ARTICLE IN PRESS

The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■

Contents lists available at ScienceDirect

The Journal of Foot & Ankle Surgery

j o u r n a l h o m e p a g e : w w w. j f a s . o r g

Original Research

High Incidence of Recurrent Ulceration and Major Amputations

Associated With Charcot Foot
Fredrik A. Nilsen, MD 1, Marius Molund, MD 1, Kjetil H. Hvaal, MD, PhD 2
1Surgeon,Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Østfold Hospital, Grålum, Norway
2
Surgeon, Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 4 Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evalu-
ated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable
Keywords:
Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for
amputation
complication Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had
conservative treatment developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major
diabetes mellitus amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all sub-
foot ulcer components were found. The major amputation rate was significantly greater for hindfoot than for midfoot
weightbearing manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifes-
tation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint
orthotic walker as treatment of Charcot foot was not supported by the results from the present study.
© 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.

Charcot foot, also known as Charcot neuroarthropathy (CN), is a
condition that can be caused by different diseases that resulted in pe-
ripheral neuropathy. At present, the most common disease associated
with Charcot foot is diabetes mellitus, with a prevalence of 0.08% to
7.5% (1). The prevalence of diabetes mellitus is increasing world-
wide; thus, the associated end-stage complications are also increasing
(2). To a great degree, CN is a condition that affects the bone, joints,
and soft tissue of the foot and ankle. The risk of diabetic foot ulcer-
ation (DFU) and lower extremity amputation (LEA) increases if the
midfoot collapses and the patient develops plantar bony promi-
nences (a rocker bottom foot) before the Charcot foot consolidates (3).
The first option for treatment of this disorder is casting or orthotic
use, with the aim of preserving the normal foot architecture. Surgery
is an option for correcting the deformity after consolidation, al-
though some investigators have advocated surgery for the early stages
of the disease (4,5). Anatomically, CN can affect the midfoot, hindfoot,
and calcaneus and/or the ankle, and the most commonly used ana-
tomic classification is that described by Brodsky (6). The long-term
outcome after CN has been described as leaving the patient with
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Fredrik A. Nilsen, MD, Section for Foot and Ankle
Surgery, Department of Orthopaedic Surgery, Østfold Hospital, PB 300, Grålum 1714,
Norway.
E-mail address: drfreanil1@me.com (F.A. Nilsen).
reduced function and a high-risk of developing DFUs of the foot, with
a large proportion of patients requiring secondary surgery (7).
We investigated the outcomes of patients treated with early
weightbearing in off-loading devices, initially a total contact cast (TCC)
until a removable Charcot restraint orthotic walker (CROW) could be
produced. The primary aim of the present retrospective cohort study
was to evaluate the long-term clinical outcomes associated with Charcot
foot stratified by the Brodsky classification and the occurrence of DFUs
and LEAs.
Patients and Methods
The primary aim of the present study was to evaluate the long-term outcomes of
Charcot foot after early weightbearing in a CROW as determined by the occurrence of
DFUs and LEAs. The secondary aims included determination of the outcomes using the
American Orthopaedic Foot and Ankle Society (AOFAS) midfoot (for midfoot manifes-
tations) and hindfoot-ankle (for hindfoot manifestations) scales (8,9) and the Short Form
36-item (SF-36) questionnaire (10,11) scores. Our regional ethics board approved the
present study. All of us contributed in regard to participant recruitment, data abstrac-
tion, outcomes assessments, and statistical analyses.
