TREATMENT
Conservative therapy Early immobilization and joint offloading are critical in the initial treatment of acute Charcot's arthropathy. Nonoperative management strategies are historically the standard of care. The total contact cast (TCC) remains the gold standard for prolonged immobilization. This type of cast is made to conform exactly to the shape of the foot and ankle, with distribution of the pressure over a wide area. The principles of this approach are to control and decrease swelling, provide skeletal stability, and protect the soft tissues.
The healing process in the foot and ankle of a patient with diabetes takes about twice as long as it does in a healthy person's limb; therefore, the immobilization period is lengthy. In general, treatment with nonweight-bearing immobilization is recommended for a minimum of 3 months, followed by a period of protected weight bearing.10 During TCC treatment, frequent assessment of the skin, soft tissues, and bony structures is necessary.
Patient education regarding the diagnosis, length of treatment, and prognosis is essential. If the patient understands the nature of this limb-threatening condition, he or she may be more motivated to adhere to the treatment plan. Emphasis on total joint off-loading, weight loss, and strict glucose control may improve the outcome of this disease.
After the plaster TCC is removed, a variety of specialized footwear options are available to continue the healing process and to prevent future deformity. The Charcot's restraint orthotic walker is designed to offload the foot and distribute plantar pressures more evenly. Patellar tendon braces have also been used to reduce plantar pressure. Custom-molded shoes and orthotics are important treatments as well, but these need to be checked regularly to ensure proper fit.
Surgical intervention Indications for surgery include chronic or recurrent ulcers associated with a bony prominence, unstable joints that are not amenable to bracing, acute displaced fractures in a patient with adequate circulation, and persistent pain. The goal of operative treatment is to restore a stable, plantigrade foot with acceptable biomechanics and to prevent a future amputation.
Arthrodesis, or joint fusion, is the most common surgical procedure used to treat a diabetes-related foot deformity. This is the procedure of choice for realigning the deformity and preventing amputation. Other surgical procedures include exostectomy of the bony prominence, osteotomy, partial tarsectomy, and Achilles tendon lengthening.
Surgical intervention in acute Charcot's arthropathy, however, is controversial. Some clinicians advocate surgery 
only when conservative measures have failed, whereas others propose early surgical intervention as a means for improved outcomes. Simon and colleagues demonstrated good results with early surgical intervention, measured by reulceration rates and a return to walking ability, in 14 patients with stage 1 Charcot's arthropathy who underwent midfoot arthrodesis.3 Advocates of early surgical intervention believe TCC to be too cumbersome for treatment over an extended period of time. In addition, patients who are managed conservatively may still suffer a nonunion, which would eventually require surgery.
A 6-year study by Pinzur compared surgical interventions and nonsurgical therapy in 198 patients with Charcot's arthropathy. Surgical interventions for patients with nonplantigrade feet included osteotomy, with or without arthrodesis; debridement; simple exostectomy; and amputation. The desired endpoint in this study was long-term management with commercially available, therapeutic footwear and custom foot orthoses. This study concluded that more than half of the patients with midfoot Charcot's arthropathy could be successfully managed without surgery.11
Although surgical intervention for acute Charcot's arthropathy is becoming more common, the most effective treatment course should be determined through individual evaluation of each patient. Patients with diabetes often are morbidly obese and have multiple comorbidities that should be considered when contemplating surgical intervention. In addition, complications of surgery such as deep wound infection, 
nonunion of osteotomy or arthrodesis, malunion, fracture, and hardware failure are possibilities that should be taken into account.
Bisphosphonates A new area of interest in the treatment of this disease is the use of bisphosphonates, which target the underlying physiologic mechanism of the disease. Bisphosphonates bind to hydroxyapatite located in the bony matrix and prevent osteoclastic resorption of bone.12 Multiple reports have demonstrated decreased local temperature and pain, suggesting an anti-inflammatory action of pamidronate. 13,14 Although the exact mechanism of how these drugs halt bone loss and osseous destruction is not completely understood, study results using pamidronate as an adjunct to traditional treatments for Charcot's arthropathy appear to be promising.
CONCLUSION
The role of surgical intervention in the treatment of acute Charcot's arthropathy continues to be debated. Recognition of the subtle early signs of this disease process and prompt initiation of treatment are the keys to preventing permanent deformity. Conservative therapy is the standard of care. Immobility and prevention of weight bearing are used until the disease progresses to the chronic stage, which is signified by decreased pain and swelling along with radiographic signs of resolution. Too often, Charcot's arthropathy is misdiagnosed as an infection and treated improperly with devastating consequences. Perhaps the key to managing this costly disease is an increased awareness of its complications and associated long-term disability. JAAPA
Brianne Johnsen is a physician assistant fellow with Watauga Orthopaedics in Johnson City, Tennessee. She has indicated no relationships to disclose relating to the content of this article.
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