51: Charcot Neuroarthropathy - Greenhagen Flashcards
define charcot neuroarthropathy
Non-infectious destruction of bone associated with neuropathy
classification charcot
eichenholtz 1966
neurovascular theory charcot arthropathy
•Increased blood flow in region of destruction
–Sympathetic failure causes a hyper-vascular reflex
–State of overactive bone resorption
–Bone scans show increased uptake in Charcot arthropathy
•Due to sympathetic denervation or local inflammatory process?
unifying theory of charcot arthropathy
how does RANKL work?
- Best understanding at this point is multifactorial
- Balance between RANKL (receptor activator of nuclear factor kappa beta ligand) and osteoprotegerin (OPG)
- RANKL activates RANK, osteoclasts, bone destruction
- OPG has opposite effect
- Vascular calcification in DM occurs by same pathway
- Intima-MEDIA-adventitia
- If you see vascular calcification, be suspiscious
hx keys
- Hot, Swollen Foot
- •+/- Trauma
- 55-75% do not remember any trauma
- Trauma is not limited to sprains and strains. Joint infections and surgical trauma can induce this
- Mild/ moderate pain
- No previous Ulcerations
- No systemic signs of infection
PE keys
- Swollen, Deformed? Foot
- Warmth
- Erythema
- Joint effusion
- Neuropathy
- +/- Ulcerations
- Contralateral foot
- Elevation test
- raise foot, turn different color = inflammation or venous stasis
natural progression of charcot neuroartropathy
- Advanced Glycosylation
- Pull of the triceps surae
- Intrinsic Atrophy
- Alters the mechanical properties of bone
- Midfoot Collapse
- Reversal of Arch
- Tarsal prominence
- Increased Plantar Pressure
earliest signs x-ray
- Earliest sign is bone resorption and soft tissue swelling before the architecture is altered
- also see… Bony destruction, Fracture, Subluxation, Dislocation
- if there is no wound = no osteo!
brodsky anatomic classification
- Type I
- Tarsometarsal and naviculocuneiform jts
- Most common (60%)
- Most stable
- Type II
- Transverse tarsal and subtalar joints
- Second most common (35 %)
- Hindfoot instability
- Ulceration (talar head)
- Type IIIa Ankle Type IIIB Calcaneus
- 5% of Charcot but most unstable
- Frequently requires surgery
- High risk of major amputation (BKA, AKA)
Sanders and Frykberg Classification
Eichenholtz Classification
stage 0 = charcot in situ
stage I = development (clinically red hot)
stage 2 = coalescene (calming)
stage 3 = consolidation
describe eichenholtz stage 0
- period of inflammation after acute trauma in a pt with neuropahty
- no deformity has occurred
- we can arrest the process adn prevent stage 1 from occurring
- most important stage to recognize
goals of charcot tx
- Plantigrade
- Stable
- Shoeable/Braceable
- Heal any ulcers
- Prevent recurrences
- Decrease or eliminate pain
- Avoid amputation
- Maintain ambulation
non-surgical management stage 0 and 1
- Patient education
- Immobilization
- Total contact Casting & Non-WB
- Nonweight bearing
- Instant TCC
How effective is nonoperative treatment in Charcot patients?
Able to manage 60% of midfoot Charcot without surgery at minimum of 1 year follow up
which pts need to have surgery?
- Deformities causing instability
- Inability to brace a deformity
- Impending compromise of the skin
- Non-healing ulcers
- Recurrent ulcers due to malalignment
- Pain
- 25-50% of patients will require some type of surgery
risks of amputation
- No ulcer @ presentation 7%
- Ulcer @ presentation 28%
- Recurring (2 or more) ulcers after treatment for Charcot 31%
when is exostetomy effective?
Effective if midfoot deformity stable
–> Concern is iatrogenic instability
describe exostectomy
- Used to prevent or cure plnatar ulceration
- Effective if midfoot deformity stable
- Concern is iatrogenic instability
- Patient maybe WB
- Limited use in the central and lateral midfoot
describe midfoot reconstruction
•Midfoot arthrodesis
–Intractable ulceration
–Instability
- Prolonged healing time to obtain union (3+month)
- Rigid fixation required
- External Fixation if a wound is present
describe calcaneal reconstruction
- Calcaneal avulsions or break fractures the most common forms
- Bone is very soft
–Consider fracture excision and tendon reattachment
–Screws alone will not work
describe ankle reconstruction
- Ankle Charcot arthropathy
- Usually following ankle trauma) leading to:
- Ulcer / Pending Ulcer
- +Unstable Ankle
- Usually following ankle trauma) leading to:
- •Prolonged healing time to obtain union (3+month)
- •Rigid fixation required
- –Compression screws
- –Blade plate
- –IM Nail
steps for arthrodesis correction
- surgical pre-planning
- k-wires as guide for osteotomy
- remove corrective wedge
- fusion site reduction
- temporary stabilization
what is a superconstruct?
Superconstructs are defined as follows:
–Fusion that extends beyond the zone of injury to include joints that are not affected to improve fixation.
–Bone resection performed to shorten the extremity to allow for adequate reduction of the deformity without undue tension on the soft tissue envelope.
–Use of the strongest fixation device that can be tolerated by the soft tissue envelope.
–Application of the fixation devices in a position that maximizes mechanical function.
“beaming”
axial screw placement
Solid or cannulated screws within medullary canal of bone
- Screw placement helps reduction of deformity
- Fixation is perpendicular to joint for arthrodesis
- Eliminates stress risers
- No exposed hardware
- Limited exposure
- Accepts tension dorsal/plantar
Grade B Recommendation (best we have right now)
Achilles tendon or gastrocnemius lengthening reduces forefoot pressure and improves the alignment of the ankle/hindfoot to the midfoot/forefoot and allows forefoot ulcers to heal
What is the most common location for a Charcot event?
What are the Eichenholtz stages and what is the most important stage to recongize?
What are the primary non-operative treatments?
What are the two primary treatments for Charcot bone deformities?
What are the principles superconstruct?
What soft tissue procedures may be necessary?
know the answers to these questions
