Pressure relief (offloading) and immobilization with total contact casting (TCC) are critical to helping ward off further joint destruction. TCC involves encasing the patients complete foot, including toes, and the lower leg in a specialist cast that redistributes weight and pressure in the lower leg and foot during everyday movements. This redistributes pressure from the foot into the leg, which is more able to bear weight, to protect the wound, letting it regenerate tissue and heal. TCC also keeps the ankle from rotating during walking, which prevents shearing and twisting forces that can further damage the wound. TCC aids maintenance of quality of life by helping patients to remain mobile.There are two scenarios in which the use of TCC is appropriate for managing neuropathic arthropathy (Charcot foot), according to the American Orthopaedic Foot and Ankle Society. First, during the initial treatment, when the breakdown is occurring, and the foot is exhibiting edema and erythema; the patient should not bear weight on the foot, and TCC can be used to control and support the foot. Second, when the foot has become deformed and ulceration has occurred; TCC can be used to stabilize and support the foot, and to help move the wound toward healing. Walking braces controlled by pneumatics are also used. In these patients, surgical correction of a joint is rarely successful in the long term. However, offloading alone does not translate to optimal outcomes without appropriate management of vascular disease and/or infection.
Note that it is often difficult to differentiate osteomyelitis from a Charcot joint, as they may have similar tagged WBC scan and MRI features (joint destruction, dislocation, edema). Definitive diagnosis may require bone or synovial biopsy. Radiologic findings
First, it is important to recognize that two types of abnormality may be detected. One is termed atrophic, in which there is osteolysis of the distal metatarsals in the forefoot. The more common form of destruction is hypertrophic joint disease, characterized by acute peri-articular fracture and joint dislocation. According to Yochum and Rowe, the "6 Ds" of hypertrophy are:  

Distended joint
Density increase
Debris production
Dislocation
Disorganization
DestructionThe natural history of the joint destruction process has a classification scheme of its own, offered by Eichenholtz decades ago:
Stage 0: Clinically, there is joint edema, but radiographs are negative. Note that a bone scan may be positive before a radiograph is, making it a sensitive but not very specific modality. Stage 1: Osseous fragmentation with joint dislocation seen on radiograph ("acute Charcot"). Stage 2: Decreased local edema, with coalescence of fragments and absorption of fine bone debris. Stage 3: No local edema, with consolidation and remodeling (albeit deformed) of fracture fragments. The foot is now stable. Atrophic features:

"Licked candy stick" appearance, commonly seen at the distal aspect of the metatarsals
Diabetic osteolysis
Bone resorption

Treatment
Once the process is recognized, it should be treated via the VIPs — vascular management, infection management and prevention, and pressure relief. Aggressively pursuing these three strategies will progress the healing trajectory of the wound.