Charcot neuroarthropathy: An often overlooked complication of diabetes
ABSTRACTIn patients with long-standing, poorly controlled diabetes and peripheral neuropathy, a red, hot, swollen foot without open ulceration should raise the suspicion of Charcot neuroarthropathy, an often-overlooked diabetic foot complication. The authors discuss key diagnostic features and how to differentiate this condition from cellulitis, osteomyelitis, and other conditions. They review key elements of the workup and emphasize the importance of early diagnosis and prompt treatment to preserve a functioning foot.
KEY POINTS
- One must pay particular attention to the history in diabetic patients and assess the risk of diabetic foot complications.
- Without the presence or history of an open ulceration, infection is rare.
- Paramount to the treatment of this condition are the avoidance of weight-bearing and the immediate referral to a foot and ankle specialist. Prevention, suspicion, early diagnosis, and protection of the involved foot preserve the ability to walk and quality of life.
TREATMENT: IMMOBILIZATION, BISPHOSPHONATES, SURGERY
The goals of treatment for acute or quiescent Charcot neuroarthropathy should be to maintain or achieve structural stability of the foot and ankle, to prevent skin ulceration, and to preserve the plantigrade shape of the foot so that prescription footwear can be used.
Patient and family education is important for compliance with the regimen, particularly because patients with diabetic neuropathy lack the protective pain response.
Immobilization. A total-contact cast is worn until the redness, swelling, and heat subside, generally 8 to 12 weeks, after which the patient should use removable braces or a Charcot restraint orthotic walker for a total of 4 to 6 months of treatment.23 The cast is typically changed every 1 to 2 weeks as the swelling subsides to minimize irritation to the insensate limb.
Many physicians also recommend elastic stockings (eg, Stockinette) or an elastic tubular bandage (eg, Tubigrip) to reduce edema under the cast.
Bisphosphonates. Some clinicians also prescribe bisphosphonates in the early stages of treatment, as the bone mineral density of the affected foot is low.24 Unfortunately, while these drugs can significantly reduce the levels of bone turnover markers, temperature, and pain, evidence of clinical benefit such as an earlier return to ambulation or radiographic improvement is weak at best.
Surgery is reserved for severe ankle and midfoot deformities that are susceptible to skin ulcerations and that make braces and orthotic devices difficult to use.
TREATMENT OUTCOME
The patient’s condition resolved, with eventual multiplanar deformity and with widening of the midfoot and increased pressure points, particularly to the first ray. He is able to wear an extra-depth shoe, with a custom totalcontact inlay. He continues his profession as an attorney and goes about his normal daily activities; however, he is no longer able to golf and must limit his walking. He subsequently developed ulcerations to both feet, but they resolved with conservative wound care and surgical care. He is seen in the diabetic foot clinic every 6 to 8 weeks.
