The Role of Weight-Bearing Computed Tomography in the Assessment and Management of Charcot Foot Deformity: A Narrative Review

Charcot neuro-osteoarthropathy (CNO) is a devastating complication of peripheral neuropathy, characterized by progressive bone and joint destruction that leads to severe foot deformity, ulceration, and a high risk of amputation. The management of CNO is predicated on an accurate understanding of its biomechanical instability, yet conventional imaging modalities like non-weight-bearing computed tomography (CT) and magnetic resonance imaging (MRI) fail to capture the true, load-dependent nature of the deformity. This review elucidates the paradigm shift facilitated by weight-bearing computed tomography (WBCT) in the diagnosis and management of CNO. A comprehensive narrative review of the literature was conducted to synthesize the pathophysiology of CNO, the limitations of conventional imaging, and the technological principles, clinical applications, and future directions of WBCT in CNO management. The review integrates findings on CNO pathophysiology, radiological assessment, and the debate surrounding weight-bearing protocols in conservative management. WBCT provides a three-dimensional, functional assessment of the Charcot foot under true physiological load, overcoming the critical limitations of non-weight-bearing imaging. It reveals the full extent of osseous collapse, unmasking hidden instabilities and enabling the use of novel quantitative 3D metrics for deformity characterization and risk stratification. Clinically, WBCT enhances the entire management pathway, from improving early diagnostic accuracy and informing surgical strategy with patient-specific instrumentation to enabling objective postoperative evaluation of reconstructive outcomes. WBCT is a promising technology that redefines the assessment of CNO from a static, morphological description to a dynamic, quantitative biomechanical analysis. Its integration into clinical practice offers the potential to improve diagnostic precision, optimize surgical planning, and ultimately enhance patient outcomes. The future synergy of WBCT with artificial intelligence holds promise for further advancing patient care, moving towards a predictive and prescriptive model for managing this complex condition.