A 46-year-old man with type 1 diabetes of 33 years' duration, end-stage renal failure treated by renal transplantation and severe neuropathy, received regular foot checks under a renal foot study protocol. Three days before he went on holiday to the Channel Islands his feet were routinely checked and nothing abnormal was discerned. Two weeks later he came to the clinic on his return from holiday to report that his foot was 'a little swollen'. He reported no trauma to the foot, but had been walking more than usual on cobbled pavements. The foot was red, 5°C hotter than the contralateral foot and very
swollen. X-ray revealed a Lisfranc's fracture-dislocation and he developed a rockerbottom foot. He was treated in a total-contact plaster cast for 6 months following which he wore bespoke boots to accommodate his deformity. The foot remained ulcer free apart from one episode of sepsis which was precipitated by dropping a heavy object on the foot. This led to a break in the skin with resulting infection on the dorsum of the foot which needed surgical drainage (Fig. 3.19).
• Charcot's osteoarthropathy can develop with great rapidity
• Severe injuries normally associated with gross trauma can develop in high-risk patients simply through walking or unperceived trauma
• Renal transplant patients have a very high risk of Charcot's osteoarthropathy
• Deformed feet can be successfully accommodated in footwear.
Bone and joint destruction can occur in any part of the foot or ankle, but the common presentations can be divided into forefoot, mid-foot and hindfoot. The forefoot involves the metatarsophalangeal and interpha-langeal joints. The mid-foot involves the tarsometatarsal joints and the hindfoot includes the ankle and subtalar joints. Each region of the foot has specific clinical presentations of bony destruction or deformity.
This presents with generalized swelling of the forefoot and osteonecrosis of the metatarsal heads. It is rare for a significant structural deformity to develop in forefoot
Charcot's osteoarthropathy. The resorption of the distal metatarsal bones giving 'sucked candy' appearances is in our experience usually associated with chronic ulceration and infection.
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