Deformity Including the Charcot Foot

Ideally, deformity should be recognized early and accommodated in properly fitting shoes before ulceration occurs. Footwear can be divided into three broad types:

■ Sensible shoes (from high street shops) for patients with only minimal sensory loss.

■ Ready made stock (off the shelf) shoes, suitable for neuroischemic feet that need protection along the margins of the foot but that are not greatly deformed.

■ Customized or bespoke (made to measure) shoes containing cushioned insoles that redistribute areas of high plantar pressure.

With regard to the prevention of ulcers, most studies have examined the effect of therapeutic shoes on ulcer recurrence. The majority have been positive, but not all. In a recent review of studies, assessing the association between therapeutic footwear and re-ulceration, risk ratios in all of them were below 1.0, suggesting some protective footwear benefit (17). One study (N = 69) found that therapeutic shoes with custom-made insoles could reduce ulcers in people at high risk (18). The relapse or new ulcer rate at 1 year was 28% in the intervention group compared with 58% among those who continued to wear their own shoes (P < 0.01). However, in the most rigorous experimental study, no statistically significant benefit was observed between control patients wearing their own footwear and intervention patients wearing study footwear (19). However, in patients with severe foot deformity or prior toe or ray amputation, observational studies suggested a significant protective benefit from therapeutic shoes. However, this issue remains contentious (20).

The Charcot foot refers to bone and joint destruction that occurs in the neuropathic foot (21). It is important to diagnose it early so as to prevent severe deformity. The foot presents with unilateral erythema, warmth and edema. There may be a history of minor trauma. About 30% of patients complain of pain or discomfort. X-ray at this time may be normal. However, a technetium-99 m diphosphonate bone scan will detect early evidence of bony destruction, which in this particular situation, is indicative of a Charcot foot. Early diagnosis is essential. Cellulitis, gout and deep vein thrombosis may masquerade as a Charcot foot.

Initially the foot is immobilized in a cast to prevent bone destruction and deformity that on X-ray is shown as fragmentation, fracture, new bone formation, subluxation and dislocation. Immobilization is continued until there is no longer evidence on X-ray of continuing bone destruction and the foot temperature is within 2°C of the contralateral foot. The patient can now progress from a cast to an orthotic walker, fitted with cradled moulded insoles. Bisphosphonates may be helpful in the initial treatment of the Charcot foot (22).

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