Our institution has consistently used the same manufacturer (Ryen Ortopediteknikk
A/S, Oslo, Norway) for the CROW offloading devices we used for the patients in the
present investigation during the 11-year, 3-month period from January 2003 through
March 2014. We used these records to cross-check all the patients with data included
in our institution’s electronic patient records (DIPS AS, PB1435, 8037 Bodø), search-
ing for patients with the Charcot foot diagnosis (International Classification of Diseases,
10th edition, World Health Organization, codes M14.2 and M14.6) treated at our di-
abetic foot outpatient clinic. All patient records were individually reviewed to ascertain
that only patients treated for Charcot foot were included, excluding all other indica-
tions for using a CROW for offloading the foot. Charcot foot was diagnosed in all patients

1067-2516/$ - see front matter © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2017.10.008
 ARTICLE IN PRESS
2 F.A. Nilsen et al. / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
Fig. Flowchart for inclusion of the study population. LTF, lost to follow-up.
using the patient history, clinical examination findings, and plain radiographs, after ex-
cluding infection in the clinical evaluation. In some cases, Charcot foot was diagnosed
after magnetic resonance imaging scans were reviewed. The medical records of all the
patients with a confirmed diagnosis of Charcot foot were followed forward to identi-
fy the incidence of DFU and/or LEA. Amputations were categorized as major if at or
above the ankle, intermediate if transmetatarsal to, but not including, the ankle joint,
and minor if a single or multiple toe amputation. Multiple episodes of DFUs in a patient
were counted as 1 episode per foot. Similarly, for patients who had undergone mul-
tiple amputations of the same extremity, the most proximal amputation level was
counted. Patients who had developed a DFU and had undergone LEA, 1 episode for each
category was counted.
All the patients in the present study had a diagnosis of Charcot foot, after which
they were treated with offloading, initially in a TCC and, as soon as possible, a remov-
able CROW, and allowed weightbearing as tolerated. Typically, the interval until the
CROW was used was ~2 weeks. After consolidation of the disease and classification of
the CN as Eichenholtz stage 3 (12), the stage at which the Charcot process becoming
quiescent, all the patients were referred for fabrication of accommodative footwear and/
or custom-molded foot orthoses for ongoing use. Patients who, on presentation, had
a DFU or infection were treated with serial debridement and antibiotics, as needed.
Of 71 potentially eligible patients, 67 (94.4%) met our inclusion criteria and were
included in our analyses. Of these 67 patients, 5 (7.5%) were lost to follow-up, for ap-
parently random reasons. Therefore, a total of 62 patients (74 feet) were included in
the present study. By spring 2015, 12 patients (19.4%) had died, and 14 patients (18.9%)
had undergone a transmetatarsal or more proximal amputation.
The purpose of the clinical follow-up in the present study was to measure the AOFAS
hindfoot-ankle scale and SF-36 questionnaire scores. Thus, the remaining 36 patients
(53.7%) were contacted by mail and asked to attend the outpatient clinic for a study-
related follow-up examination. Of these patients, 24 (35.8%) accepted the invitation,
and 4 (6%) were available for a telephone interview. Therefore, 28 patients (41.8%) com-
pleted the SF-36 questionnaire, and 24 (35.8%) were evaluated using the AOFAS scale
corresponding to the anatomic site of the Charcot changes (midfoot or hindfoot). The
Fig. depicts the patient flow in the present investigation. The feet that developed DFUs
and those that had undergone LEAs were stratified using the Brodsky classification.
Statistical analyses were performed using the Statistical Package for Social Sci-
ences software, version 21.0 for Windows (IBM Corp., Armonk, NY). A comparison of
the binary data for the incidence of DFUs and LEAs stratified by Brodsky type was com-
puted using the χ2 test. Differences were considered statistically significant at the 5%
(p ≤ .05) level. For comparison of the SF-36 component scores between the study pop-
Table 1
Statistical description of affected feet (N = 74 in 62 patients)
Anatomic Site Brodsky 1 Brodsky 2
Affected feet (N = 74) 44 (59.5) 18 (24.3)
Patients (n = 62) 38 (61.3) 15 (24.2)
DFU 28 (63.6) 12 (66.7)
Minor amputation 4 (9.1) 0 1 (14.3)
Intermediate amputation 3 (6.8) 0 0
Major amputation 1 (2.3) 6 (33.3)
AOFAS midfoot/hindfoot score 62.5 (n = 15) 49.5 (n = 5)
Data presented as n (%).
