By Asma Khan, D.P.M.
April 03, 2013
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Charcot Neuroarthropathy, Part II:  Treatment

Asma Khan, D.P.M.

            The most important part of treatment for Charcot neuroarthropathy rests with early diagnosis.  Once the condition is recognized as an acute Charcot destruction of a lower extremity joint, the limb must be immediately immobilized and off-loaded.  This means that the patient must be maintained non-weightbearing on that extremity.  This protects the limb from further external destructive forces.  However, for many diabetic patients who are older, this most important part of treatment is often the most difficult to achieve.  Assistive devices, such as wheelchairs, walkers, and crutches, can all be used, either alone or in combination, to help the patient stay off of the affected leg and foot.  In more difficult situations, a temporary stay in an extended care facility may become necessary to allow for safe and monitored non-weightbearing transfers.

            If the acute Charcot changes are not complicated by an overlying cellulitis or ulcer at a bony prominence, the condition is monitored until the warmth, redness, and swelling resolve.  X-ray evaluation is performed periodically to monitor the condition of the joint.  While the acute phase is characterized by joint destruction and washing out of the bones, as the process evolves into a chronic Charcot joint, the bones become fused into a more stable mass.  This can take several weeks or months.  In the vast majority of cases, the end result of the Charcot changes are a rockerbottom arch with a high probability of bony prominences.  If no ulcerations are present, the patient may be placed in a custom boot or patellar-tendon bearing brace and ambulation can then be attempted on the involved extremity.  However, due to the extended period of non-weightbearing, most patients benefit from a course of physical therapy for re-conditioning and gait re-training in order to walk properly and safely again.  Patients may also require training and counseling in the use of their new, permanent device. 

            An alternative approach is to perform surgery to either “plane” off the bony prominences or to reconstruct the arch of the foot altogether.  While the former is a simple surgery to resect the prominent areas, there continues to be a need for custom shoes and continued monitoring, as recurrence of the bony prominences with progression of the Charcot disease is often seen.  The latter surgical option, reconstruction of the arch, is much more complicated, requiring resection of large areas of deformities, use of bone grafts, and significant amount of internal and/or external hardware.  However, the benefits for the patient include a return to normal shoe gear and avoidance of large boots and braces for protection.  The return to a more active lifestyle is also more likely once the foot is surgically reconstructed.  However, not every patient is a candidate for the extensive surgical intervention that is required for Charcot reconstruction.

            Unfortunately, the course of Charcot joint disease is routinely riddled with complications.  The majority of these problems are due to the bony prominences that are the result of the collapse of the natural contours of the lower extremities.  Ulcerations develop at these bony prominences because they are at very high risk of rubbing and trauma in shoe gear.  Because peripheral neuropathy is present in patients who develop Charcot changes, ulcerations are often not noted until they are very deep and draining with a concomitant deep infection that usually involves the underlying bones.  In this situation, surgery becomes necessary to drain the infected areas and resect infected parts of the bone.  The wounds are treated with local wound care, and may require many weeks and months of treatments and multiple surgical washouts.  Long-term antibiotics through a permanent intravenous line are also utilized.  If the infection is controlled and the wounds start to heal, the patient may then be evaluated for either reconstructive or conservative management long-term.  However, if the infection persists and spreads to include the major joint structures of the foot or ankle, either a partial foot amputation, such as a transmetatarsal amputation, or a below-knee amputation may be the most functional result.  Even though the prospect of facing a below-knee amputation is a dreaded end result, oftentimes it is the best way to prevent the spread of life threatening infections, and enable the patient to get back to ambulation with a prosthesis and an improved quality of life outside of the hospital or nursing home setting.  



Figure One:  External fixation used in Charcot reconstruction surgery.