FOOT ULCERS AND THEIR IMPACT ON DIABETIC CHARCOT FOOT

Image Credit: ndiabeticfoot.org 

“The secret of health for both mind and body is not to mourn for the past, not to worry about the future, or not to anticipate troubles, but to live in the present moment wisely and earnestly.”- Buddha

What is a Foot Ulcer? 

Foot ulcers occur when there’s a deep sore that develops on the foot. With careful care, the condition can be treated and healed, and in the adverse condition it becomes infected. The conditions that induce foot ulcers include cuts from external sources, or even from an abrasive shoe. Foot ulcers are common in diabetics, and if they are not carefully monitored, they can degenerate into adverse conditions that may require either surgery or amputation. 

What is Charcot Foot? 

Charcot Foot is a severe complication of diabetes that ultimately results in the weakening of bones, joints and tissues in the foot and ankle regions. The condition is a downstream effect of the presence of peripheral neuropathy, that causes the patient to lose their ability to feel pain. This condition is classified as an insensate condition. The nervous system is the means via which we are able to sense and feel the environment. Without this capability, patients often experience injuries such as cuts, and are unaware of them unless they take the time to actually inspect their feet on a daily basis. 

As Charcot foot progresses, there is an associated weakening of the bones that causes fractures and joint dislocation. As the joint collapses, there is an eventual deformity of the foot that results from the inability of the joint system to sustain itself. The eventual appearance is a rocker-bottom appearance. Under such conditions, foot ulcers are able to develop. With open sores on the feet, there is also the possibility of bone infections, as bacteria can travel from the skin into the bone structure. 

Charcot foot is one of those conditions that can be mistakenly diagnosed, because it is often the result of some underlying condition such as diabetes. As diabetes is on the rise, the occurrences of Charcot foot are expected to increase in a linear fashion. For this reason, diabetics need to be aware of the fact that they can develop this condition, and take the necessary precautions and care to ensure that their systems are kept under control. Visits to specialists like vascular surgeons and podiatrists will ensure that the adequate foot health is being maintained. 

Causes and Clinical Course

Charcot foot is defined as a neuropathy induced condition which results in the weakening of the ankle joint, and ultimately the flattening of the feet. Neuropathy patients often can’t feel their extremities due to nerve damage, and ultimately end up deforming the foot as the joint collapses. This condition is quite serious, and several treatments have been proposed, that facilitate the restoration of balance in the body. 

Additionally, Charcot foot can develop as a downstream effect of an untreated injury. As a condition that results in the weakening of the ankle joint, if a patient continues to operate with the ankle as it is, the joint will eventually degenerate. As the structure weakens, the joint weakness and subsequent bone loss will result in the collapse of the foot. 

If the foot degeneration is in the middle region of the foot, there will be the formation of the rocker bottom that is associated with Charcot foot. The ankle will eventually become unstable. With Charcot foot, if there are any sharp edges of bone pressure can be placed on the skin from the inside out, and as a result they will ultimately cause the formation of chronic skin sores. If left untreated, these sores can cause foot ulcers, which can be detrimental to the health of the patient. 

Patients should take the time to actually check their feet for indications of any abnormality. This can include changes in the temperature of the feet, redness and swelling, or any occasional soreness that appears to be chronic. 

Diagnosis

The best way to ensure that Charcot foot is diagnosed, is to ensure that the appropriate tests are taken by an Orthopaedic surgeon. The key to ensuring that the foot integrity is maintained, is to ensure that early detection is incorporated into the treatment process. Via medical tests and the utilization of imaging technologies such as X-rays, the appropriate analyses will be done in order to assess the internal condition of the feet. 

Non-Surgical Treatment

Traditional non-surgical treatment of Charcot foot includes immobilization, the utilization of custom shoes and braces, and modification of patient activity. With time, treatments evolve, and Charcot foot treatments have been coupled with bone regeneration and repair treatments via the use of Mesenchymal Stem Cells (MSC). Stem cell therapy is an evolving phenomenon, which is having widespread applications in medical therapy, and orthopaedics is not exempt.