Total patient number, 62; however, 2 patients had bilateral manifestations with different Brodsky types; mean age 55.2 ± 11.4 years; 32 males, 30 females; 50 unilateral, 12 bi-
lateral; mean follow-up, 8.9 (range 2 to 16) years; 10 patients had a bilateral manifestation of the same Brodsky type; Medical Outcomes Study short-form, 36-item questionnaire
scores: physical functioning, 57.4; physical role; bodily pain, 58.1; general health, 54.0; vitality, 53.2; social functioning, ; emotional role, 61.3; mental health, 73.3.
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society scale (score for each Brodsky type); DFU, diabetic foot ulceration; NA, not available.
Table 2
Statistical comparison of incidence of diabetic foot ulcerations and lower extremity
amputations between midfoot and hindfoot Charcot
Variable Brodsky Type 1 Brodsky Types 2 + 3A
DFUs* (n) 28 17
LEAs* (n) 1 10
Abbreviations: DFUs, diabetic foot ulcerations; LEA, lower extremity amputations.
* Comparison of DFUs between Brodsky type 1 and Brodsky types 2 and 3A, p = .71;
comparison of LEAs between Brodsky type 1 and Brodsky types 2 and 3A, p < .01.
ulation and the normative values for the Norwegian population (11), a 1-sample t test
was used.
Results
The mean age at the first identification of the diagnosis of Charcot
foot was 55.2 (range 26 to 76) years. All the patients included in the
present study had >2 years of follow-up data available. The mean
follow-up duration was 8.9 (range 2 to 16) years. During the obser-
vation period, 12 patients (19.4%) died. The distribution of Brodsky
Charcot foot types was type 1 in 44 (59.5%), type 2 in 18 (24.3%), type
3A in 7 (9.5%), and type 3B in 3 (4.1%) feet. Two patients(2.7%) dis-
played forefoot manifestations that were not described in the original
Brodsky classification (6), with typical Charcot changes and symp-
toms from the metatarsophalangeal joints. A statistical description of
the cohort is provided in Table 1.
The mean AOFAS midfoot scale score for the patients with midfoot
Charcot was 62.5 ± 16. The mean AOFAS hindfoot score for the pa-
tients with hindfoot Charcot was 49.5 ± 14 (Table 1).
Of the 74 Charcot feet, 48 (64.9%) had had ≥1 episode of DFU related
to the Charcot deformity during the follow-up period. The overall in-
cidence of LEA was 25.7% (19 patients), with 11 major amputations
(14.9%), 3 intermediate amputations (4.1%), and 5 minor amputa-
tions (6.8%). For the Brodsky type 1 Charcot foot, the incidence of DFU
was 63.6% (28 feet), the incidence of an intermediate amputation was
6.8% (3 feet), and the incidence of a major amputation was 2.3% (1
foot). For patients with Brodsky type 2 and type 3A Charcot feet, the
incidence of DFU was 66.7% (12 feet) and 71.4% (5 feet) and the in-
cidence of major amputation was 33.3% (6 feet) and 57.1% (4 feet),
respectively (Table 1). The difference between the incidence of DFU
for Brodsky type 1 versus Brodsky types 2 and 3A Charcot feet was
not statistically significant (p = .71). However, the difference between
the incidence of LEA for Brodsky type 1 versus Brodsky types 2 and
3A was statistically significant (p < .01; Table 2).
When comparing the study population components of the SF-36
to the normative values for the Norwegian population, the results were
significantly lower for physical functioning (Charcot population
57.4 ± 27.5 versus general population 87.3 ± 18.2; p ≤ .001), role physical
Brodsky 3A Brodsky 3B Sanders 1 Total
7 (9.5) 3 (4.1) 2 (2.7)
6 (9.7) 3 (4.8) 2 (3.2)
5 (71.4) 1 (33.3) 2 (100)
0 0 5 (6.8)
0 0 3 (4.1)
4 (57.1) 0 (0) 0 (0) 11 (14.9)
NA NA NA NA
 ARTICLE IN PRESS
F.A. Nilsen et al. / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
Table 3
Short-Form 36-item questionnaire scores and statistical comparison
SF-36 PF RP
Charcot population 57.4 51.0
Normative for Norwegian population 87.3 77.9
p Value <.01 <.01
Abbreviations: BP, bodily pain; GH, general health; MH, mental health; PF, physical functioning; RE, role emotional; RP, role physical; SF, social functioning; VT, vitality.
