A 78-year-old woman comes to the physician with a red and swollen right foot for the last 2 weeks. She also reports mild pain that is relieved with acetaminophen. There is no associated fever, chills, or morning stiffness. She has not fallen or had trauma to the foot. The patient's other medical problems include coronary artery disease, hypertension, and type 2 diabetes mellitus complicated by peripheral neuropathy and chronic kidney disease. Her medications include aspirin, lisinopril, metoprolol, insulin, and gabapentin.
Vital signs are within normal limits. Her body mass index is 32 kg/m². Examination shows warmth, erythema, and edema to the plantar surface of the right foot. There is a visible collapse of the arch of the right mid-foot. No skin ulcers or sinus tracts are present.
X-ray reveals advanced degenerative changes with dislocation of the mid-foot. Fluid aspiration from the right tarsus shows 200/mm³ red blood cells and 200/mm³ white blood cells (60% neutrophils) . No crystals are seen and the Gram stain is negative.
Which of the following is the most appropriate next step in management?

Question

Quizplus · Accepted Answer

This patient's presentation is consistent with acute diabetic neuropathic arthropathy, known as Charcot joint. Charcot joint is progressive bony and soft-tissue destruction leading to joint dislocation, incapacitating deformities, and instability. It is more common in diabetics likely due to neuropathy and vasculopathy but can occur in other conditions (eg, syphilis, chronic alcoholism). The presentation can mimic inflammatory or septic arthritis, with erythema, warmth, and edema to the foot and ankle. These conditions should be ruled out with joint aspiration and synovial fluid analysis, as in this patient. Acute treatment involves casting and avoiding weight bearing until clinical findings resolve and x-ray findings improve. The cast is usually changed after 1-2 weeks to allow for resolving edema. Patients usually improve after 8 weeks of acute treatment and can progress to partial weight bearing and then full weight bearing by the 4th-5th month. Well-fitting shoes and podiatry referral are essential at this stage to prevent chronic deformities, skin ulceration, and infections. (Choice B) Custom or prefabricated orthotic shoe inserts are often recommended for conditions related to overuse injuries or foot deformities (eg, pes planus). However, they are not first-line intervention for Charcot joint. (Choice C) Avoidance of weight bearing on the affected joint rather than physical therapy is recommended. (Choice D) Sulfasalazine and acetaminophen are warranted for certain inflammatory arthropathies (eg, rheumatoid arthritis) but are not as beneficial for Charcot joint. (Choice E) Surgical intervention is avoided in most patients due to a 27% failure rate. Educational objective: Diabetic neuropathic arthropathy or "Charcot joint" can present acutely with foot or ankle erythema, warmth, and swelling in a diabetic patient, similar to inflammatory or septic arthritis. Joint aspiration and imaging can assist in confirming the diagnosis. Treatment includes casting and avoiding weight bearing. Anti-resorption therapy with bisphosphonates is also useful in some patients. __________ References: The diabetic Charcot foot. (http://www.ncbi.nlm.nih.gov/pubmed/22429012)

A 78-Year-Old Woman Comes to the Physician with a Red