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Figure. Lateral weight-bearing radiograph of the left foot.
A 54-year-old woman presents to the office with severe Charcot arthropathy in the left foot. The patient has a history of insulin-dependent diabetes, and her most recent glycated hemoglobin was elevated at 7%). She has had a plantar ulcer for 4 months despite treatment with total contact casting. Lateral radiograph of the left foot is obtained (Figure).
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Charcot neuropathic osteoarthropathy, commonly referred to as Charcot arthropathy or Charcot foot, is a progressive condition that destroys the bones, joints, and soft tissue of the foot and ankle. Diabetic neuropathy is the most common etiology and leads to loss of the protective sensation in the foot. This syndrome has also been seen in patients with distal neuropathies caused by alcohol or drug abuse, leprosy and other infections, and spinal cord and nerve root injuries.
Repetitive microtrauma, inflammation, and increased blood flow to the foot can cause bone resorption, weakening, and collapse of the midfoot. As the bones in the midfoot collapse, patients may develop a classic “rocker bottom” deformity, a condition that can occur in up to 7.5% of all patients with diabetes and up to 35% of patients with diabetes and apparent peripheral neuropathy.1
The initial medical treatment of Charcot arthropathy is aimed at taking the weight off the foot to prevent further foot fractures.2 Offloading in the acute stage includes total contact casting of the foot to halt progression. Nonadherence to immobilization is high among patients, who often cannot tolerate being non-weight-bearing. Casts should be routinely checked; if recurrent ulceration cannot be controlled by total contact casting, then surgical interventions are warranted.3
There are no universal recommendations on initial surgical treatment for Charcot arthropathy; however, exostectomy is a common initial procedure. Exostectomy, or removal of the ulcer-inciting bony prominence, is a successful surgical option that has less morbidity and quicker healing time than arthrodesis.2,3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants.
References
1. Rosskopf AB, Loupatatzis C, Pfirrmann CWA, Böni T, Berli MC. The Charcot foot: a pictorial review. Insights Imaging. 2019;10:77.
2. de Souza LJ. Charcot arthropathy and immobilization in a weight-bearing total contact cast. J Bone Joint Surg Am. 2008;90(4):754-759.
3. Dodd A, Daniels TR. Charcot neuroarthropathy of the foot and ankle. J Bone Joint Surg Am. 2018;100(8):696-711.
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