From the Guidelines
Charcot foot should be treated with immediate non-weight bearing and immobilization using a non-removable knee-high device to promote remission and prevent deformity, as recommended by the International Working Group on the Diabetic Foot (IWGDF) guidelines 1.
Diagnosis and Treatment
The diagnosis of Charcot foot involves considering the condition in patients with diabetes mellitus, neuropathy, and intact skin, who present with clinical findings of increased temperature, edema, and/or redness of the foot compared to the contralateral foot 1. Infrared thermometry can be used to measure skin temperature, and calculating the temperature difference between both legs can aid in diagnosis 1.
Key Recommendations
- Initiate knee-high immobilization/offloading promptly while further diagnostic studies are performed to confirm or rule out active Charcot neuro-osteoarthropathy (CNO) 1.
- Perform plain X-ray of the foot and ankle, including anteroposterior (AP), medial oblique, and lateral projections, and consider standing radiographs if possible 1.
- Use Magnetic Resonance Imaging (MRI) to diagnose or exclude the disease and its activity if plain X-rays appear normal 1.
- Consider a nuclear imaging scan, CT scan, or SPECT-CT if MRI is unavailable or contraindicated 1.
Treatment Approach
The treatment approach for Charcot foot involves using a non-removable knee-high device to immobilize and offload the foot, promoting remission and preventing deformity 1. Custom orthotic footwear is essential to prevent ulceration and recurrence once acute inflammation resolves. Surgical intervention may be necessary for severe deformities or instability. Regular monitoring with X-rays and maintaining strict blood glucose control are crucial for optimal outcomes.
Patient Education
Patients should be educated on the importance of daily foot inspections and seeking immediate medical attention for any unusual changes in foot appearance or sensation. Early recognition and treatment of Charcot foot are critical to preventing permanent deformity, skin breakdown, ulceration, and potentially amputation.
From the Research
Definition and Pathophysiology of Charcot Foot
- Charcot foot, also known as Charcot neuroosteoarthropathy (CN), is a rare complication of diabetic neuropathy, characterized by neuropathic changes in the foot 2.
- The pathogenesis of Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels 2.
Diagnosis of Charcot Foot
- The diagnosis of Charcot foot is often delayed, and it can be difficult to diagnose timely due to its insidious mode of presentation 3.
- A high index of suspicion is required from both the diabetic patient and their physicians for early diagnosis and treatment 3.
- The clinical diagnostic pathways based on different classifications are presented, and multidisciplinary assessment between diabetologists and radiologists is fundamental for prompt diagnosis [(3,2)].
Treatment of Charcot Foot
- Offloading of the foot to stop the perpetuation of trauma and inflammation is the cornerstone of medical therapy of Charcot foot 3.
- Casting therapy has been accepted as the mainstay treatment of the acute Charcot foot, although there are still controversies regarding its duration and the choice of removable and non-removable devices 4.
- Surgical reconstruction of the diabetic Charcot foot can be successful, but significant decrements in quality of life can result if not diagnosed early [(5,6)].
Challenges and Future Directions
- The available evidence for diagnosis and treatment of Charcot foot remains of low quality, and prospective nationwide registries of patients with diabetic neuropathy are needed to clarify the prognostic factors 3.
- More randomized clinical trials are needed to identify whether medical treatment may improve Charcot foot outcomes 3.
- There is an urgent need for action to increase awareness of the disease in both practitioners and people with diabetes 3.