choice: Total Contact Cast (TCC) - non-removable 1
   • Second choice: Knee-high walker rendered non-removable 1
   • Third choice (if non-removable devices contraindicated): Removable knee-high device worn at all times 1
   • Do not use below-ankle devices (surgical shoes, postoperative sandals) as they provide inadequate immobilization 1

2. Weight-bearing Restrictions:

   • Use assistive devices (crutches, walker) to reduce weight-bearing on affected limb 1

3. Duration of Treatment:

   • Continue offloading until clinical signs of active Charcot have resolved
   • Typically requires 4-6 weeks after clinical signs have resolved 1
   • Monitor disease activity through serial temperature measurements 1

4. Monitoring for Remission:

   • Consider combination of:
     • Temperature normalization
     • Resolution of clinical edema
     • Imaging findings 1

Pharmacological Management

• Not Recommended:

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

• Consider:

  • Vitamin D and calcium supplementation during fracture healing phase (per standard guidelines for deficiency) 1

Surgical Intervention

• Consider surgery when:
  • Instability of foot/ankle joints
  • Deformity with high risk of ulceration
  • Pain not manageable with offloading devices 1
• Surgical options may include:
  • Triple arthrodesis
  • Talo-navicular arthrodesis
  • Subtalar arthrodesis
  • Tibio-calcaneal arthrodesis
  • Midfoot fusion 2

Long-term Management

After Remission

• Custom-made orthopedic shoes with appropriate insoles 1, 2
• Regular follow-up with podiatry
• Ongoing monitoring for recurrence or new ulceration

Common Pitfalls to Avoid

1. Delayed diagnosis: Always consider Charcot foot in patients with diabetes, neuropathy, and a hot, swollen foot - even when ulceration or infection is present 1

2. Inadequate offloading: Below-ankle devices provide insufficient immobilization and should not be used 1

3. Premature weight-bearing: Continuing offloading for 4-6 weeks after clinical resolution is essential to prevent deformity 1

4. Missing concurrent infection: Charcot foot can coexist with infection, and both conditions require appropriate management 1

5. Inadequate long-term footwear: Custom-made orthopedic shoes are essential after treatment to prevent recurrence and ulceration 2

Special Considerations

• In patients with bilateral Charcot foot or absence of contralateral limb, consider using ascending temperature gradients (toe-knee) for monitoring 1

• Surgical complications are common and may include:

  • Infections
  • Nonunions
  • Talus necrosis
  • Wound healing disorders 2

By following this treatment approach, the goals of preventing deformity, promoting remission, and reducing the risk of ulceration, infection, and amputation can be achieved in patients with Charcot foot.