Understanding Charcot Foot: A Diabetic Complication and Its Prevention

Computed Tomography (CT) Scan

Magnetic Resonance Imaging (MRI) and Ultrasound

Bone Scan and Indium Scan

Treatment Goals

• Stability: Ensuring the foot and ankle have the structural strength to support body weight and facilitate walking without causing further deformities.
• Plantigrade Position: The foot should rest flat on the floor, similar to a three-legged stool where the heel, big toe, and little toe evenly bear weight.
• Braceability: Even if the foot's position isn’t completely normal, it should be possible to make it stable and plantigrade using shoe inserts or braces to minimize deformities and ulcers.
• Ulcer-Free Foot: Preventing ulcers is critical to avoiding infections and amputations. Addressing bony prominences under the skin helps prevent ulcers while promoting a functional walking ability.

Nonsurgical Treatment

1. Casting:

   • In the early stages, casting or a special boot is used to protect the foot and ankle, allowing the bones to heal in a stable position and preventing further deformities.
   • A "total contact cast," which covers the entire foot, is the most commonly used type for Charcot foot.
   • Patients must avoid putting weight on the foot until healing begins, often requiring crutches, a knee scooter, or a wheelchair. Healing can take up to three months or longer.
   • Casts are typically changed every one to two weeks to accommodate reduced swelling and to prevent ulcers.
   • Once swelling subsides, patients may transition to a removable, heavy-duty boot that allows for limited walking and easier foot examination and cleaning.

2. Custom Shoes, Braces, and Orthotics:

   • Some patients may need specialized diabetic shoes or custom footwear to accommodate foot deformities.
   • Custom inserts or braces can provide additional support, helping to prevent further injuries and deformities.

Surgical Treatment

1. Debridement of Ulcers:

   • Involves cleaning and removing dead skin to promote ulcer healing. Casting may follow to offload pressure from the ulcer during recovery.

2. Calf Muscle or Achilles Tendon Lengthening:

   • Tightness in these muscles can create pressure points on the sole, especially near the ball of the foot, leading to ulcers. Lengthening the tendon or muscle helps redistribute pressure and prevent these issues.

3. Exostectomy (Removal of Bony Prominences):

   • Deformities often lead to prominent bones under the skin, increasing ulcer risk. Removing these bony prominences can significantly reduce pressure and prevent skin breakdown.

4. Charcot Deformity Correction:

   • For severe fractures, dislocations, or misaligned bones, surgical correction using plates, screws, or rods may be necessary to restore proper alignment and stability.
   • Poor bone quality in diabetic patients may require additional hardware and bone graft materials for proper healing.

5. Joint Fusion (Arthrodesis):

   • This procedure fuses dislocated bones into a single solid unit, effectively correcting deformities and enhancing foot stability. It is a cornerstone of Charcot treatment.

6. Open Reduction and Internal Fixation (ORIF):

   • For acute fractures without significant joint dislocations, repairing broken bones with plates and screws may suffice.

7. Large Rod Implantation:

   • For severe deformities, particularly in the ankle or heel, inserting a large rod can provide long-term stability and support.

(Top) In this X-ray taken from the side, the patient has unstable Charcot of the back of the foot (hindfoot). The dislocation of the joints is seen where the two bones in the back of the foot do not line up (arrowhead). (Bottom) A complex realignment and fusion was performed to prevent the patient from developing a prominence and ulceration.