Orthotist urges early intervention for Charcot foot

Marc Tessier, an orthotist and prosthetist, practices at the Nipissing Orthopaedic Laboratory in North Bay. He’s pictured here at his work bench with a Charcot restraint orthortic walker and an air cast walker.

Condition often results in amputation

Marc Tessier, an orthotist and prosthetist practicing in North Bay, is on a mission to educate family doctors about the importance of early diagnosis of Charcot foot, one of the most devastating complications of diabetes.

Charcot foot is characterized by fractures and dislocations that result in profound shape changes and loss of weight bearing capacity.

“The foot just collapses on itself,” said Tessier. A consequence of bone resorption, a process by which bone is broken down and weakened, Charcot foot often goes unnoticed because of a loss of protective sensation, or neuropathy, another consequence of diabetes.

Failure to treat the condition in its earliest stages often results in amputation. “I used to see Charcot foot once every three months in the 90s,” said Tessier. “Now, I see it weekly, if not two or three times a week.”

Charcot foot arthropathy is said to affect eight per cent of the diabetic population, but the number is probably higher due to misdiagnosis, claims Tessier. Family physicians and orthotists need to have a high degree of suspicion when seeing patients who have had diabetes for 10, 15 or 20 years and present with a red, inflamed or swollen foot, he advises.

Forty to 50 per cent of longstanding diabetics have a loss of protective sensation in their feet and may not be aware of a fracture or dislocation.

A non-diabetic who fractures or dislocates a bone will keel over in pain, but someone with Charcot foot has such advanced diabetes that they can’t feel it, so it’s often unreported and misdiagnosed, he explained.

A definitive diagnosis can be made with lab tests and imaging.

“Our default position should be ultracautious when we suspect Charcot until it is ruled out completely,” counsels Tessier. “Immobilization stops the deformity from progressing. You have to lock the foot up immediately with a total contact cast or an air cast walker, often for as long as 24 months.

“As soon as you immobilize a Charcot joint, you tend to lose a lot of the swelling because the strain is taken off the joint, so the (the device) is always changing. You make a $3,200 Charcot restraint orthotic walker, or CROW and then you have to change it, so you have to warranty the fit. Sometimes, you make it just right and the patient can stay in the device for years. Sometimes, they never progress and they have to wear the CROW for the rest of their lives.

“Once the joint calms down, you can go to an ankle foot orthotic in a custom-made shoe or, if there’s minimal deformity, a well-made foot orthotic in an orthopedic shoe,” added Tessier. “If caught early, the patient will get through the episode, the foot will calm down and they can come out of it unscathed. They should wear orthopedic footwear and foot orthotics for the rest of their life – indoors and outdoors – but that’s a very small price to pay.”

Compliance is critical, advise Tessier and colleague, Patrick Reilly, in a cowritten article in Alignment, a journal of the Canadian Association for Prosthetics and Orthotics.

“Patients need to understand that they must be extremely cautious about weight bearing. The absence of pain may incorrectly lead patients to believe that they can take a few unprotected steps. Education regarding peripheral neuropathy is essential. We recommend very direct language when explaining the importance of protected weight bearing.”

Patients, according to the two orthotists, should be told ‘the foot never touches the ground without the cast walker…EVER,’ or ‘don your device whenever you are not in bed, without exception.”

Education should begin as soon as a patient is diagnosed with diabetes, advises Tessier.

“Go to a diabetes clinic as soon as you’re diagnosed, even if you don’t have an ulcer or a loss of protective sensation. Just go and get educated, and check your feet daily.”

Early diagnosis and education can reduce the number of amputations, which are extremely costly and devastating for patients, many of whom are never fitted with a prosthetic device, he notes.

Tessier lived in Wawa and Hearst before moving to North Bay for his final two years of high school and trained in orthotics and prosthetics at George Brown College in Toronto. He did a twoyear residency in orthotics and a further two years in prosthetics before landing a job in Montreal, and returned to North Bay in 1988.

He currently looks after patients in North Bay, Timmins and New Liskeard. The Canadian Association for Prosthetics and Orthotics lists eight members in Northern Ontario – four in Sudbury and two each in North Bay and Thunder Bay.



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