The basic principles of nonsurgical management for

Charcot's joint include early recognition, immediate and

adequate immobilization with protected weight-bearing,
and vigilant use of therapeutic footwear to prevent or
limit permanent foot deformity, subsequent disability,
and potential lower extremity amputation [19]. The mostimportant
management during the acute phase is immobilization
and off-loading with a total-contact cast, and
the treatment should be continued with signs of local
inflammation until radiographic evidence of consolidation
of the osteoarticular fractures and dislocations. And
then, patients need partial weight-bearing in a walking
brace to prevent a new attack [2,11,20,21]. In a doubleblind
randomized controlled trial, the bisphosphonate,
pamidronate, was given as a single dose of 90 mg
intravenously. It reduced bone turnover and improved
symptoms and disease activity in diabetic patients with
active Charcot's foot [22]. But the long-term benefits of
this approach needs further study. Surgical intervention
should be performed to manage chronic ulcers or correct
the deformed bones.

CN may be defined as a medical emergency,

since failure to act quickly can lead to
irreversible consequences.70 Once established,
surgery may be necessary to remove bone
deformities and reduce disability. Techniques
include arthrodesis, exostectomies,
reconstruction and Achilles tendon
lengthening.58 Two studies investigating any
benefits of ultrasound are limited by small

samples and produced conflicting results.71,72

Given the non-specific nature of early
presentation, it may be appropriate to treat the
diabetic patient presenting with a warm swollen
foot with antibiotics if an infection cannot be
excluded.73

Examen mdico
Antecedentes mdicos y examen fsico
Su mdico hablar con usted de su salud general y tambin de cualquier sntoma que usted pueda tener. Si
usted sabe cmo pudo lesionarse el pie, su mdico tambin querr discutir eso.
Despus de discutir sus antecedentes mdicos y sntomas, el mdico examinar cuidadosamente su pie.

Estudios con imgenes

Radiografas (rayos X). Estos estudios con imgenes proporcionan figuras detalladas de las estructuras
densas, como el hueso. En la etapa muy temprana de Charcot, las radiografas pueden dar imgenes
normales. Si la condicin ha avanzado a las etapas intermedias, podran verse mltiples fracturas y
dislocaciones de las articulaciones en una radiografa.
Resonancia Magntica (MRI) y ecografa. Estos estudios pueden crear mejores imgenes de tejidos
blandos del pie y del tobillo. Podran ser indicados si su mdico sospecha una infeccin del hueso. Si no hay
una ruptura en la piel, la infeccin del hueso es sumamente rara.
Tomografa sea/ tomografa con radiofrmaco indio. Una tomografa sea es un examen de medicina
nuclear muy efectivo para determinar si hay una infeccin del hueso. Hay diferentes tipos de tomografas
seas y el mdico debe determinar qu tipo(s) es(son) el(los) mejor(es) para usar en un problema especfico.
Una tomografa con el radiofrmaco indio es un examen especializado que implica la colocacin de un
marcador en los glbulos blancos. Estas clulas se trazan para saber si estn yendo hacia el hueso a
combatir una infeccin.
El pie de Charcot y la infeccin del hueso darn una tomografa sea positiva (actividad aumentada). Sin
embargo, solo una infeccin mostrar actividad significativamente aumentada en la tomografa con indio.
Top of page

El objetivo del tratamiento para la artropata de Charcot es soldar los huesos fracturados, y tambin prevenir
ms deformidad y destruccin del hueso.

Tratamiento no quirrgico
Enyesado. Las etapas iniciales de Charcot por lo general se tratan con un enyesado o bota de yeso para
proteger al pie y al tobillo. El uso de un enyesado es muy efectivo para reducir la inflamacin y proteger a los
huesos.

El enyesado requiere que el paciente no se apoye poniendo peso en el pie hasta que los huesos comiencen a
unirse. Por lo general son necesarias muletas, un andador con apoyo para rodilla o una silla de ruedas. La
unin a veces puede llevar 3 meses o ms. El enyesado por lo general se cambiar todas las semanas o cada
dos semanas para asegurar que siga "calzando" en la pierna a medida que la hinchazn cede.
Zapatos especiales. Despus que la hinchazn inicial ha cedido y los huesos comienzan a unirse, podran
recomendarse una bota hecha a medida y especializada para caminar o un zapato para diabtico. Este
zapato especializado est diseado para reducir el riesgo de lceras (llagas que no cicatrizan). Algunos
diabticos no pueden usar zapatos comunes en el mercado porque no se adaptan correctamente al pie
deformado.

Tratamiento quirrgico
Podra recomendarse la ciruga si la deformidad del pie implica un mayor riesgo de lceras para el paciente, o
si el calzado protector no es efectivo. Las fracturas inestables y las dislocaciones tambin requieren ciruga
para soldar.

Deformidad leve con constriccin en el taln. En algunos casos, la deformidad es leve y est
asociada con constriccin en la parte posterior del taln. Las lceras en la parte delantera del pie,
que no responden a un perodo de enyesado y calzado protector, podran ser tratadas con
alargamiento del tendn de Aquiles. Alargar quirrgicamente el tendn que corre a lo largo de la
parte posterior de la pierna y se une detrs del taln reduce la presin en la parte media y frontal del
pie. Esto permite que la lcera cicatrice y reduce la probabilidad de que regrese.

Prominencia sea en la base del pie. Una deformidad ms severa es un bulto grande de hueso en
la base del pie. Si esto no puede resolverse con modificacin del zapato, se requiere ciruga. El tipo
de ciruga depende de la estabilidad de los huesos y articulaciones en el pie.

