Charcot Foot is a neuroarthropathic process with osteoporosis, fracture, acute inflammation and disorganisation of foot architecture. (SIGN 2001). This affects <1% of the diabetic population.
Clinical features
- Diabetes patient presents with red, oedematous, hot and possibly painful foot.
- Usually bounding pedal pulses with evidence of impaired neurological testing.
Diagnosis / Investigations
Diagnosis should be made by clinical examination”. (Frykberg et al 2000; Jeffcoate et al 2000).
- Usually a good blood supply to lower limb with degree of neuropathy.
- Observe foot for obvious signs of tissue trauma, cellulitis or systemic toxicity to rule out infection.
- History of trauma to limb may be present.
- Heat differentiation between limbs – affected limb often 2-8 degrees higher than contralateral foot
- Blood test HbA1c, Hb, ESR and C-reactive protein.
- X-Ray for baseline and to exclude diabetic neuropathic fracture
- If Charcot foot suspected consider MRI / Bone Scan
Management.
“Refer people with suspected Charcot`s Foot immediately to a multidisciplinary foot care team for immobilisation of the affected joint(s) and for long- term management to prevent ulceration”. (NICE 2004)
- Off loading urgently required ideally with either Total Contact Casting or Aircast Boot. Pressure relieving footwear usually worn until inflammation settles, heat differentiation disappears and bone activity reduces. (SIGN 2001)
- Patient education. Patients require education on the causes and management of Charcot foot and advice on prevention of complications.
- There is insufficient evidence to support the routine use of Bisphosphonates in the acute Charcot Foot (SIGN 2001) however there are a number of studies that indicate that Bisphosphonates may be useful in halting the acute phase of Charcot neuroarthropathy in some patients. (Anderson et al 2004, Jude et al 2001). All suspected Charcot Foot cases to be reviewed by Consultant Physician to consider options.
- Refer to Orthopaedic surgeon for assessment and discussion of appropriate surgical procedures.
- Discontinue therapy when foot temperature equal.
Long Term Management
- Long- term pressure relief with orthopaedic footwear and orthoses. Refer to Orthotist.
- Classify patient as high current risk and review regularly for signs of long- term complications. (NICE 2004)
References: Anderson et al (2004). Bisphosphonates for the treatment of Charcot neuroarthropathy. Jn. foot and Ankle Surg, 43 (5); p 285-9. Fryberg RG and Mendeszoon E (2000). Management of the diabetic Charcot foot. Diabetes Metab Res Rev; 16 S59-65. Jeffcoate et al (2000). The Charcot foot. Diabetic Medicine, 17 (4): p253-8. Jude et al (2001). Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetiologia; 44 (11) p2032-7. Nice (2004) Type 2 Diabetes: prevention and management of foot problems. SIGN (2001). Guideline 55 section 7: Management of diabetes foot disease.
Distal symmetrical neuropathy may be symptomless initially but put the feet at risk due to loss of pain sensation. Later, numbness, paraesthesiae, burning pain and contact sensitivity (allodynia) may develop and these symptoms are often difficult to treat.
General
- Improve glycaemic control
- Exclude or treat other factors e.g. alcohol excess, vitamin B12 deficiency
Pharmacological
- Simple analgesics e.g. aspirin, paracetamol, codeine phosphate are not usually effective
- Tricyclic anti-depressants (TCAs) e.g. Amitriptyline given at bedtime should be considered as first line therapy unless contra-indicated (SIGN 55)
- Gabapentin is also recommended and is associated with fewer side effects than TCAs and older anti-convulsants
- Topical Capsaicin cream may be applied sparingly to the affected area if the pain is very localized. It may take several weeks to work and patients should be warned of this
- Allodynia may respond to use of a plastic film e.g.”Op-site” applied to the affected area.
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