Charcot Neuroarthropathy

CROW_bootCROW BOOT USED TO TREAT CHARCOT FOOT

 

A 60 year old man complains of a red, hot, and swollen foot. He has diabetes and has had peripheral neuropathy for a many of years. He was previously told that he probably has an infection and was prescribed antibiotics. However, xrays show fragmentation of bone in his midfoot that resemble small fractures. What condition could he have? Does he really have an infection?

 What is Charcot Neuroarthropathy?

 People with longstanding high blood sugar from diabetes have a increased chance of developing peripheral neuropathy, a condition in which the feet and possibly hands become numb. Unfortunately, this condition leaves patients susceptible to injury, whether it is wounds under the feet, infection, or trauma. Charcot Neuroarthropathy is a condition that is thought to occur after repeated injury to bones in a neuropathic (Numb) patient. In diabetic patients, the bone breakdown often occurs in the midfoot. Because people with longstanding diabetic peripheral neuropathy may not notice that they have injured themselves, they continue to walk on the injured limb. As the ground forces from walking are applied to the numb foot multiple small fractures continue to develop. This leads to eventual deformity of the foot and possibly infection and amputation. Since this condition is very rare, it is commonly mistaken for an infection and is improperly treated. It is important to quickly recognize the signs of a Charcot foot and treat it appropriately to prevent the disease from progressing.

 Symptoms and signs

A Charcot foot initially presents as a red, hot, and swollen foot. This can be explained as the body’s natural way of attempting to heal the broken fragments of bone. Bone healing occurs with increased blood flow to the affected area, which causes the heat, redness and swelling. In attempting to heal bone, the body sends inflammatory molecules that signal to resorb and remodel the bone. However, long-term diabetics with uncontrolled blood sugar have a decreased ability to heal themselves. The resorption of bone occurs more rapidly then remodeling with new bone and the disease process continues to worsen. As the diabetic patient continues to walk on the limb, the fragmentation increases and the cycle continues. Xrays may or may not show fragmentation of the affected area during early symptoms of Charcot, which makes the condition harder to diagnose.

 After a period of time, healing of the bone fragments occurs and the swelling of the affected foot decreases, xrays may show healing of the bone. Unfortunately, the disease process has not stopped there. The decrease in symptoms can be mistaken as resolution of the disease itself, and as the patient continues to walk, the affected area of the foot begins to cave in and deform, causing what is commonly known as a “rocker bottom” deformity. The dislocated fragments of bone continue to heal in this shape, causing permanent deformity of the foot. This is dangerous for the patient with peripheral neuropathy because deformity increases the chances of developing a diabetic foot ulcer, subsequent infection and possibly amputation of the limb.

 Treatment

An important aspect of treating the Charcot foot is recognizing the condition early and ensuring that the patient does not ambulate further on the affected leg. This method of restricting weight bearing on a limb or part of a limb is called offloading. The total contact cast (TCC) is commonly used to initially offload the foot. The TCC is a below-knee cast that is non removable and, if used appropriately, can halt the disease process cycle. The cast allows forces from the ground to be dispersed when the patient is standing. The TCC is changed every week by the physician and should be used for 4-6 months. Crutches, wheelchair and ankle foot braces can also be used to aid in off loading the foot.

 Once the redness, swelling and heat have decreased in the affected foot, other forms of support can be used to allow the patient to carefully get back to walking.

The Charcot Restraint Orthotic Walker is a boot that is designed specifically to treat the Charcot foot once the swelling has decreased. The outer fiberglass shell provides rigid support for the foot and ankle. The foot bed of this device consists of a custom insole that distributes forces equally across the bottom of the foot. The custom fit of the boot allows the patient to get back to activities of daily living. When the patient starts using the boot, they can walk short distances as instructed by their doctor and can gradually increase as long as the symptoms do not return. An advantage to using this boot is that it can be removed when the patient bathes or sleeps. The patient needs to carefully monitor their foot when using this brace to ensure that the boot is not rubbing causing wounds to develop. Once the doctor deems that the CROW is no longer necessary, the patient can begin using custom diabetic shoes or an Ankle Foot Orthosis (link to AFO blog?)

 Advanced cases of Charcot Neuroarthropathy with severe deformity may require reconstructive surgery. Talk to your doctor about your need for surgery and the options available.

 As is the case with all diabetic foot conditions, patients need to be mindful of their feet and check for new wounds, discoloration, or any other differences daily. Patients with Charcot Neuroarthropathy must recognize the importance of doing this and need to comply with their doctor’s recommendations to help their feet improve.

 

 

 

 

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