Management of hindfoot and ankle in Charcot arthropathy.

Abstract

Charcot neuroarthropathy is the most severe complication of the diabetic foot. Its diagnosis is difficult and often overlooked, delaying management, with sometimes disastrous consequences. Its incidence is increasing due to the rapid global rise in the number of people with diabetes. Its pathophysiology remains unclear, although the activation of the RANK/RANK-L system appears to be involved, triggered either by neurotraumatic or neurovascular mechanisms, leading to the differentiation of monocytes into osteoclasts. Diagnosis relies on clinical and radiological arguments, particularly MRI. There are different types of Charcot foot depending on the evolution, according to Eichenholtz's classification and based on location according to Sanders and Brodsky's classifications. Treatment involves a multidisciplinary approach with diabetes management and addressing other general complications. Medical treatment is indicated as the first line, with offloading and immobilisation using a 'total contact cast'. In case of failure of this method, or if there is immediate deformity, surgical intervention is indicated, and techniques are evolving rapidly. Depending on the deformity, minimally invasive or arthroscopic procedures may be performed. In cases of significant deformity, foot reconstruction may be proposed, using the so-called 'super construct' technique if necessary. Infection will be treated concurrently or initially, depending on severity. Many complications are reported, but increasingly early and aggressive surgery improves patients' quality of life and reduces amputation rates.