Research: Delaying Charcot Foot Treatment Could Cost You Big Time
Posted by Jenn F. on Friday, December 28th, 2018
Neuropathic arthropathy, also known as Charcot Foot, is a comorbidity for up to 7.5% of diabetic patients with neuropathy. A third of these patients have trouble with both feet. Most patients have had poorly controlled diabetes for 15 to 20 years by the time we see degeneration of the joint and bone loss, causing the deformity. We suspect these figures are low due to how easy it is for clinicians to miss the progression of Charcot Foot. The acute stage mimics cellulitis and the chronic condition resembles osteomyelitis—which are also common diabetic comorbidities.
What Is Charcot Foot & What Causes It?
Charcot foot begins with some sort of microtrauma, which triggers uncontrollable inflammation and nerve damage known as neuropathy. Pro-inflammatory cytokines trigger bone and joint destruction, causing the foot to fracture or the arch to collapse and distort into a bony protrusion at the middle joint. The foot is warm, swollen with fluid, hot to the touch, dry, and may or may not present along with pain.
One modern theory is that Charcot Foot is triggered by repetitive, mechanical trauma to the feet. Up to 50% of patients recall a sprained ankle or past foot procedure. The second theory is that muscle imbalances produce eccentric loading of the foot, causing micro-fractures, lax ligaments, and bony degradation.
How Is Charcot Foot Diagnosed?
MRI is the gold standard for a Charcot Foot diagnosis, as conventional radiology may miss the subchondral bone marrow edema common to the disease. Of course, bone marrow edema could also mean arthritis, gout, or bone infection. Microfractures are also more visible on MRIs, which increase the likelihood of a positive diagnosis. If a patient with diabetic neuropathy has no history of ulceration, and the foot has swollen, warm, red skin, there is a good chance of Charcot Foot. In patients with ulcers already, a bone culture may be necessary to confirm or deny Charcot Foot.
Why Is Charcot Foot Commonly Misdiagnosed?
By the time there is a complete loss of foot shape, the clinical diagnosis is rather obvious. The progression of Charcot Foot could take anywhere from six months to two years. When early-stage inflammation begins, it’s easy to presume that there is a tarsal bone infection (osteomyelitis) or gout arthritis. If ulcers are already present, it’s even easier to say that the inflammation is simply due to that, and not look any further to see that it was the Charcot Foot inflammation that actually preceded the ulcers. We routinely test for Charcot Foot in patients with Diabetes and Neuropathy.
Why Is It Dangerous To Miss Early Treatment?
Without offloading pressure, the continued weight-bearing will destroy the foot. The new bony prominences that develop almost always lead to callus formation—and it’s these calluses that lead to diabetic foot ulcers in at least 50% of all patients. Ulcers, of course, translate to costlier care, worse outcomes, amputation, and even death.
Dangers of delayed Charcot Foot diagnosis include:
- Greater cost of care: One study found delayed Charcot Foot patints paid 10.8% more for their hospital care and had a 12.1% longer stay.
- Infection and Amputation: The risk of amputation is 30.4% higher with delayed Charcot Foot.
- Premature Death: One study found 43% of patients with diabetic foot ulcers died within five years.
Reasons To Seek Treatment for Charcot Foot Early
Most cases of acute Charcot Foot are treated non-surgically with pressure-relieving total contact casts. This method of treatment dates back to the 1950s and is designed to evenly distribute pressure along the plantar surface of the foot. The cast is comprised of a three-layer inner plaster shell and a fiberglass outer shell, with low-density foam or felt and synthetic padding added to the metatarsal heads. Rapid reduction of water retention will require a new cast one week later. Subsequent casts will be made at two and four weeks. It’s not uncommon for patients to remain in a TCC for up to four months.
Once we have noted stabilization on radiography and the acute symptoms have subsided, you can graduate to a Charcot Restraint Orthotic Walker for six months to two years. We recommend protecting the foot with custom orthotics afterward as well. Patients with grade 3 or higher ulcers will require drainage, antibiotic therapy, and perhaps even ultrasonic debridement to heal the open wound.
With treatment, 25% of patients will not develop any further foot deformity. For most patients, it’s a long, ongoing monitoring process. Some patients never return to conventional foot gear or walk completely unassisted. One to two-month periods of immobilization with protected weight beating may be advised if lower extremity trauma presents itself. Though it sounds extreme, this care usually prevents the breakdown of the foot. Though the prognosis isn’t perfect, early diagnosis is the most important factor in preventing amputation.
The Center for Podiatric Care and Sports Medicine is one of New York City’s finest diabetes foot care clinics. Contact us to have board-certified podiatrists examine your feet and test for early signs of Charcot Foot.
If you have any foot problems or pain, contact The Center for Podiatric Care and Sports Medicine. Dr. Josef J. Geldwert, Dr. Katherine Lai, Dr. Ryan Minara and Dr. Mariola Rivera have helped thousands of people get back on their feet. Unfortunately, we cannot give diagnoses or treatment advice online. Please make an appointment to see us if you live in the NY metropolitan area or seek out a podiatrist in your area.