The beauty of the MSC’s is their ability to differentiate into the relevant cells needed for healing the ankle site, once they are introduced. The MSCs evolve into osteoblasts, and are critical to the restoration. In situations where the bone tissue is significantly reduced for various reasons, the MSC have proven to be quite effective in their restoration of the ankle site. The complications that diabetes-induced Charcot foot inherently carries are overcome by the ability of the MSCs to suit their current environment and adapt to the needs of the body as it heals. 

Scientific studies have identified the benefits gained by diabetic Charcot foot patients who coupled reconstructive surgery with MSC grafting. The studies identified accelerated healing of up to approximately 60% improvement compared to patients who were not treated with MSC treatments. As science and technology advances, the utilization of stem cell treatments in the treatment of Charcot foot is proving to be an effective therapy that is expecting to improve with time. In the treatment process, a scaffold is inserted into the healing site, which houses the MSC, and facilitates the generation of the ideal healing attributes for bone regeneration. These are identified as: osteoinductive, osteoconductive, and osteogenic. As treatments advance, you can generate a brand new you in your quest for healing. 

Surgery

In those instances where surgical methods are utilized for treatment of the Charcot foot condition, there are a variety of surgical treatments that may be applied to the patient, according to their case. These treatment options include: 

  1. Realignment Osteomy and Fusion
  2. Ostectomy 

The first treatment is a corrective mechanism that treats the joint and stabilizes it, while the latter treatment is a procedure that aims to adjust the bone structure. Via removing any sharp internal protrusions, the occurrence of ulcers is reduced dramatically. 

Preventive Care

The treatment of Charcot foot is directly linked to the treatment of diabetes. By maintaining a good diet and an exercise regime, it will be possible to keep the condition at bay. Via the diet and prescribed medications, it will be important for a patient to ensure that their blood sugar levels are being kept under control. On a daily basis it will be important to ensure that you are inspecting your feet. Take the time to ensure that you’re getting your regular check ups from a foot and ankle surgeon. 

CONCLUSIONS

As a progressive degenerative arthropathic condition, the formation of Diabetic Charcot foot is one that is induced by microtraumatic conditions. As a condition that can present itself as an acute or chronic case, the treatments will vary according to the diagnosis. Careful diagnosis will be important, because Charcot Foot is often diagnosed as alternate conditions such as osteomyelitis and cellulitis. The presence of the foot ulcers is what often leads to the initial conclusion that the condition is either osteomyelitis or cellulitis. At the primary care level, it will be important for doctors to ensure that diabetic patient cases are escalated to alternate specialists for second opinions in the determination of a final diagnosis. 

With Diabetic Charcot foot resulting in what are diagnosed as gross structural deformities of the foot and ankle inclusive of ulceration and amputation, careful management will be important for the condition to be treated adequately. With foot ulcers identified as one of the most common complications for patients with Diabetic Charcot Foot, the link between their presence and worst case scenarios such as amputations are also linked to this initial root cause. Careful treatment of the baseline health, will be key to ensuring that the adverse cases inclusive of surgery and amputation are avoided. 

References: 

  1. University of California: https://limbpreservation.ucsf.edu/conditions–procedures/charcot-foot.aspx
  2. Foot Ulcers And Diabetic Charcot Foot: https://www.researchgate.net/publication/339009618_Foot_ulcers_and_their_association_with_diabetic_Charcot_foot_complications

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Dr. Gordon Slater

Dr. Slater is one of the first foot and ankle surgeons in Australia to adopt minimally invasive surgical techniques. He routinely uses MIS to treat a range of conditions, including bunions.

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Dr Gordon Slater is a highly-skilled surgeon specialising in foot and ankle conditions and sports injuries. Dr Slater is one of the first foot and ankle surgeons in Australia to adopt minimally invasive surgical techniques. He routinely uses MIS to treat a range of conditions, including bunions. MIS  has many advantages including shorter operating times, reduced post-operative pain, reduced risk of infection, minimal scarring and better cosmetic outcomes.

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