What is the best treatment approach for a patient with diabetic arthropathy and a history of diabetes?

Diabetic Arthropathy (Charcot Neuro-Osteoarthropathy) Treatment

Immediately initiate immobilization with a non-removable knee-high total contact cast as soon as Charcot neuro-osteoarthropathy is suspected in a diabetic patient with a warm, swollen foot—this is the single most critical intervention to prevent catastrophic deformity and amputation. 1

Immediate Recognition and Action

Clinical Presentation to Recognize

• A warm, erythematous, edematous foot with intact skin in a patient with diabetes and peripheral neuropathy 2
• Temperature difference >2°C between the affected and unaffected foot 1
• Often misdiagnosed as cellulitis or infection, leading to dangerous delays 3
• May occur even as the first presentation of undiagnosed type 2 diabetes 3

Urgent Diagnostic Workup

• Obtain bilateral weight-bearing plain X-rays (AP, medial oblique, and lateral views of foot; AP, mortise, and lateral views of ankle) immediately 1
• If X-rays are normal but clinical suspicion remains high, obtain MRI to diagnose or exclude active disease 1
• Do not delay offloading while waiting for advanced imaging—initiate treatment immediately 1
• Blood tests (CRP, ESR, white blood count) are not useful for diagnosis and should not be used 1

Primary Treatment Algorithm

First-Line: Non-Removable Knee-High Offloading (STRONG Recommendation)

Use a total contact cast (TCC) as the preferred first-line treatment 1

• TCC provides superior immobilization of the entire foot and ankle, redistributing plantar pressure proximally 1
• Immobilizes the ankle joint and minimizes deforming effects of lower limb muscles 1
• Median time to remission is 3 months shorter compared to removable devices 1

A non-removable knee-high walker is the second choice if TCC expertise is unavailable 1

• Must be rendered truly non-removable (not just instructed to keep on) 1
• Provides adequate immobilization when properly applied 1

Second-Line: Removable Devices (Only When Non-Removable Contraindicated)

Removable knee-high devices worn at all times are third-line treatment 1

• Only use when non-removable options are contraindicated or not tolerated 1
• Major concern: non-adherence leads to delayed remission and progressive deformity 1
• Despite intensive education, patients with diabetes do not wear removable devices as advised 1

What NOT to Use

Never use below-ankle devices (surgical shoes, post-operative sandals, custom molded shoes, slipper casts) 1

• Provide inadequate immobilization of diseased bones and joints 1
• Limited offloading capacity increases risk of deformity progression 1

Adjunctive Measures

Weight-Bearing Reduction

• Use assistive devices (crutches, walker, wheelchair) to reduce weight-bearing on the affected limb 1
• This complements but does not replace the knee-high offloading device 1

Pharmacological Therapy: What NOT to Use

Do not use bisphosphonates (alendronate, pamidronate, zoledronate), calcitonin, parathyroid hormone, or methylprednisolone 1

• Despite theoretical rationale for reducing bone resorption, randomized trials show no significant benefit on clinical outcomes 1
• These agents do not reduce time to remission or prevent deformity 1
• Strong recommendation against their use based on moderate-quality evidence 1

Do not use denosumab 1

• Limited quality and inconsistent evidence 1
• Awaiting results of randomized clinical trials 1

Nutritional Support: Consider Supplementation

Evaluate need for vitamin D and calcium supplementation during fracture healing 1

• Patients with type 2 diabetes frequently have low vitamin D levels 1
• Dose according to national/international guidelines for those at risk of deficiency 1
• Low cost, minimal side effects, and important for bone repair justify pragmatic use 1

Monitoring Disease Activity

Serial Temperature Measurements

• Measure skin temperature of affected and unaffected limbs at each visit 1
• Use the highest temperature on affected foot compared to same anatomic point contralaterally 1
• Temperature normalization (difference <2°C) suggests approaching remission 1

Clinical Assessment

• Monitor for reduction in erythema and edema 1
• Do not use soft tissue edema alone to determine remission 1
• Consider temperature measurement, clinical edema, and imaging together when concluding remission 1

Follow-Up Frequency

• Frequency depends on fluctuation in edema, comorbidities, treatment risks, and patient progress 1
• Typical duration in offloading device: 3-6 months until remission 1

Surgical Intervention: When Conservative Treatment Fails

Consider surgery in specific high-risk scenarios 1

Indications for Surgical Intervention:

• Instability of foot and ankle joints that cannot be stabilized in TCC or non-removable device 1
• Deformity with high risk of developing ulcer within the offloading device 1
• Intractable pain that cannot be sufficiently managed conservatively 1
• Impending skin ulceration from severe deformity 1

Rationale for Early Surgery in Selected Cases:

• Deformities leading to ulceration increase major amputation risk 6-12 fold 1
• Proximal deformities (hindfoot, ankle) are especially difficult to manage with casting 1
• Early surgical realignment can restore anatomical alignment and improve function 4

Prevention of Reactivation After Remission

Appropriate Footwear (STRONG Recommendation)

Prescribe footwear and orthoses that accommodate and support the foot shape 1, 2

• Essential to prevent reactivation of disease 1, 2
• Must accommodate any residual deformity safely and redistribute pressure 1

Custom Devices for Deformity

When deformity or joint instability is present, use below-knee customized devices 1, 2

• Optimizes plantar pressure distribution 1
• Provides additional protection against ulceration 1, 2
• Custom-molded shoes required for severe deformities including Charcot foot 1

Critical Pitfalls to Avoid

Diagnostic Errors

• Mistaking Charcot for cellulitis and treating with antibiotics alone 3
• Failing to consider Charcot in patients with newly diagnosed diabetes 3
• Delaying treatment while awaiting advanced imaging 1

Treatment Errors

• Using removable devices when non-removable options are available 1
• Prescribing below-ankle devices that provide inadequate immobilization 1
• Using pharmacological agents (bisphosphonates, calcitonin) that lack evidence of benefit 1
• Inadequate offloading duration—must continue until clear remission 1

Follow-Up Errors

• Failing to provide appropriate footwear after remission, leading to reactivation 1, 2
• Not monitoring for temperature changes during treatment 1
• Transitioning to regular footwear too quickly without custom orthoses 1

Prognosis and Long-Term Outcomes

Morbidity and Mortality

• Charcot foot significantly impacts quality of life and increases mortality risk 2
• Pooled 5-year mortality rate: 29% 2
• Deformities increase risk of ulceration, infection, and amputation 2
• 6-12 times increased risk of major amputation with foot ulcers from Charcot deformity 1, 2

Multidisciplinary Team Approach

• Treatment requires specific training, skills, and experience in applying TCCs 1
• Healthcare professionals working as part of a multidisciplinary team are ideally positioned 1
• Access to high-quality training according to national or regional standards is essential 1