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Background At the onset of acute diabetic Charcot foot, therapeutic intervention may be delayed because plain X-rays may not show fractures.
Aim of the study To assess the clinical course of acute Charcot foot in 24 patients without evidence of definite fractures on the first X-ray after onset of symptoms, who were referred to the foot clinic for diagnosis and treatment either early or delayed, i.e. before or after definite fractures were detectable on repeat X-rays.
Patients and methods Eleven patients were referred early (incipient Charcot foot, case group), and 13 patients were referred delayed (overt Charcot foot, control group). In the foot clinic, both groups were immediately treated with off-loading and total contact casting. After the healing process of the Charcot foot was complete, the extent of fractures and subsequent deformities were evaluated.
Results Based on X-rays at the onset of symptoms, in 19 of the 24 patients the condition had been misdiagnosed prior to referral (in 11 patients as sprain injury). Additional imaging techniques (MRI, CT scan or bone scintigraphy) had been performed in 10 patients prior to referral. While these techniques had been used more frequently in the cases vs. the controls (P = 0.012), misdiagnosis was less frequent in the cases vs. the controls (P = 0.013). Only one out of 11 case patients developed extended foot fractures and severe deformity, vs. 12 out of 13 control patients (P < 0.001).
Conclusion Early detection of incipient Charcot foot is facilitated by imaging techniques other than plain X-rays. Immediate off-loading of incipient Charcot foot appears to minimize fractures and incapacitating deformities.
Great example of how important the diagnosis of acute Charcot’s is! I have always found it hard to translate to people, health professionals and patients, the seriousness of this condition. My experience has shown that Rx in the more acute phases of this process has far better outcomes with respect to foot deformity.
The area, which has also been a dilemma for myself, is how long should acute Charcot pts be Rx with TCC. As this is a common question by pts I often tell them until the swelling and temperature return to the bilateral foot state and there is no evidence of osseous destruction. However I have had pts who’s foot temperature has never seemed to return to the same as the bilateral foot. Has the pathological process stopped and there is an increase in dermal temperature due to an increase in vasodilation and AV shunting!
Well any comments would be much appreciated.
Press release from ACFAS: Rare diabetes foot complication becoming more common
Few patients or care providers know about the limb-threatening foot condition, or its warning signs
Quote:
(CHICAGO - October 23, 2007) At first, Kim Schraeder didn’t worry about the swelling in her left foot. After all, it was pulling double-duty while her other foot recovered from surgery.
“I have a high threshold for pain,” she says. “It hurt to walk on it, but I didn’t think it was serious.”
Just a year earlier, doctors diagnosed the 48-year-old mother of four with diabetes. The recent surgery on her right foot corrected a bunion to prevent reoccurring diabetic ulcers. As Schraeder’s bunion recovery moved forward, her left foot moved outwards. Her ankle bent inwards. The foot grew so swollen none of her shoes fit. The skin was warm and red. Schraeder started to worry.
During a follow-up visit with her foot and ankle surgeon, she spoke up. Her doctor took one look and said, “We have a problem.”
Schraeder was diagnosed with a rare diabetic complication called Charcot foot. It is estimated to affect less than one percent of people with diabetes. Now doctors with the American College of Foot and Ankle Surgeons (ACFAS) say Charcot foot’s prevalence appears to be growing as more Americans get diabetes. Some worry that few patients – or their diabetes care providers – seem to know about this complication or its warning signs.
Charcot foot is a sudden softening of the foot’s bones caused by severe neuropathy, or nerve damage, a common diabetic foot complication. It can trigger an avalanche of problems, including joint loss, fractures, collapse of the arch, massive deformity, ulcers, amputation, and even death. As the disorder progresses, the bottom of the foot can become convex, bulging like the hull of a ship. Since most people with Charcot cannot feel pain in their lower extremities, they continue walking on the foot, causing further injury.
Charcot cannot be reversed, but its destructive effects can be stopped if the complication is detected early.
The symptoms of Charcot foot appear suddenly. They include warm and red skin, swelling and pain. A person with diabetes who has a red, hot, swollen foot or ankle requires emergency medical care because these can also be symptoms of deep vein thrombosis or an infection.
Doctors say Charcot’s ambiguous symptoms can lead to misdiagnosis. Since patients don’t feel pain, doctors may presume the swelling is due to infection and prescribe antibiotics. Meanwhile the patient continues walking on a foot that is collapsing.
“More people with diabetes, their families and their care providers need to know about Charcot foot,” says J. T. Marcoux. DPM, FACFAS, one of only a handful of Massachusetts foot and ankle surgeons who performs Charcot foot reconstructions. “When I diagnose a patient with this complication, I telephone their primary care doctor and educate them about it as well.”
Schraeder says no one told her about Charcot. “It was not even in my vocabulary,” she says. “If someone had educated me, I think I would have been more aware that I had a major problem.”
But educating patients and their care providers is only half the battle. Keith Jacobson, DPM, FACFAS is the Houston foot and ankle surgeon who diagnosed and reconstructed Schraeder’s Charcot foot. He and Marcoux say there’s little they can do when patients are apathetic or in “diabetic denial.”
“I’ve had patients who are literally blind, on dialysis and neuropathic who refuse to admit they have diabetes,” says Jacobson. “I have seen horrific deformities with this condition.”
Marcoux tells of a middle-aged woman he diagnosed with Charcot. Typically the first order of business is to immobilize the foot by putting the patient in a boot or cast, and to keep the patient off the foot by using crutches or a wheelchair. Marcoux says his patient was “in massive denial” about her Charcot diagnosis.
“I tried to get her off the foot, but she wouldn’t do it” he says, “Six months later she came in with a bone infection and a gaping hole in her foot.”
Foot and ankle surgeons expect to see more patients like that as diabetes rates soar.
Today, Schraeder is back to walking on both feet. Three months after her Charcot diagnosis, she underwent reconstructive surgery. Her recovery included spending three months in a “halo” external fixator where a series of pins and screws are placed into the bones and connected to clamps and rods outside the skin. She then wore a custom shoe boot for nearly a year.
The experience taught her four children to appreciate their mother a lot more, since all the cooking, cleaning, and laundry fell on their shoulders.
“They’re all like hawks now,” she says. “If I’m sitting here with bare feet, they’ll look to make sure they’re not red, hot and swollen.”
Charcot's - the perils of procrastination
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