Treatment Alternatives in Charcot Arthropathy of the Foot

CASE STUDY
Treatment
Alternatives
in Charcot
Arthropathy
of the Foot
Early postoperative phase with foot stabilized
in thin-wire frame construct.
A patient avoids amputation
A 72-year-old man with type 2 diabetes mellitus
was referred to Duke Medicine in October 2014
for treatment of Charcot arthropathy of the foot,
a sequela of diabetes. Although his blood glucose
levels had been well controlled for 5 to 6 years,
he developed numbness, pain, and peripheral
neuropathy in both feet.
In October 2014, he was referred to a local
orthopaedic surgeon who diagnosed Charcot
arthropathy of the midfoot based on radiographic
findings. Due to severe arthropathy, osteomyelitis,
and skin ulceration, the patient was offered
below-the-knee amputation or referral for a
second opinion.
“Charcot arthropathy is an uncommon complication
in patients with long-standing diabetes
and peripheral neuropathy,” says Beatrice Hong,
MD, a diabetologist at Duke, who did not treat
the patient. “The presentation is variable, initially
with warmth and swelling that progresses into a
characteristic collapse of the arch of the midfoot,
resulting in bony prominences.”
One month earlier, the patient had noticed
redness and swelling in his left foot and was
treated for presumptive cellulitis. Fragmentation
went unnoticed on radiographs. He continued
walking on the foot and developed a skin ulcer
on the lateral plantar aspect. Subsequently, he
received local debridement and more antibiotics.
If it is diagnosed before destructive changes of
the bone/joint take place, Charcot arthropathy
can often be managed with casting, offloading
braces, custom shoes, and orthotic devices.
However, when the bones and joints have become
unstable, fragmented, and malaligned with
compromised skin and soft tissue, surgery is
typically necessary. Reconstructive surgery might
be a viable option to avoid amputation.
In Charcot arthropathy of the foot, the goal of
surgical intervention is to realign and stabilize the
foot with osteotomies, arthrodesis, and internal
and/or external fixation. Unfortunately, the foot
cannot always be salvaged, and amputation may
be necessary for some patients. Many factors
10 Clinical Practice Today from Duke Medicine