Charcot Neuroarthropathy

Charcot neuroarthropathy (CNA) is a condition primarily affecting the foot and ankle in diabetic patients with neuropathy. Although the prevalence of CNA is not precisely known, a reasonable estimate is 0.5% in patients with diabetes. The prevalence rises substantially in patients with diabetes and peripheral neuropathy. Some form of injury, either perceived or not, results in a proinflammatory state that activates osteoclastic resorption of bone. Consequently, an imbalance occurs between resorption and deposition of bone leading to osseous injury. The associated hyperemia contributes to ligamentous laxity, and patients can experience fractures, dislocations and fracture dislocation of the foot and ankle. The midfoot is the most common site of anatomic involvement, followed by the ankle and hindfoot. The initial treatment of acute Charcot neuropathy involves offloading the foot and ankle with total contact casts, removable boots or boots rendered irremovable. In some cases, the use of external walking aids provides additional offloading (cane, crutches, walker, knee scooter and wheelchair). The goal of treatment is to preserve a plantigrade foot that is stable and able to wear shoes that are commercially available (diabetic extra-depth shoes with inserts). Some patients may require lifelong bracing with above-ankle orthoses (CROW or AFO). Deformities can increase the risk of foot ulceration which can in turn lead to infection and amputation. Patients who do not have a plantigrade foot are candidates for surgical reconstruction.