(Charcot 51.0 ± 45.8 versus general 77.9 ± 35.7; p = .006), bodily pain
(Charcot 58.1 ± 28.2 versus general 75.1 ± 25.8; p = .006), general health
(Charcot 54.0 ± 23.5 versus general 76.9 ± 21.9; p ≤ .001), social func-
tioning (Charcot 70.5 ± 33.6 versus general 85.7 ± 22.0; p = .033), and
role emotional (Charcot 61.3 ± 43.6 versus general 81.8 ± 32.2; p = .028).
A statistical description of the comparative results is provided in
Table 3.
Discussion
The purpose of the present study was to evaluate the long-term
results after conservative treatment of CN using offloading methods
that included the initial use of a TCC, followed by use of a CROW and
early weightbearing. All the patients included in the present study were
treated using the same regimen, with offloading of the involved ex-
tremity until a CROW was manufactured, after which they were allowed
weightbearing as tolerated until reaching Eichenholtz stage 3. To the
best of our knowledge, the mean follow-up duration in the present
study is one of the longest reported, with only 1 other report describ-
ing a similar follow-up duration (7). Moreover, the mean age of our
cohort (55.2 years) was similar to that described by other investiga-
tors (7,10). Also, the distribution of Brodsky types (59.5% Brodsky type
1, 24.3% Brodsky type 2, and 9.5% Brodsky type 3A) was similar to that
previously reported (6). Deformity after consolidation of a Charcot foot
is considered a major risk factor for the development of a plantar ul-
ceration (13). The incidence of DFU in our study population was high
at 64.9% (48 feet), greater than that described for the general diabet-
ic population. For the latter, the annual incidence of foot ulceration
has been estimated at 1% to 4%, with a prevalence ranging from 4%
to 10%. In contrast, the lifetime risk for the development of a DFU in
patients with diabetes ranges from 15% to 25% (14). The increased risk
probably results from the effect of the deformity on the insensate di-
abetic Charcot foot. Compared with patients with Charcot foot described
in other studies (7,15,16), in which the incidence of DFU ranged from
37% to 67%, we observed a relatively high incidence at 64.9%. Fur-
thermore, a large number of our Charcot patients underwent LEA, most
commonly because of infection, with as many as 11 feet (14.9%) un-
dergoing major amputation. This was greater than that previously been
reported, with an incidence of amputation of 2% to 9.7% (7,15,16). One
possible explanation for this difference between our study popula-
tion and those described by Fabrin et al (15), Saltzman et al (16), and
Pakarinen et al (7), could have been the offloading regimen we used.
Fabrin et al (15) used a treatment regimen of offloading and foot pro-
tection involving therapeutic footwear, with a rigid bottom and pedal
arch supports until the temperature difference was <1°C to 2°C.
Saltzman et al (16) also used a non-weightbearing regimen with a TCC
until a temperature difference of <1°C was observed, after which a
CROW was used. Pakarinen et al (7) used a weight-off regimen with
a TCC until the skin temperature difference compared with the un-
affected side was <1°C, after which weightbearing was allowed in a
fixed ankle-foot orthosis. Common to these 3 studies was offloading
of the affected foot until the inflammatory response had subsided, after
which protected weightbearing was allowed until resolution of the
disease. In our study population, patients were allowed early
weightbearing in a CROW after a short period of offloading in a TCC.
