How to offload the foot in acute Charcot (Charcot-Marie-Tooth disease) arthropathy?

Offloading the Foot in Acute Charcot Arthropathy

A non-removable knee-high device should be used immediately to immobilize and offload the foot in acute Charcot arthropathy to promote disease remission and prevent progression of deformity. 1

Primary Treatment Options (Prioritized)

1. Total Contact Cast (First Choice)

   • Provides optimal immobilization and pressure redistribution 1
   • Usually made of plaster of Paris or fiberglass in close contact with entire foot and lower limb 1
   • Should be applied to safely accommodate any foot deformity and provide pressure redistribution 1
   • Treatment should begin as soon as active Charcot is suspected, even before definitive diagnosis 1

2. Knee-High Walker Rendered Non-Removable (Second Choice)

   • Pre-fabricated walker made irremovable by applying a layer of cast or tie wrap 1
   • Comparable offloading to total contact cast when properly applied 1
   • Provides necessary immobilization of the complete foot and ankle 1

3. Removable Knee-High Device (Third Choice)

   • Only for patients who cannot tolerate non-removable devices 1
   • Must be worn at all times with appropriate foot-device interface 1
   • Main disadvantage: potential non-adherence leading to deformity progression and delayed healing 1

Important Considerations

• Avoid Below-Ankle Devices: Surgical shoes, postoperative sandals, custom molded shoes, or slipper casts provide inadequate immobilization and limited offloading capacity 1

• Use Assistive Devices: Crutches, walkers, or wheelchairs should be used alongside knee-high devices to further reduce weight-bearing on the affected limb 1

• Immediate Implementation: Offloading should begin as soon as Charcot is suspected, even before confirmatory imaging is complete 1

• Duration of Treatment:

  • Average duration of casting is approximately 18.5 weeks but varies based on individual factors 2
  • Continue until disease remission, which should be determined by multiple factors 1

Monitoring for Disease Remission

• Temperature Measurement: Serial examination of skin temperature differences between affected and unaffected limb 1

• Clinical Assessment: Soft tissue edema alone is insufficient to determine remission 1

• Imaging: Consider radiographs and/or advanced imaging to confirm bone healing 1

• Combined Approach: Use temperature, clinical edema assessment, and imaging together to determine when active Charcot is in remission 1

Common Pitfalls to Avoid

• Delayed Treatment: Failure to offload immediately can lead to progressive deformity and potential skin ulceration 1

• Inadequate Immobilization: Below-ankle devices fail to properly immobilize the foot and ankle 1

• Poor Patient Adherence: Removable devices may not be worn consistently, compromising treatment 1

• Skin Complications: Improperly applied casts can cause new ulcers or blisters (reported in 14% of patients) 1

• Premature Weight-Bearing: Returning to normal footwear too early can reactivate the condition 2, 3

Transition After Acute Phase

• After remission, transition to protected weight-bearing via a removable cast walker before returning to permanent footwear 2

• Following the acute phase, provide customized footwear and/or orthoses that accommodate foot deformity to prevent reactivation 1

• When deformity or joint instability is present, below-knee customized devices should be used for additional protection 1