Each year in the United States, over 60,000 lower extremity amputations occur in patients with diabetes, and about a half million people have a diabetic foot infection. Charcot foot, a diabetes-associated neuropathic osteoarthropathy, has gotten increased recognition as a debilitating disease that frequently leads to severe disability and poor quality of life. The increasing incidence of morbidly obese patients with diabetes may be partially responsible for the increased prevalence of Charcot foot.

Over the past decade, it has been recognized that patients with diabetes who develop Charcot foot arthropathy often experience a significant decline in their quality of life—the disability associated with foot ulcer, foot infection, or Charcot foot is comparable to that of a below-the-knee amputation. This potentially devastating condition consumes significant healthcare resources for multiple surgical procedures and often leads to lower extremity amputation and premature death. As a result, there has been growing interest in the medical community to address surgical correction of acquired foot deformities, with the goal being to improve walking independence.

Current Treatments Are Lacking

Traditionally, the primary intervention for treating Charcot foot has been non-weight-bearing immobilization with a total contact cast until the problem is resolved. This approach, however, can often lead to severe structural deformity of the foot and ankle. Additionally, obese patients may have difficulty walking in a cast and are often forced to confinement in a wheelchair. Following removal of the cast, patients are then accommodated with cumbersome, protective therapeutic shoes and braces, but these can significantly limit overall function.

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Data have shown that surgical correction of foot deformities so that the foot remains flat on the ground can improve outcomes for sufferers of Charcot foot. This procedure may also enable patients to wear standard therapeutic footwear rather than braces. In order to accomplish this end result, some treatment options involve internal fixation—similar to how fractures are surgically treated—and correcting deformities with internal plates, screws, and rods. Reconstructive surgery, however, can often lead to unique complications. Patients with diabetes tend to have underlying chronic osteomyelitis with poor bone quality and have impaired immunity. Furthermore, weakened bones could collapse under the heavy weight of Charcot patients who are obese.

Exploring a New Surgical Treatment

In a recent review published in the June 2010 issue of Hospital Practice, I described a surgical technique that appears to secure foot bones with an external frame. In the study, over 90% of patients were able to walk with commercially available diabetic shoes. A circular external fixator is a rigid frame made of stainless steel and aircraft-grade aluminum. Three rings surround the foot and lower calf and have stainless-steel pins extending off them and into the foot to secure the bones after surgery. The device has been shown to achieve a high potential for enhancing clinical outcomes with few incisions and a minimal risk for infection.

Identifying patients with diabetes who are at risk for Charcot foot is crucial to preventing potentially devastating complications of the disease. Patients at risk include those who have peripheral neuropathy and/or deformities of the foot. These patients should be seen by a foot care specialist. Patients who are at risk frequently present with painless swollen feet, and they are often misdiagnosed with tendonitis or gout. Physicians should maintain a heightened awareness for the disorder when patients with diabetes present to their institution with a swollen foot—with or without pain—and if they lack systemic signs of infection.

References

Pinzur MS. Circular fixation for the nonplantigrade Charcot foot. Hosp Pract. 2010;38:56-62.

Molines L, Darmon P, Raccah D. Charcot’s foot: newest findings on its pathophysiology, diagnosis and treatment. Diabetes Metab. 2010 Jun 4. [Epub ahead of print].

Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32:495.

Stuck RM, Sohn MW, Budiman-Mak E, et al. Charcot arthropathy risk elevation in the obese diabetic population. Am J Med. 2008;121:1008-1014.

Sohn MW, Stuck RM, Pinzur M, et al. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care. 2010;33:98-100.

Sohn MW, Lee TA, Stuck RM, et al. Mortality risk of Charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone. Diabetes Care. 2009;32:816-821.