Conservative management of Charcots osteoarthropathy of the hindfoot

A 46-year-old male with type 1 diabetes of 40 years' duration presented with bilateral Charcot's osteoarthropathy. He was referred from a clinic 80 miles away and had been advised to have a right below-knee amputation. The left foot had stable mid-foot Charcot's osteoarthropathy with rockerbottom deformity: the right foot was hot with unstable hindfoot Charcot's osteoarthropathy with lateral talotibiofibular displacement. The Charcot's osteoarthropathy was diagnosed 3 years previously following a first ray amputation (Fig. 3.24). In view of the considerable distance he had to travel it was decided that casting him would be unwise. As an alternative, the treatment plan was to try to achieve stability by providing a CROW. After 5 weeks in the CROW, swelling had improved and the

Amputation First Ray
Fig. 3.24 Right foot shows stable mid-foot Charcot's osteoarthropathy; left foot shows unstable hindfoot Charcot's osteoarthropathy and first ray amputation.

skin temperature difference between the two feet was less than 2°C. An AFO was manufactured containing a moulded EVA insole (Fig. 3.25a,b). The patient was advised to take 5-10 steps daily for the first week and then at each week to double the steps taken. At 10 months he was taking up to 50 steps daily and the temperature difference was still less than 2°C. At this stage there was clinical and radiological evidence that the hindfoot had stabilized. He remained in the AFO for his long-term orthotic prescription. There was no relapse and he has remained ulcer free.

Images Stages Diabetic Foot
Fig. 3.25 (a) Ankle-foot orthosis (AFO) containing a moulded ethyl vinyl acetate insole, (b) Patient wearing AFO in bespoke boot.
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