Charcot neuroarthropathy in diabetes mellitus

Charcot neuroarthropathy has been recognised for over 130 years and yet it remains a major cause of morbidity for patients with diabetes mellitus and a continuing challenge for physicians. It is rare but it seems to be increasing in prevalence and this provides hope that with larger studies it will soon be possible to clarify the natural history and optimal treatment regimens. The underlying cause is thought to be trauma in a neuropathic foot that leads to a complex series of pathological processes culminating in bone and joint destruction and subsequent deformity. The acute reaction is often misdiagnosed and many patients present late with established deformity. Even when the diagnosis is considered at an early stage there are no definitive criteria or tests to confirm charcot neuroarthropathy and a high index of suspicion is necessary in any diabetic patient with a swollen warm foot in the presence of somatic or autonomic neuropathy. Treatment has traditionally involved the use of various methods to avoid weight bearing but recent work has begun to suggest that bisphosphonates might be able to arrest the acute process. In the long term, treatment involves a multidisciplinary approach aimed at providing appropriate footwear to reduce plantar pressures and avoid foot ulceration; in some circumstances this involves surgical correction of deformities before adequate footwear can be supplied. Further studies of the emerging treatments for Charcot neuroarthropathy are needed to provide long-term outcome data on morbidity and deformity.