3
BP GH VT SF RE MH
58.1 54.0 53.2 70.5 61.3 73.3
75.1 76.9 60.1 85.7 81.8 78.1
<.01 <.01 .19 .03 .03 .29
This might not have been sufficient offloading to prevent deforma-
tion. It is also possible that this approach could have resulted in a more
severe deformity and greater risk of ulceration. However, because of
the lack of standardized radiographic protocols, this could not be de-
termined. Compliance could also have been an issue when using the
CROW as in our study population. One study (14) showed that pa-
tients offloaded with removable cast boots walked without them 72%
of the time. This might also explain some of the differences between
our results and those of Saltzman et al (16) and Pakarinen et al (7).
The incidence of major LEAs was significantly lower in the group
of patients with Brodsky type 1 than in those with Brodsky types 2
and 3A (p < .01). In contrast, the difference between the incidence of
DFU between these groups was not statistically significant (p = .71).
It, therefore, seems that the risk of major amputation in patients with
Brodsky type 1 is lower than that for those with Brodsky types 2 and
3A, although the incidence of DFUs is high in all 3 groups. To the best
of our knowledge, no such difference in the incidence of amputation
when stratified using the Brodsky classification of Charcot foot has
been previously described. The AOFAS scale is a clinical rating system
designed to provide a standard method of reporting patients’ clini-
cal status related to the ankle and foot. It incorporates both subjective
and objective factors into numerical scales to describe function, align-
ment, and pain (8). The subjective component of the AOFAS scale has
been shown to produce reliable information related to the patient’s
assessment of the influence that their foot has on their life (9). In our
cohort, the AOFAS scale scores of the patients available for follow-
up were lower than those previously described by Pakarinen et al (7),
with a mean AOFAS scale score for the midfoot group (AOFAS midfoot
scale score) of 62.5 and for the hindfoot group (AOFAS scale hindfoot
score) of 49.5. Moreover, a trend was seen toward lower AOFAS scales
scores in the Brodsky type 2 group than in the Brodsky type 1 group,
although the groups were too small for meaningful statistical com-
parisons. As previously discussed, we observed a greater incidence of
DFUs and LEAs than reported by other investigators (7,15,16), which
might have resulted from the presence of more severe deformities sec-
ondary to earlier weightbearing in the course of the Charcot foot
disease. This same effect could have influenced the AOFAS scale scores
we observed in our patients. Still further, it is important to remem-
ber that the pain component of the AOFAS scale might lead to
overstating the overall score because Charcot patients generally lack
pain sensation. Regarding the SF-36 scores in the Charcot popula-
tion, the scores were significantly lower statistically in the physical
function, role physical, bodily pain, general health, social function, and
role emotional domains compared with the normative values for the
general Norwegian population. This partly corresponded with similar
findings by Pinzur and Evans (17), although no statistically signifi-
cant difference was found within the mental health and vitality
domains. The most marked differences were found in the domains of
physical functioning and general health, which makes sense consid-
ering the effect that a Charcot foot has on an individual’s ability to stand
and walk. Historically, Pakarinen et al (7) also found that the largest
reduction was in the domain of physical functioning. These differ-
ences could have been partly influenced by other comorbidities
associated with diabetes mellitus. Previous studies have shown that
patients with Charcot arthropathy, on average, have physical component
 ARTICLE IN PRESS
4 F.A. Nilsen et al. / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
summary scores lower than those reported for any other major medical
illness, with scores >1 standard deviation less than those of diabetic
patients in general (18). It is therefore probable that Charcot arthropa-
thy has a significant effect on a patient’s physical function.
The main limitation of the present study was its retrospective design
and the absence of a control group to compare our method of early
weightbearing. Our results could, therefore, only be compared with
previous reported data (historical controls). Such comparisons can be
faulted because of the different inclusion and exclusion criteria, cul-
tural differences, and different methods of treatment and outcomes
assessments over time. Moreover, only 28 patients (77.8%) responded
to our invitation to return to our outpatient clinic for a final reassess-
ment. Furthermore, in our retrospective study population, no
standardized radiographic protocol was used; therefore, it was not pos-
sible to correlate the degree of deformity with the main outcome
measures. Still further, the lack of regression analysis to identify the
statistical significance of univariate and multiple variables on the out-
comes and the lack of a sensitivity analysis for the potential influence
of an unmeasured variable potentially threaten the validity of our con-
clusions. The strengths of the present study, however, were that all
the patients were treated with a standard regimen and the main
outcome measures (DFU and LEA) were objective endpoints. Also, we
based our results on the complete medical records for 62 of the pa-
tients (92.5%).
