Asymptomatic Charcot foot in longstanding diabetes

Charcot neuropathic osteoarthropathy complicates an estimated 0.1-7.5% of diabetic patients in general clinic populations, yet misdiagnosis rates remain high - partly because the foot is often warm, swollen, and painless rather than obviously deformed. Undiagnosed cases range from 0.4% to 13% in published series.

To detect preclinical Charcot disease by plain X-ray in longstanding diabetic patients attending routine follow-up, before clinical deformity develops.

Cross-sectional prevalence/screening study, with structured short-term follow-up restricted to X-ray-positive patients, of 60 consecutive adults with type 2 diabetes mellitus (DM) of >10 years duration, seen at Al-Ramadi Teaching Hospitals between September 2023 and March 2024. All underwent bilateral foot X-ray in antero-posterior and oblique views, full clinical and neurological assessment, and laboratory investigations including HbA1c.

Thirty-one patients (51.7%) had X-ray changes fulfilling a pre-specified Charcot pattern - predominantly focal bone demineralization, subchondral fragmentation, and debris formation at articular margins. X-ray positivity correlated significantly with older age (p = 0.024), longer DM duration (p < 0.001), higher HbA1c (p < 0.001), and greater BMI (p < 0.001). Gender and medication type were not significant. At 6-month follow-up, six of the 31 initially positive cases (19.4%) showed radiological progression; all underwent MRI and were offloaded with total contact cast or airwalker. These findings were not adjudicated against MRI or a validated staging system in most cases and represent radiographic suspicion rather than confirmed neuroarthropathy.

Over half of longstanding diabetic patients attending routine follow-up had X-ray changes fulfilling a Charcot pattern, though most were not MRI-confirmed. These findings support further investigation, with MRI-validated confirmation in a larger sample, before systematic plain bilateral foot X-ray screening can be recommended in this population; glycemic optimization and patient education on trauma avoidance remain appropriate in the meantime.