Charcot Revisited: Roger(s) that!

In February 2011, 18 Charcot foot experts from six different countries gathered in Paris at the La Salpetriere Hospital to achieve a consensus on the diagnosis and treatment of this debilitating condition. I was honored to co-chair this historic meeting with Robert Frykberg, DPM. Both the American Diabetes Association and the American Podiatric Medical Association sanctioned the International Task Force on the Charcot Foot. The proceedings were jointly published in Diabetes Care and the Journal of the American Podiatric Medical Association.^1,2

Participants received special access to some of the original writings of Professor Jean-Martin Charcot (1825-1893), who was most prolific in researching tabetic arthropathy (the original name of the Charcot joint) in the 1880s. Physicians first noticed tabetic arthropathy as a disease of large joints associated with syphilis. In 1881, at the 7th International Medical Congress in London, Prof. Charcot presented cases of the tabetic arthropathy of the foot and the condition received the eponym Charcot's foot. Although it wasn't until 1936 that W.R. Jordan first described arthropathy of the diabetic foot, the eponym Charcot's foot describes any neuropathic arthropathy of the foot or ankle. Certainly, in the developed world, Charcot foot is most often associated with diabetes.

The task force reached consensus in several areas, which I will summarize in the next couple of paragraphs.

On the topic of diagnosis, we found that Charcot foot is primarily a clinical diagnosis characterized by a red, hot, swollen foot in the presence of neuropathy and the absence of infection. Inflammation is the earliest finding and rocker bottom deformity is a late finding. The task force agreed that acute fractures and dislocations in those with diabetes and neuropathy comprise Charcot foot. We also agreed on classifying Charcot foot simply as “active” or “inactive” depending on whether inflammation is present or absent.

In regard to treatment, offloading and immobilization are the most important initial treatments. Available pharmacologic therapies (bisphosphonates or calcitonin) have little evidence to promote the healing of Charcot foot. One should prescribe protected weight-bearing after an active episode. The panel agreed that the initial management of acute fractures and dislocations should not differ from those without diabetes and neuropathy. Exostectomy can be useful for a plantar prominence not amenable to offloading. A tendo-Achilles lengthening or gastrocnemius recession can reduce plantar forefoot or midfoot pressures. Arthrodesis can be useful for instability, pain or recurrent ulcers, despite the high incidence of incomplete union.

One can download the whole consensus report PDF from the Diabetes Care website athttp://care.diabetesjournals.org/content/34/9/2123.full.pdf .

References

1. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011; 34(9):2123-9.
2. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. J Am Podiatr Med Assoc. 2011; 101(5):437-46.