eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Charcot Arthropathy: Treatment

Author: Mrugeshkumar Shah, MD, MPH, Staff Physician, Physical Medicine and Rehabilitation, Massachusetts General Hospital/Spaulding Rehabilitation Hospital
Coauthor(s): Walter Panis, MD, Clinical Instructor, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School
Contributor Information and Disclosures

Updated: Aug 29, 2007

Treatment

Medical Therapy

Treatment of Charcot arthropathy is primarily nonoperative. Treatment consists of 2 phases: an acute phase and a postacute phase. Management of the acute phase includes immobilization and reduction of stress.

Immobilization usually is accomplished by casting. Total contact casts have been shown to allow patients to ambulate while preventing the progression of deformity. Casts must be checked weekly to evaluate for proper fit, and they should be replaced every 1-2 weeks. Patients with concomitant ulceration must have their casts changed weekly for ulcer evaluation and debridement. Serial plain radiographs should be taken approximately every month during the acute phase to evaluate progress. Casting usually is necessary for 3-6 months and is discontinued based on clinical, radiographic, and dermal thermometric signs of quiescence. Other methods of immobilization include metal braces and ankle-foot orthoses (AFOs), but they may prolong healing times.

Reduction of stress is accomplished by decreasing the amount of weight bearing on the affected extremity. While total non-weight bearing (NWB) is ideal for treatment, patients are often not compliant with this treatment. Studies have shown that partial weight bearing (PWB) with assistive devices (eg, crutches, walkers) also is acceptable without compromising healing time. However, full weight bearing (FWB) in the acute phase tends to lengthen total time in the cast.

Healing time varies according to the location of the disease. Pattern 1, or forefoot pathology, heals in two thirds the time of pattern 3 or pattern 4. One study revealed that the mean time in a cast is 18.5 weeks, while another study showed that the acute phase lasts 12.5 weeks.

Management following the removal of the cast includes lifelong protection of the involved extremity. Patient education and professional foot care on a regular basis are integral aspects of lifelong foot protection. After cast removal, patients should wear a brace to protect the foot. Many types of braces may be used, including a patellar tendon-bearing brace, accommodative footwear with a modified AFO, a Charcot restraint orthotic walker (CROW), and a double metal upright AFO.

Custom footwear includes extra-depth shoes with rigid soles and a plastic or metal shank. If ulcers are present, a rocker-bottom sole can be used. Also, Plastazote inserts can be used for insensate feet. This regimen may be eliminated after 6-24 months, based on clinical, radiographic, and dermal thermographic findings. Continued use of custom footwear in the postacute phase for foot protection and support is essential.

The total healing process typically takes 1-2 years. Preventing further injury, noting temperature changes, checking feet every day, reporting trauma, and receiving professional foot care also are important tenets of treatment.

Surgical Therapy

Surgical procedures and techniques vary based on the location of the disease and on surgeon preference and experience with Charcot arthropathy. Surgical procedures include exostosectomy of bony prominence, osteotomy, arthrodesis, screw and plate fixation, open reduction and internal fixation, reconstructive surgery, fusion with Achilles tendon lengthening, autologous bone grafting, and amputation. Patients treated with surgery have longer healing times.

Surgical methods can be based on Schön's classification system. Open reduction and internal fixation should be used for an ankle with displaced fractures. Ankle arthrodesis is necessary in patients with tibiotalar destruction. In cases in which the hindfoot has avascular necrosis of the talus, a talectomy with tibiocalcaneal fusion is necessary. Arthrodesis may be necessary for patients with hindfoot involvement. For a midfoot pattern, surgical correction of rocker-bottom deformity and osteotomies for bony prominences are used. If there is an associated hindfoot/ankle equinus contracture, then a posterior release/Achilles tendon lengthening procedure is required. For forefoot patterns, patients with bony prominences or recurrent ulcerations may need a resection arthroplasty or cheilectomy.

Follow-up

For excellent patient education resources, visit eMedicine's Diabetes Center, Sexually Transmitted Diseases Center, and Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Diabetic Foot Care and Syphilis.

Complications

Charcot fractures that are not identified and treated properly may progress to marked joint deformity and to skin ulceration over a bony prominence. The ulceration can result in a severe infection, which may lead to amputation of the extremity. Another complication of Charcot arthropathy is foot collapse leading to the formation of a clubfoot. Another commonly seen deformity is the rocker-bottom foot, in which collapse and inversion of the plantar arch occurs. Other complications include the ossification of ligamentous structures, the formation of intra-articular and extra-articular exostoses, the collapse of the plantar arch, and the development of osteomyelitis.

More on Charcot Arthropathy

Overview: Charcot Arthropathy
Workup: Charcot Arthropathy
Treatment: Charcot Arthropathy
Follow-up: Charcot Arthropathy
References
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References

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Further Reading

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Keywords

Charcot joint, neuropathic osteoarthropathy, diabetic osteoarthropathy, diabetic neuroarthropathy, Charcot foot, Charcot neuroarthropathy, neuropathic arthropathy, neuropathic joint, Schon classification, Brodsky and Rouse system, Saunders and Mrdjencovich system

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Contributor Information and Disclosures

Author

Mrugeshkumar Shah, MD, MPH, Staff Physician, Physical Medicine and Rehabilitation, Massachusetts General Hospital/Spaulding Rehabilitation Hospital
Mrugeshkumar Shah, MD, MPH is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Walter Panis, MD, Clinical Instructor, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School
Walter Panis, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neurorehabilitation, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shepard R Hurwitz, MD, Director of Clinical Services, Department of Orthopedic Surgery, University of Virginia School of Medicine; Director, Division of Foot and Ankle Surgery, Department of Orthopedic Surgery, University of Virginia Health System
Shepard R Hurwitz, MD is a member of the following medical societies: American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, and Orthopaedic Trauma Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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