In conclusion, we found that conservative treatment of Charcot foot
using early weightbearing in a TCC, followed by use of a removable
CROW, resulted in a relatively high incidence of DFUs and LEAs, with
the incidence of LEAs significantly greater in patients with hindfoot
Charcot manifestations compared with those with midfoot Charcot.
From the results of the present study, we would recommend a strict
offloading regimen until consolidation of the disease, and the use of
a TCC without weightbearing should be considered. Our findings should
be investigated in future randomized controlled trials and prospec-
tive cohort studies.
References
1. Armstrong DG, Peters EJ. Charcot’s arthropathy of the foot. J Am Podiatr Med Assoc
92:390–394, 2002.
2. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of
diabetic foot disease. Lancet 366:1719–1724, 2005.
3. Sammarco GJ, Conti SF. Surgical treatment of neuroarthropathic foot deformity.
Foot Ankle Int 19:102–109, 1998.
4. Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early
alternative to nonoperative management of Charcot arthropathy of the diabetic foot.
J Bone Joint Surg Am 82-A:939–950, 2000.
5. Mittlmeier T, Klaue K, Haar P, Beck M. Should one consider primary surgical
reconstruction in Charcot arthropathy of the feet? Clin Orthop Relat Res 468:1002–
1011, 2010.
6. Brodsky JW. The diabetic foot. In: Surgery of the Foot and Ankle, p. 1281, edited by
MJ Coughlin, RA Mann, CL Saltzman, Mosby Elsevier, Philadelphia, PA, 2007.
7. Pakarinen TK, Laine HJ, Maenpaa H, Mattila P, Lahtela J. Long-term outcome and
quality of life in patients with Charcot foot. Foot Ankle Surg 15:187–191, 2009.
8. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical
rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle
Int 15:349–353, 1994.
9. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity
of the subjective component of the American Orthopaedic Foot and Ankle Society
clinical rating scales. J Foot Ankle Surg 46:65–74, 2007.
10. Hays RD, Sherbourne CD, Mazel RM. The RAND 36-item health survey 1.0. Health
Econ 2:217–227, 1993.
11. Loge JH, Kaasa S. Short form 36 (SF-36) health survey: normative data from the
general Norwegian population. Scand J Soc Med 26:250–258, 1998.
12. Eichenholtz SN. Charcot Joints, Charles C. Thomas, Springfield, IL, 1966.
13. Van Acker K, Weyler J, De Leeuw I. The Diabetic Foot Project of Flanders, the
northern part of Belgium: implementation of the St Vincent consensus.
Sensibilisation and registration in diabetes centres. Acta Clin Belg 56:21–31, 2001.
14. Amin N, Doupis J. Diabetic foot disease: from the evaluation of the “foot at risk”
to the novel diabetic ulcer treatment modalities. World J Diabetes 7:153–164, 2016.
15. Fabrin J, Larsen K, Holstein PE. Long-term follow-up in diabetic Charcot feet with
spontaneous onset. Diabetes Care 23:796–800, 2000.
16. Saltzman CL, Hagy ML, Zimmerman B, Estin M, Cooper R. How effective is intensive
nonoperative initial treatment of patients with diabetes and Charcot arthropathy
of the feet? Clin Orthop Relat Res 435:185–190, 2005.
17. Pinzur MS, Evans A. Health-related quality of life in patients with Charcot foot. Am
J Orthop (Belle Mead NJ) 32:492–496, 2003.
18. Dhawan V, Spratt KF, Pinzur MS, Baumhauer J, Rudicel S, Saltzman CL. Reliability
of AOFAS diabetic foot questionnaire in Charcot arthropathy: stability, internal
consistency, and measurable difference. Foot Ankle Int 26:717–731, 2005.