What is the treatment approach for Charcot's joint (neuropathic arthropathy)?

Treatment of Charcot Joint (Neuropathic Arthropathy)

Immediately immobilize the affected foot with a non-removable knee-high device as soon as Charcot arthropathy is suspected—this is the cornerstone of treatment to prevent progressive deformity and promote disease remission. 1

Acute Phase Treatment: Hierarchical Approach to Offloading

First-Line: Total Contact Cast

• Use a total contact cast as the preferred initial treatment for active Charcot arthropathy with intact skin 1, 2
• This provides optimal immobilization of the diseased bones and joints while redistributing plantar pressures 2
• Begin treatment immediately upon clinical suspicion, even before confirmatory imaging is complete 1

Second-Line: Non-Removable Knee-High Walker

• A knee-high walker rendered non-removable is the second choice when total contact cast is not feasible 1, 2
• This device must be made non-removable (e.g., with straps or wrapping) to ensure continuous immobilization 1

Third-Line: Removable Knee-High Device

• Consider a removable knee-high device only when non-removable options are contraindicated or not tolerated 1, 2
• The major limitation is patient non-adherence, which can compromise treatment outcomes 2
• This device must be worn at all times, including during sleep 1

Critical Pitfall to Avoid

• Never use below-ankle devices (surgical shoes, postoperative sandals, custom molded shoes, or slipper casts) as they provide inadequate immobilization and insufficient offloading 1

Adjunctive Measures During Active Phase

Weight-Bearing Reduction

• Use assistive devices (crutches, walkers, or wheelchairs) to minimize weight-bearing on the affected limb while in the knee-high device 1, 2

Pharmacologic Considerations

• Do NOT use bisphosphonates (alendronate, pamidronate, zoledronate), calcitonin, PTH, or methylprednisolone for treatment—these have strong evidence against their use 1
• Avoid denosumab as well 1
• Consider vitamin D and calcium supplementation during fracture healing phase, dosed according to standard guidelines for those at risk of deficiency 1

Note: While one older case report 3 suggested benefit from pamidronate, the most recent 2024 IWGDF guidelines provide strong evidence (moderate quality) against bisphosphonate use, which takes precedence.

Monitoring for Disease Remission

Multi-Modal Assessment Required

• Use serial skin temperature measurements comparing the affected foot to the contralateral foot at the same anatomical points 1, 2
• Do not rely on soft tissue edema alone to determine remission 1
• Combine temperature measurement, clinical edema assessment, and imaging findings to conclude that active Charcot is in remission 1, 2
• Frequency of monitoring appointments should be individualized based on edema fluctuation, comorbidities, treatment risks, and patient progress 1

Surgical Intervention Indications

Consider surgery when:

• Joint instability of the foot and ankle persists 1
• Deformity creates high risk of ulceration within the offloading device 1
• Pain cannot be adequately controlled in a total contact cast or non-removable device 1

Post-Remission: Prevention of Reactivation

Mandatory Long-Term Footwear

• Provide customized footwear and/or orthoses that accommodate and support the foot shape to prevent reactivation 1, 2
• This recommendation has strong evidence with moderate quality 1

Enhanced Protection for Deformity

• Use below-knee customized devices for additional protection when deformity and/or joint instability is present to optimize plantar pressure distribution 1, 2
• This also carries strong evidence with moderate quality 1

Common Clinical Pitfalls

• Delayed treatment leads to progressive deformity and potential skin ulceration 2
• Premature discontinuation of immobilization before achieving remission 2
• Inadequate immobilization with below-ankle devices 2
• Skin complications (ulcers, blisters) from improperly applied casts—reported in 14% of patients 2
• Misdiagnosis as cellulitis, gout, or deep vein thrombosis due to the warm, erythematous, swollen presentation 4