The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture

Abstract

At the onset of acute diabetic Charcot foot, therapeutic intervention may be delayed because plain X-rays may not show fractures. To assess the clinical course of acute Charcot foot in 24 patients without evidence of definite fractures on the first X-ray after onset of symptoms, who were referred to the foot clinic for diagnosis and treatment either early or delayed, i.e. before or after definite fractures were detectable on repeat X-rays. Eleven patients were referred early (incipient Charcot foot, case group), and 13 patients were referred delayed (overt Charcot foot, control group). In the foot clinic, both groups were immediately treated with off-loading and total contact casting. After the healing process of the Charcot foot was complete, the extent of fractures and subsequent deformities were evaluated. Based on X-rays at the onset of symptoms, in 19 of the 24 patients the condition had been misdiagnosed prior to referral (in 11 patients as sprain injury). Additional imaging techniques (MRI, CT scan or bone scintigraphy) had been performed in 10 patients prior to referral. While these techniques had been used more frequently in the cases vs. the controls (P=0.012), misdiagnosis was less frequent in the cases vs. the controls (P=0.013). Only one out of 11 case patients developed extended foot fractures and severe deformity, vs. 12 out of 13 control patients (P<0.001). Early detection of incipient Charcot foot is facilitated by imaging techniques other than plain X-rays. Immediate off-loading of incipient Charcot foot appears to minimize fractures and incapacitating deformities.