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School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet]. Sheffield (UK): University of Sheffield; 2003. (NICE Clinical Guidelines, No. 10.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet].

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8Care of people with Charcot osteoarthropathy

Caring for people with Charcot osteoarthropathy

Recommendation

People with suspected or diagnosed Charcot osteoarthropathy should be referred immediately to a multidisciplinary foot care team for immobilisation of the affected joint(s) and for long term management of off-loading to prevent ulceration. (D)

Evidence statements

Mobilising in the active disease state leads to further joint damage. (IV)

The resulting deformity with neuropathy increase the risk of ulceration and protective footwear needs to be provided. (IV)

Introduction

Charcot osteoarthropathy is a progressive condition. It is characterised by dislocation of joints, fractures and destruction of the bony architecture. It is associated with severe peripheral neuropathy. In people with severe diabetic neuropathy the osseous breakdown, in most cases, is localised to the midfoot, with risk of collapse of the pedal arch. The acute swelling and the later deformity associated with this are major risk factors for ulceration and subsequently amputation. Such patients also have decreased bone mineral density compared with those without diabetes of a similar age and sex (Childs et al 1998). It is thought that bony trauma in a severely neuropathic limb may be a trigger for the development of Charcot osteoarthropathy. Continued walking promotes progression of the osteoarthropathy and worsening of the deformity.

Incidence and prevalence of Charcot’s osteoarthropathy

The incidence of Charcot deformity was found to be 0.3%/year in a study of people with diabetes attending a specialist hospital for diabetes (Fabrin et al 2000). Armstrong et al (1997) reported a prevalence of acute-onset Charcot’s osteoarthropathy among all patients reporting to their Diabetic Foot Centre in Texas of 12.9% or 3.8%/year (55 in 426 patients, between February 1991 – June 1994 inclusive).

Incidence of ulceration in patients with Charcot’s osteoarthropathy

In a study of 140 feet with Charcot’s osteoarthropathy in 115 patients with diabetes followed up for median time of 48 months (range 6–114 months), 43 patients developed 68 ulcers on 53 feet. The incidence rate of ulceration was 17% per year (Larsen et al 2001).

Screening for Charcot’s osteoarthropathy

Isotope and MR bone scans can be used as an imaging modality to help distinguish osteoarthropathy from osteomyelitis, often a difficult differential diagnosis. The Tc-99m HMPAO Labeled Leukocytes Scan may also help to distinguish those with osteomyelitis. None of these tests has 100% sensitivity and specificity. People with a Charcot deformity of the foot have serious ambulatory disabilities. Using the Sickness Impact Profile questionnaire, Dahmen et al (1995) found reduced scores for physical, social, psychological, communicative and activities of daily life categories in 12 patients with diabetes and osteoarthropathy lesions of the foot, compared with scores expected from people without disability.

Various treatment options are available, the aim being to maintain skin integrity and avoid infection and amputation.

Evidence

From the literature three studies only were identified that described interventions for the treatment or management of Charcot’s neuroarthropathy. Two of these three were randomised double blind trials (Chantelau and Schnabel 1997, Jude et al 2001) and both were concerned with healing of the condition using outcomes such as loss of swelling and redness (Chantelau and Schnabel 1997) or reduction in foot temperature or foot pain (Jude et al 2001). The treatment approaches in the two groups differed totally. Chantelau and Schnabel administered radiotherapy whilst Jude et al delivered a single infusion of pamidronate, a biophosphate. Given the incidence of this condition, Chantelau and Schnabel took three years to recruit their 12 patients, whilst Jude et al used four centres in the UK to recruit 39 patients. The impact of both of these treatments on defined outcome compared with their placebo alternative was not significant with one exception. Symptom scores, based on an aggregation of patient assessed pain, discomfort and swelling fell in both the treatment and placebo groups within the first three months, but then continued to fall in the treatment group over the next nine months (p<0.01) giving a significant area under the symptom score curve difference (treatment group 14.3±8.7, placebo group 23.8±8.4, p=0.01) (Jude et al 2001).

The other paper was a retrospective review of treatment for a cohort of patients with Charcot’s neuroarthropathy. Armsrong et al (1997) treated their 55 patients with total contact casting, the frequency of changing being based upon ulcer status. Casting was replaced by removable cast walkers and ultimately by prescription footwear on the basis of clinical, radiographic and dermal thermometric signs of quiescence of the condition, with none of these terms being clearly defined. All patients were casted for 18.5 ±10.6 weeks (range 4–56 weeks) and progression to prescription footwear took 28.3 ±14.5 weeks.

References for Charcot osteoarthropathy (with evidence grades where appropriate)

  • [III] Armstrong et al (1997)
  • [Ib] Chantelau and Schnabel (1997)
  • [Ib] Jude et al (2001)
Copyright © 2003, School of Health and Related Research (ScHARR), University of Sheffield.
Bookshelf ID: NBK51714

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