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I have an elderly gentleman, who I am going to commence treatment tomorrow for Step 0 - 1 Charcot's joint. He is not diabetic, but has compromised neuro supply from a WW2 spinal injury and circulation is quite pathetic in his lower limbs...( but I have given up trying to get him to stop smoking ).
The x-ray shows early changes to the med cuneiform and base of 1st Met.

My concern is how do I immobilise an old man who isn't very stable ?? I can't see him sitting in bed for 17 weeks waiting for the inflammatory stage to hopefully pass. Nor would he be able to get around with a total contact cast and total non-WBing.

He is in pain with this foot and we have only just cleared up ulcerations on the foot and leg.

Any ideas ??

Trudi

It’s always a dilemma trying to immobilise frail elderly patients with Charcot changes. My first line of thinking is

1. TCC, if pt wouldn’t be able to tolerate this or in the presents of peripheral vascular disease present then

2. Removable walker, I have found a very low compliance with removable walkers. Again if PVD is present extreme caution is needed. If pt can’t tolerate this device then

3. Crutches

4. Orthopaedic footwear and accommodative orthotics

5. Wheelchair

That’s my line of thinking for an elderly pt with stability problems. Generally I would combine points 3, 4 and 5 in any combination. I also didn’t mention the use of a soft cast shoe with cast boot. I would love to hear from anyone else to add to the above comments.

David

Thanks David

Spoke with his GP today and we are both wondering the best next step. The only thing I can see working is a respite stay for the 4 months with the TCC. Practical ??

I'll let you know our decision.

Trudi

Hi Trudi,

If he can't have a TCC, EVA orthoses are almost a must if you're considering using a walking cast for him ("almost" is being generous). Whilst I agree with David about compliance, it's not unknown for the treating clinician to simply scotchcast around the uprights to prevent removal between visits.

I'm inclined to stick with David's options 1 and 2, as crutches can cause other issues with a frail elderly gentleman, such as upper limb and balance difficulties, whilst orthopaedic footwear is expensive and by the sound of things he'd need them custom made, which takes substantial time to obtain.

Total contact cast is still best option, changed reasonably frequently. Hope this helps.

Richard

Trudi, just as a matter of interest where on the foot was the previous ulceration, if in and around the med cuneiform and or base of 1st met can you exclude osteomyletis as the change that you are seeing on x-ray?

In regard to offloading you must reduce the bending demand acting across the mid foot. All our destructive arthopathies are immobilised on an Aircast pneumowalker. The patients are told and shown visual images of the consequences of not wearing the boot. There is the option as stated previously to wrap the boot if you question the compliance.

If the arterial supply is that compromised is revascularisation an option?

This is the foot that you can not compromoise with in terms of mechanical offload. We have just acquired one from our Trauma team ten weeks down the line that is absolutely shafted due to not immobilising. Its a quick and effective way of managing the condition and at least salvaging the remaining joints.

Regards

Mark

Once the foot is imobalised, via TCC, Cam Walker or CROW, you need to improve his stability with walking aids, and the best option for an 84 year old is a 4 wheeled Zimmer Frame rather than cructhes etc.
He may then require just a short stay in a GEM or rehab unit to ensure he would be safe at home

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

Trudi,
Have a similar pt (non, smoker lower spine injury Charcot B/feet DVT) who keeps crushing his Charcot feet, he runs a gradualy worsening cycle of Hospitalisation/rest/Iv antibiotics, which brings enough improvement to allow him to feel well anough to mash them again. every time he is admitted surgeon looks at his drugs list & decides golf is the legally wise option, so at the risk of sounding pessimistic it could be, with the levels of compliance you have, the best you might achieve is stability. Have had some success with simple insoles made of "Plastazote", in orthopaedic type "slippers", also using cut-out type pads wound into the OUTER layers of an elastic type dressing use to apply sterile dressings (this man has large ulcers in the usual places for Charcot's)
Reckon anything you try will have to be pretty conservative, also it seems his problem is probably vascular so would probably steer clear of Casting, unless you can get guidance from someone/a centre who actually uses it a lot, hope this is of some use.
Darren

Well a month down the track and he is not looking too bad.

The old guy ended up in hospital soon after my last post, in quite a bit of pain.

Now he is home, using a wheelie-walker and I have fitted him with a 3mm poly pair of orthotics. ( Support with flexibility ). He is quite happy and pain free... due to the drugs prescribed, but I am still advising him to do as little WB-ing as possible for the next 'little' while.

The doctor thought it may be just an acute arthritic episode, but the clues are all there, and it is better to be safe than sorry... Though if what I do works well, then there shouldn't be any joint deformation and hard to say I told you so ?! But the patient thinks I am on the right track too.

Next update when something happens.... or doesn't !

Thanks for your help everyone!!

Trudi