Foot & Ankle

Question 1

What position should you fuse the first MTP?

Answer 1

Clinically at neutral, which, radiographically, corresponds to ~15-20deg of extension

Question 2

What is the classification of Charcot foot?

Answer 2

Eichenholtz classification:
Stage 0: joint edema, x-rays (-), Bone scan +
Stage 1: fragmentation.
- Joint edema, x-rays show osseous fragmentation with joint dislocation
Stage 2: Coalescence
- Decreased local edema, x-rays show coalescence of fragments and absoprtion of fine bone debris
Stage 3: Reconstruction
- No local edema, x-rays show consolidation and remodeling of fracture fragments

Question 3

What are the 4 stages of Charcot Foot?

Answer 3

Stage 0: x-rays negative, +joint edema
Stage1: fragmentation
Stage2: coalescence
Stage3: reconstruction

Question 4

What is the differential diagnosis for Charcot foot?

Answer 4

Anything that causes redness of the foot:

• Cellulitis/infection
• DVT/thrombosis
• Tabes dorsalis (syphylis)

Question 5

What is the mechanism/pathophysiology for diabetic (Charcot) foot?

Answer 5

Theories:
Neurotraumatic:
- Insensate joints subjected to repetitive microtrauma
- Body unable to adapt protective mechanisms to compensate for microtrauma due to abnormal sensation
Neurovascular:
- AV shunting due to autonomic dysfunction
- Leads to bone reabsorption and remodeling

Question 6

What percentage of people with Charcot’s foot have bilateral disease?

Answer 6

9-35%

Question 7

What are other sites for Diabetic Fractures?

Answer 7

Shoulder/Elbow

Knee - this often leads to ligamentous instability and bone loss

Question 8

What is the most common area for Charcot Foot?

Answer 8

Tarsometatarsal and naviculocuneofirm joints (midfoot) (Brodsky type 1)

Question 9

What are some classic clinical findings of Charcot Foot?

Answer 9

Acute:
- Swollen, red, hot +/- deformed foot
Chronic:
Structurally deformed foot
- Rocker bottom
- Bony prominences
- Collapse of medial arch (Valgus)

Question 10

What is the principle behind treatment of charcot foot?

Answer 10

Immobilize and even out the pressures along the foot

Question 11

What is the first line of treatment of a patient with Charcot Foot?

Answer 11

Non-operative:
Total contact casting
- Changed every 2-4 weeks for 2-4 months
- Orthotics (Charcot restraint orthotic walker aka CROW)
- Shoe modifications
- Medications

Question 12

What are some medications used for treatment of Charcot Foot?

Answer 12

Diabetes optimization
Bisphosphonates
Neuropathic pain meds
Antidepressants
Topical anasthetics

Question 13

Can Charcot foot be painful?

Answer 13

Yes - 50% of the time patients present with pain

Question 14

What does a positive Silverskiold test indicate?

Answer 14

Tight Gastrocs

Question 15

Name 4 characteristics of lateral ankle OCD lesions compared to medial:

Answer 15

Smaller & shallower
More anterior
Less chance of spontaneous resolution
Rarer