From the Guidelines
Charcot arthropathy treatment should prioritize the use of a non-removable knee-high device to immobilize and offload the foot, as recommended by the International Working Group on the Diabetic Foot (IWGDF) guidelines [ 1 ]. The treatment of Charcot arthropathy focuses on preventing further joint destruction and deformity through a combination of approaches.
Treatment Options
- The cornerstone of treatment is offloading the affected foot with non-weight bearing for 8-12 weeks, typically using a total contact cast that distributes pressure evenly across the foot [ 1 ].
- A removable knee-high device worn at all times can be considered as the third treatment choice in a person with diabetes mellitus, active Charcot neuro-osteoarthropathy, and intact skin of the foot for whom a non-removable knee-high offloading device is contraindicated or not tolerated [ 1 ].
- Below the ankle offloading devices, such as surgical shoes, postoperative sandals, custom-molded shoes, or slipper casts, should not be used due to inadequate immobilization of the diseased bone and joints, and limited off-loading capacity [ 1 ].
Surgical Intervention
- Surgical intervention should be considered in cases with instability of foot and ankle joints, and/or deformity with a high-risk of developing ulcers in the offloading device, or pain that cannot be sufficiently stabilized in a total contact cast or a non-removable knee-high device [ 1 ].
- Blood glucose control is crucial throughout treatment, as hyperglycemia worsens outcomes [ 1 ].
Monitoring and Follow-up
- Regular monitoring with clinical examination and imaging (X-rays every 4-6 weeks during the acute phase) helps track progress and determine when weight-bearing can safely resume [ 1 ].
From the Research
Charcot Arthropathy Treatment
- Charcot arthropathy, also known as neuropathic osteoarthropathy, is a common complication of diabetes that often is unrecognized and misdiagnosed 2.
- Treatment of Charcot arthropathy typically consists of joint immobilization in a total contact cast and then an ankle foot orthosis with custom footwear 2.
- Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase 3.
- The median TCC duration for resolution of acute Charcot foot was 4.3 months, with an overall complication rate of 5% per cast 3.
- Osteoarthritis was significantly associated with a TCC duration of more than 4 months 3.
- Casting therapy has been accepted as the mainstay treatment of the acute Charcot foot, although there are still controversies regarding its duration, the choice of removable and non-removable device and weight-bearing casts vs. non-weight-bearing casts 4.
- Two groups of antiresorptive therapies have been evaluated in the treatment of the acute Charcot foot, bisphosphonates (intravenous and oral) and calcitonin, which have clearly shown a reduction of bone turnover, although they have not shown a significant effect on temperature reduction 4.
- Weightbearing total contact cast therapy has been shown to be successful in the treatment of acute Eichenholtz stage I Charcot foot arthropathy, with all subjects able to use commercially available depth-inlay shoes and custom accommodative foot orthoses at an average of 9.2 weeks 5.
- Conservative and pharmacologic treatments for the diabetic Charcot foot are limited, with prolonged immobilization in a total contact cast being among the main treatments, and there is an overwhelming need for a new therapeutic approach 6.