Acute onset Charcots osteoarthropathy

A 64-year-old type 2 diabetic patient of 26 years' duration telephoned the foot clinic complaining of a swollen foot. He attended the next day and his foot was red, swollen and 3°C hotter than the contralateral foot. X-ray was normal. A total-contact cast was applied which was removed 5 days later in order for a technetium MDP bone scan to be performed. The bone scan showed increased uptake around the navicular. The total-contact cast was reapplied and he remained in a cast for 6 months, when the foot was within 1°C of the remaining foot, and with minimal deformity.

Key points

• If Charcot's osteoarthropathy is diagnosed early there maybe no X-ray changes

• If Charcot's osteoarthropathy is suspected and the X-ray is normal, the foot is put into a cast until an urgent MDP bone scan can be performed.

Treatment of acute Charcot's osteoarthropathy

Initially the foot is immobilized in a non-weightbearing plaster cast. The cast is checked after 1 week, and replaced if it has become loose due to reduction of oedema, regularly checked and replaced as necessary. After 1 month the patient may walk for brief periods, using crutches and being encouraged to keep his weightbearing to a minimum. The casting is continued until the swelling has resolved and the temperature of the affected foot is within 2°C of the contralateral foot.

An alternative treatment is the Aircast, a prefabricated walking cast, described in Chapter 4. A moulded insole should replace the standard insole provided with the cast by the manufacturer.

A recent randomized controlled study of a single 90 mg pamidronate infusion has shown that markers of bone turnover and skin temperature decreased in both treated and untreated subjects, although to a greater degree in the treated subjects.

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