Medical Case Conference Call
Acute Charcot Foot
Steve Quevedo, MD, Lawrence & Memorial Hospital
May 21, 2007
Attendance:
 Baltimore Washington Medical Center, Glen Burnie, MD
 Doctors Community Hospital, Lanham, MD
 Maryland General Hospital, Baltimore, MD
 St. Mary's Medical Center, Huntington, WV
 UC Irvine, Irvine, CA
 Western Pennsylvania Hospital, Pittsburgh, PA
 Lawrence & Memorial Hospital, New London, CT
Incidence:
 0.1 - 0.4% prevalence in > 15 yrs duration diabetes
 6% in patients with neuropathy
Clinical Presentation:
 Sympathetic edema often to ipsilateral knee, erythema/heat esp. medial mid-foot,
variable pain
 Often misdiagnosis as DVT or cellulitis
 Loss of architecture, early decreased arch (compare sides)
Goals:
 Timely diagnosis
 Try to preserve function of arch
 Avoid rocker panel
 Decrease pain
Diagnostic tools:
 X ray not that helpful for early Charcot
 MRI to differentiate infection/osteo from Charcot
 Infrared non-contact skin thermometers – inexpensive at about $128 for equipment
 > 2 degree Centigrade temperature difference in feet consistent with
Charcot and evaluate treatment effectiveness
Treatment:
 Off load pressure (MOST IMPORTANT), Refer Podiatry ASAP
 IV Bisphosphonates 1 time dose (?)
 Oral Bisphosomates 70 mg for 8 weeks
 Calcitonin nasal spray in renal insufficient patients
Outcomes seen in some studies:
 Decreased pain
 Decreased temperature difference
 Improved bone alk phos, other markers of bone turnover
 Improved foot bone mineralization
 No data yet on improved anatomic outcomes
Case #1 Inpatient Consult
 Admitted with pain and erythema, no elevated white count or fever - suspected
cellulitis
 Obese
 Consultation with Joslin requested for newly diagnosed diabetes not for foot
 A1C 10.2%
 Suspected Charcot
 Bed rest helped
 MRI looked like cellulitis
 IV pamidronate - improvement in 24-48 hrs in pain/erythema
Case #2
 Twenty year hx Type 2 DM, peripheral neuropathy, obese and hx Charcot
 Diabetes in control A1C down to low 6 on Metformin & Byetta
 Foot exam as part of routine follow up visit for diabetes
 Infrared thermometer showed 5 degree C difference in feet
 Immediate podiatry consult
 Off load
 Fosomax 70 mg weekly x 8 weeks
Case #3
 Long standing type 1 triopathy, heel callous infection treated and healed
 Routine diabetes follow up visit – new asymmetric edema not near infection site
 Immediate off load
 Calcitonin nasal spray because of renal insufficiency
 3 month follow up - not totally compliant with off load, edema improved but heat
difference 3.2 degree, Vit D deficiency diagnosed and treated. Off load again.
 Limping because of heal infection or increased blood flow from infection (?) may
have predisposed to Charcot
Case #4
 Type 2 morbidly obese, peripheral neuropathy
 Insulin & Byetta & Metformin
 Foot exam during routine follow up - edema, no temp gradient could be felt, arch
slightly flattened, Michigan Neuropathy score 3
 Patient reported he was in ER several times recently for foot problem, treated with
bed rest, IV & oral antibiotics, negative DVT, pain in medial foot resolved
 A1c 6.0-6.5%
 Infrared thermometer result 1.8 – 2.1 temp differential
 MRI classic for Charcot
 Back on bed rest
 At follow up down to 1 – 1.3 temp difference
 Treatment and compliance with “cellulitis” (ie bed rest) probably stopped progress
of Charcot even though not diagnosed
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Lessons learned
 Look for Charcot; foot exams on every routine visit
 Infrared thermometer whenever suspect Charcot and order MRI if > 2 degree C
temperature difference between feet; Infrared thermometer can’t distinguish
cellulitis from Charcot
 Danger of type 2 at younger age could increase incidence
 Not billing for Infrared thermometer – only takes a minute
 High risk patients can be taught to use their own thermometer
 Talk about Charcot with podiatrists and PCPs
 Teach patients with PDR early symptoms of Charcot
References:
1) Tan AL. Acute Neuropathic Joint Disease: A Medical Emergency? Diabetes Care
2005;28:2962-4
2) Jeffcoate W. A Concise Review of the Charcot Foot. Diabetic Med 2000;17:253-58
3) Ahmadi ME. Neuropathic Arthropathy with and without Osteomyelitis: MRI Characteristics.
Radiology 2006;238:622-31
4) Armstrong DG. Natural History of Acute Charcot Arthropathy. Diabetic Med 1997;14:357-63
5) Monitoring Healing of Acute Charcot Foot with Infrared Thermometry. Rehabil Res Dev
1997;34: 317-21
6) Jude EB. IV Pamidronate For Treatment of Acute Charcot. Diabetologia 2001;44: 2032-37
7) Pitocco D. Six Months of Alendronate Therapy for Acute Charcot. Diabetes Care
2005;28:1214-15
8) Bem R. Intranasal Calcitonin for Therapy of Acute Charcot. Diabetes Care
2006;29:1392-94
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