We read with some interest the commentary by Tan et al. (1) on the management of the Charcot foot in diabetes. While we agree entirely that this condition should be ranked as a medical emergency, because failure to act quickly can lead to irreversible adverse consequences, we do not agree that the evidence is available to support uncritical use of bisphosphonates. The only blinded trials conducted so far did not demonstrate any overt improvement in long-term prognosis (2,3). There is much suggestive evidence to favor the consideration of bisphosphonate use, but it is not currently accepted by all authorities that this therapy is essential.
A number of other treatments also deserve consideration (4,5). For example, intranasal calcitonin and tumor necrosis factor-α antagonists may prove useful, although the efficacy of both has yet to be established in controlled trials. In the absence of evidence to support the use of specific treatments, it is accepted by all with a specialist interest in this field that the mainstay of emergency management is the immediate institution of effective offloading, preferably in a total contact cast. Offloading results in protection of the bones and joints of the foot, as well as amelioration of the underlying inflammatory process.