Martin,
I can really only oofer my own experience with mechanical treatment options and
some observations I have made over the years. Sorry, the following isn't
evidence-based, but clearly experience-based.

I have often wondered why so many Charcot feet develop unilaterally. Since the
diabetes is systemic, and the degree of neuropathy clearly bi-lateral, why does
one foot develop the Charcot, but not the other. Clearly there must be a
biomechanical component. I contend that the apparently "natural" limb-length
inequality that nearly all humans have to varying degrees is the likely
culprit. Though we generally adapt wonderfully for this slight (varies from
1/16th to 1/4") discrepency, neuropathy also affets the vibratory response, as
is well documented. The patient responds by increasing impact in order to help
them determine when they've hit the ground. This increased impact will
certainly be greater on the longer limb, and over time, possibly develop a
Charcot breakdown.

Yes, I understand that there is probably no empirical study to support this
theory, but I offer this. Whenever I have applied orthoses or footwear to
diabetics with Charcot feet (and I have done this to many hundreds of patients
over the past twenty years), I have also applied a small lift to the opposite
side, always incorporated into rocker sole modifications. The results are
generally quite dramatic, even in comparison to those instances where I have
applied rocker soles and plastizote inlays without a lift. While nothing will
reverse the degree of breakdown already present, I have seen marked decrease in
further progression of the Charcot development.

Furthermore, I have been applying lifts to those diabetics who have not yet
developed a Charcot joint, but who display assymetric biomechanics. I have
followed a number of these patients through their podiatrists or primary care
physicians for a number of years now, and only one of those patients ever
developed any signs of impending Charcot development. Again, I realize this is
not a scientific study, but I firmly believe that the assymetric biomechanic
component is highly suspect in  cases of Charcot development.

Hope this is, at minimum, provacative, and perhaps, helpful.

Notty Bumbo

Martin Colledge wrote:

> Hi All
>
> I saw a patient yesterday with NIDDM and active Charcot's.
>
> I have no experience in managing the acute stage of this condition.
>
> Diagnosis (June 97) was based on history, appearance, technetium and
> gallium scans and a normal sed rate.
> In discussion with the referring endocrinologist, I learnt that pt was
> originally seen by an orthopedic surgeon who felt inclined to allow the
> natural course follow since there was no history of ulceration associated
> with the bony changes. This seems to be the normal protocol here in
> Winnipeg.
>
> There is considerable visible and radiographic evidence of mid foot
> deformity at this stage - which is certainly not quiescent - so far nothing
> has been done to intervene.
>
> In trying to decide where to go with this I could do with some advice from
> those of you who have experience in this area.  We have a very poorly
> integrated system for managing DM foot in this city and without going into
> the gory details I feel that changes are needed.
>
> The question I need to answer is how are most of good centres around the
> world handling acute Charcot's? and what evidence exists to support their
> methods?
>
> A medline search was fairly unproductive with the exception of
>
> Diabet Med 1997 May;14(5):357-363
> The natural history of acute Charcot's arthropathy in a diabetic foot
> specialty clinic.
> Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR
>
> which states
>
> "Regardless of the specific treatment method instituted, it is imperative
> that appropriate and aggressive treatment be undertaken immediately
> following diagnosis to help prevent progression to a profoundly
> debilitating, limb-threatening deformity".
>
> Is this a widely held and supported view?
>
> What criteria do most centres use when deciding to cast/limit weight
> bearing or otherwise?
>
> Seems to me intuitively reasonable to protect the affected foot from weight
> bearing and potentially deforming stress - however to create new or change
> existing protocols will require more than my concerns.
>
> your help and discussion, as usual, appreciated
>
> cheers
>
>  Martin
>
> ------------------------------------------------------------------------
> ------------------------------
> ------------------------------------------------------------------------
> ----------
> -------------------------------------------------------------------
>
> Martin Colledge  B.Sc.  (Hons)  D.Pod.M.
> The St James Foot Clinic
> 2105 Portage Ave
> Winnipeg
> Manitoba  R3J 0K3
> Canada
>
> Ph      204 837 6965
> Fax     204 774 9918
> Email   [log in to unmask]





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