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

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.

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


• Charcot's osteoarthropathy can develop after a first ray amputation or other surgical procedure

• Casting should not be undertaken if patients cannot return to the casting clinic quickly when problems arise

• Unstable hindfoot Charcot's osteoarthropathy can be stabilized, in some cases, by conservative means using a CROW, and maintained long term in an AFO and bespoke footwear.

If conservative care is unsuccessful, and the patient has a 'flail ankle', which is often associated with intractable ulceration over the malleoli, then internal stabilization may be necessary, and this is discussed in Chapter 8.

Following reconstructive ankle surgery, the lower limb is usually managed in a cast for several months and then a CROW is supplied to maintain the stability of the hind-foot. When all is stabilized, temperatures have stayed down and patient is fully ambulant, an AFO provides long-term stability.

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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