Charcot Foot: Clinical Clues, Diagnostic Strategies, and Treatment Principles.

Acute Charcot neuroarthropathy of the foot and ankle is often difficult to diagnose because of limited findings in the patient history, physical examination, imaging, and laboratory studies. Delay in treatment results in the development of rigid foot and ankle deformities, increasing the risk of ulceration, infection, and major lower extremity amputation. Acute Charcot neuroarthropathy should be suspected in any patient 40 years or older with obesity and peripheral neuropathy who presents with an acutely swollen foot following minimal or no recalled trauma and who reports minimal to no pain, particularly if radiography and laboratory markers of infection are normal. Magnetic resonance imaging or computed tomography should be performed in these cases. If changes consistent with acute Charcot neuroarthropathy are observed, prompt immobilization and/or referral to a foot and ankle subspecialist is needed to minimize sequelae. Immobilization should continue until lower extremity edema and warmth resolve, and serial radiography shows evidence of osseous consolidation. Intranasal calcitonin salmon may have a role as adjunctive therapy. Although controversial, surgery may be indicated if there is severe dislocation or instability, concern for skin breakdown, or failure of conservative treatment to obtain a stable, plantigrade foot.

The Ability of Fluorescence Angiography to Detect Local Ischemia in Patients With Heel Ulceration.

Heel ulcerations are a significant burden of care in both hospital and long-term care settings. The presence of peripheral arterial disease as a contributing factor to delayed healing is often not recognized, resulting in prolonged healing and high patient morbidity and mortality. Formal vascular evaluation and intervention is often not performed as these patients can have palpable pedal pulses while having localized ischemia of the heel. As routine noninvasive vascular studies can be affected by medial calcinosis and collateralization and do not specifically assess tissue perfusion to the heel, a false sense of security of adequate perfusion for healing can result. Indocyanine green fluorescence angiography (ICGFA) allows for real-time visualization and objective assessment of site specific tissue perfusion not limited by the factors that can make routine noninvasive vascular studies unreliable or unobtainable. A retrospective medical record review of a subset of patients with chronic heel ulceration from a prospective institutional review board-approved study in which serial ICGFA was performed during their treatment course was performed. ICGFA was able to identify local heel ischemia and expedite vascular intervention. ICGFA should be considered as an additional vascular study in patients presenting with chronic, nonhealing heel ulcerations. LEVELS OF EVIDENCE: Level IV: Diagnostic, Case series.