Deformidad estable. La ciruga implica una simple remocin del hueso prominente, que se recorta.

Deformidad inestable. Cuando los huesos estn demasiado laxos en el lugar de la prominencia,
una simple remocin del bulto no ser efectiva. Los huesos laxos sencillamente se movern y se
desarrollar una nueva prominencia. En esta situacin, son necesarias la fusin y el
reposicionamiento de los huesos.

Las fracturas que ocurren en el hueso ms blando de los diabticos tpicamente son ms complejas. Las
operaciones para fijarlas involucran generalmente ms soporte (placas y tornillos) que lo que normalmente se
requerira en personas sin diabetes. Los tornillos y las placas pueden incluso colocarse cruzando las
articulaciones normales para agregar estabilidad

DIAGNOSIS
The initial manifestations of the Charcot foot are frequently mild in
nature, but can become much more pronounced with unperceived
repetitive trauma. Diagnostic clinical findings include components of
neurological,
vascular,
musculoskeletal,
and
radiographic

abnormalities. There have been no reported cases of CN developing in

the absence of neuropathy. Accordingly, peripheral sensory neuropathy
associated with reduced sensation of pain is the essential predisposing
condition that permits the development of the arthropathy (1619).
Because of the very presence of insensitivity, a personal history
concerning antecedent trauma is often unreliable (18,20,21). Typical
clinical findings include a markedly swollen, warm, and often
erythematous foot with only mild to modest pain or discomfort (16,18
20,22). Acute local inflammation is often the earliest sign of underlying
bone and joint injury (23). This initial clinical picture resembles
cellulitis, deep vein thrombosis, or acute gout and can be misdiagnosed
as such. There is most often a temperature differential between the two
feet of several degrees (20,24). The affected population typically has
well preserved or even exaggerated arterial blood flow in the foot. Pedal
pulses are characteristically bounding unless obscured by concurrent
edema. Patients with chronic deformities, however, can develop
subsequent limb-threatening ischemia. Musculoskeletal deformity can
be very slight or grossly evident most often due to the chronicity of the
problem and the anatomical site of involvement (16,17,19,25). The
classic rocker-bottom foot, with or without plantar ulceration,
represents a severe chronic deformity typical for this condition
(16,26,27). Radiographic and other imaging modalities can detect
subtle changes consistent with active CN.

Imaging of the Charcot foot

Radiographs are the primary initial imaging method for evaluation of
the foot in diabetic patients. Easily available and inexpensive, they
provide information on bone structure, alignment, and mineralization.
X-rays may be normal or show subtle fractures and dislocations or later
show more overt fractures and subluxations. In later stages, the
calcaneal inclination angle is reduced and the talo-first metatarsal
angle is broken (Fig. 2). Medial calcification of the arteries is present in
most Charcot feet and is a frequent secondary finding on radiographs

(25). However, radiographic changes of CN are typically delayed and

have low sensitivity (28).

Magnetic resonance imaging (MRI) allows detection of subtle changes

in the early stages of active CN when X-rays could still be normal. MRI
primarily images protons in fat and water and can depict anatomy and
pathology in both soft tissue and bone in great detail. Because of its
unique capability of differentiating tissues with high detail, MRI has a
high sensitivity and specificity for osteomyelitis and has become the
test of choice for evaluation of the complicated foot in diabetic patients
(29). Although not required for diagnosis when X-rays are diagnostic
for Charcot bone and joint changes, MRI is very useful in making the
diagnosis at its earliest onset before such changes become evident on
plain films.
Nuclear medicine includes a number of exams based on the use of
radioisotopic tracers. Three-phase bone scans, based on technetium99m (99mTc), are highly sensitive for active bone pathology. However,
diminished circulation can result in false-negative exams and, perhaps
more importantly, uptake is not specific for osteoarthropathy. Labeled
white blood cell scanning (using 111In or 99mTc) provides improved
specificity for infection in the setting of neuropathic bone changes (30),
but it can be difficult to differentiate soft tissue from bone. Therefore,
this exam can be combined with a three-phase bone scan or sulfur
colloid marrow exam when superimposed osteomyelitis is suspected
(31). More recently, positron emission tomography scanning has been
recognized as having potential for diagnosis of infection and
differentiating the Charcot foot from osteomyelitis (32,33). However,
this remains investigational at this time.
Evaluation of bone density may be useful in those with diabetes to
assess onset of CN as well as fracture risk. BMD can be assessed using
dual-energy X-ray absorptiometry or calcaneal ultrasound. BMD has
been related to the pathological pattern of CN, whereby joint
dislocation is more prevalent in those with normal mineralization
versus fracture in those with diminished BMD (11).
Experts agree that radiographs are important as the first exam in
virtually all settings (33,34). However, a negative result obviously
should not offer any confidence regarding lack of disease. In a patient
with low clinical suspicion of osteomyelitis and no sign of CN on

radiographs, either three-phase bone scan or noncontrast MRI is very

effective at excluding osseous disease. If the patient has an ulceration
with a high likelihood of deep infection, MRI is the best diagnostic
modality. Nonetheless, one test may not be adequate for full
evaluation. In this setting where MRI diagnosis is indeterminate, a
subsequent labeled white blood cell scan can provide more specificity
and should be correlated with clinical findings. The decision of nuclear
imaging versus MRI is largely based on personal preference,
availability, and local experience. In general, if metal is present in the
foot, nuclear medicine exams are preferred, whereas diffuse or regional
ischemia makes MRI the preferred exam.

Bibliografa .
http://orthoinfo.aaos.org/topic.cfm?topic=A00683
http://care.diabetesjournals.org/content/34/9/2123.full
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3837304/