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Charcot Foot and Ankle
Selene G. Parekh, MD, MBAAssociate Professor of Surgery
Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery
Adjunct Faculty Fuqua Business SchoolDuke University
Durham, NC919.471.9622
http://seleneparekhmd.comTwitter: @seleneparekhmd
Jean Martin Charcot (1825-1893)
• Not 1st to describe neuropathic arthropathy (1703 by William Musgrave)
• Syphilis
• 1936-1st described in diabetes
Charcot Joints
• What is it?
Progressive, noninfectious, destructive
disease of the bones and
joints in persons with sensory neuropathy
Charcot Joints
•“Neuroarthropathy”•Etiology (partial list)
•Diabetes•Alcoholism •Syphilis•Leprosy (Hansen’s disease)•Meningomyelocele•Spinal cord injury•Syringomyelia•Renal dialysis
Charcot Joints
• Epidemiology• Foot and ankle most commonly
• Incidence: 0.1% - 0.12% of diabetics
• Radiographic incidence: 1.4%
Charcot Joints
• Two theories• Neurotraumatic
• Cumulative mechanical trauma• Insensate joint
• Neurovascular (autonomic neuropathy)• Neurally stimulated vascular reflex• Bone resorption, ligament weakening
Pathophysiology
• NOT understood well• Neurotraumatic
• Minor repetitive • Major
• Neurovascular• Autonomic dysfunction increased blood flow via
arteriovenous shunting• Recent theories
• TNF α, IL-1 NTF- қβ osteoclast
Clinical Presentation
• Assoc w/ advance sequelae of diabetes• Nephropathy• Retinopathy• Obesity
• Assoc w/ recipients of solid organ transplantation• Type 1 Db
• 5th decade of life (20-40yrs)
• Type 2 Db• 6th decade of life (6-9yrs)
Clinical Presentation
• Differential diagnosis• Cellulitis
• Elevation-dependent rubor resolves
• Abscess • CT/MRI
• Acute Charcot • Red• Hot
• >3.3o C
• Swollen• 50% pain
Clinical Presentation
• Sub-acute & chronic Charcot• Deformity w/ bony prominences• Rocker-bottom• Loss of calcaneal pitch w/ relative PF
Imaging
• X-rays• Fractures, dislocations• Bone compression, disintigration• Fluffy new bone formation• Deformity
• Osteomyelitis• MRI
• Most helpful in distinguishing an abscess from Charcot
• Combination technetium-99m sulfur colloid marrow & indium-111-labeled bone scans
• May have improved specificity
• Charcot
Imaging
• Osteomyelitis
• Charcot
• May be difficult to distinguish from osteomyelitis• No surrounding osteopenia in Charcot• Hematogenous osteomyelitis in adults rare
• Ulcer free extremity unlikely to have osteomyelitis
Imaging
Eichenholtz Stages
O: Normal radiographs
I: Dissolution/Fragmentation • Xray – osteopenia, periarticular fragmentation, &
subluxation or frank dislocation
Eichenholtz Stages
II: Coalescence/Early healing phase• Edema and warmth decrease• Xray – Absorption of debris, fusion of bony fragments,
and early sclerosis of bone
III: Consolidation/Reconstruction• Absence of inflammation• Xray – osteophytes and subchondral sclerosis are
often present, along with narrowing of joint spaces
Eichenholtz
Stage Clinical Radiography
I Development-fragmentation
ErythemaWarmthSwelling
Bony debrisFragmentation
SubluxationDislocation
II Coalescence Decreased erythema, warmth,
swelling
Absorption debrisNew bone
Coalescence/sclerosis
III Consolidation Resolution of edema
Residual deformity
Remodeling, rounding of bone
Decreased sclerosis
Anatomic Classification
• I: Midfoot 60%
• II: Hindfoot 10%
• IIIA: Ankle 20%
• IIIB: Calcaneal Tubercle
Type 1
• Midfoot• Require shorter immobilization• Rocker-bottom• Severe midfoot valgus• Most likely to develop ulcers
Type 2
• Hindfoot• “Bag of bones”• Persistent instability• Less likely to ulcerate (1/3)• Longer periods of immobilization (avg. ~2 yrs)
Type 3A
• Ankle• Trauma• Similar to Type 2• Instability & swelling leads to avg. immobilization >1 yr• Serious varus or valgus (ulceration @ malleoli)
Conservative Treatment
• Recommendations• Based on level IV evidence
• Goals• Achieve 3rd stage of bony healing
• Avoid & treat ulcers
• Keep patient as ambulatory as possible during treatment
Conservative Treatment
• Total Contact Cast• Rest & elevation decrease swelling• First cast change @ 1 week
• Dramatic initial reduction in swelling• Cast loosens leading to blisters & new ulcers
• Reduces load to about 1/3 of the normal foot• Do not overpad• Use felt or foam to pad bony prominences
Conservative Treatment
• Prefabricated braces• Not customized (often will not accommodate bony prominences)• Do not control edema like TCC• Can be removed by patient
Eichenholtz Stage
•I: TCC
•II: Molded total contact AFO, custom fabricated lined w/ plastizote or CROW (Charcot Restraint Orthotic Walker)
•III: Custom-molded insole w/ appropriate footwear
Weightbearing Status
• NWB preferred?• May not be possible
• Wheelchairs• Limited WB/Protected WB
Complications
• Ulceration• Deep infection/osteomyelitis• Severe, uncontrollable deformity• Amputation
Surgical Treatment
• Exostectomy• Medial or lateral incision• Excise bony prominence of tarsal bones• Flatten surfaces w/ osteotomes or saw • Smooth w/ rasps (leave no edges or ridges)
Surgical Treatment
• Arthrodesis• Salvage procedure• Realign foot to relieve pressure/correct deformity• Stabilization of instability/dislocation• Enable brace or custom footwear w/o ulceration
Surgical Treatment
• Arthrodesis• Timing
• Avoid during Stage I• Leads to infection & loss of fixation
• Goal: Stable aligned foot• Fibrous ankylosis may be positive result
Fixation Methods
• Time to fusion w/ internal fixation• 11-22 weeks• High complication rate up to 69%
• Infection, both superficial and deep• Post-op amputation rate 0-10%
• Hardware malposition requiring removal• Recurrent ulceration• Fracture
Fixation Methods
• External Fixation• Indications
• Ulcers with underlying osteomyelitis• Poor soft-tissue envelope• Poor bone quality• Morbid obesity
• Advantages • Singlestage treatment in the presence of osteomyelitis
or ulceration• Easy monitoring of soft-tissue healing• Protect somewhat against noncompliance with
postoperative non–weight-bearing instruction• Can adjust in office
Fixation Methods
• External Fixation• Limb salvage rates were >90%
• New or recurrent ulceration rare
• Pin-tract infection - most common complication
Pharmacologic
• Bisphosphonates• Promising short-term results in preventing bone
resorption
• Mechanism based on the promotion of osteoclast apoptosis and the inhibition of osteoclast activity
Pharmacologic
• Bisphosphonates• Jude et al
• 6 wks: significant reduction in bone turnover markers (bone specific alkaline phosphate, deoxypyridinoline
• > 3 months differences not significant• ? Interval doses may be necessary
• Pitocco et al• Improvement in bone turnover markers, BMD, and
pain
Pharmacologic
• Calcitonin• Jude et al
• Daily dose of 200 IU intranasal calcitonin• 3 months of treatment
• Decreased bone turnover markers• 6 months
• No difference
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