Ambulatory treatment of Charcot arthropathy – total contact casting.
I work in a rural, hospital-based practice that is a regional referral center. Much of the care I provide is related to diabetes. Subsequently, I see and treat a lot of Charcot joints. Charcot arthropathy occurs in patients who have lost sensation in their feet. Charcot arthropathy often results in collapse of the arch and chronic wounds of the plantar foot secondary to a problem called a rocker bottom flat foot.
Stages of Charcot arthropathy
Charcot arthropathy is typically classified into four stages (Eichenholzt Classification) (1).
Warmth to touch, no deformation of arch
Warmth to touch, early signs of change on x-ray, edema
Collapse of the arch, increased edema
Consolidation of collapse and remodeling
Diagnosis of Charcot arthropathy in stage 0 requires a high degree of clinical suspicion due to lack of overt signs on x-ray.
I saw a patient this month with a Brodsky type 2 (subtalar joint) Charcot joint (1). She lives alone and has been treated successfully for a Brodsky type 1 Charcot joint. With this new onset, aggressive treatment is required to arrest the process of the Charcot joint. So I placed her in a non-weight bearing cast. And just by chance, I watched her walk out of clinic on the ‘non-weight bearing’ cast. She ended up in our emergency department in the next week with wounds on the shin.
I had to come up with a compromise, something that would allow light weight-bearing but in a protected environment. I chose total contact casting (TCC). We use total contact cast as a method of off-loading until we can get our patient into a TORCH boot. A TORCH boot is an off-loading boot used to treat deformities such as Charcot arthropathy.
What is a total contact cast?
The images below show the stages used to apply a TCC. You’ll notice plenty of padding to protect the shin and ankle bones. Once padded, the final application (with the green and red stripe) is a semi-hard cast. This cast is then placed in a walker.
Why use a total contact cast?
Total contact casting is typically used for diabetic foot ulcerations of the plantar foot. In this case, we were trying to create a compromise. We were trying to allow for limited ambulation for a patient who lives alone and needs to complete a certain degree of activities of daily living. Luckily we were right in our choice. This patient has done well with good resolution of her Charcot joint.