Viva Charcot arthropathy

Question 1

75-year-old lady presented

with right foot pain-swelling
and redness”

What do you see?

Answer 1

This is a clinical photograph showing a grossly deformed and swollen
right foot and ankle. (Rocker-bottom)

Question 2

what is Charcot arthropathy?

Answer 2

• Charcot arthropathy is the progressive destruction of bone and soft tissue that
  leads to loss of bony architecture, fracture, dislocation, and deformity.
• Up to 7.5% of patients with diabetes and neuropathy develop Charcot arthropathy.
• The pathogenesis has been explained by two major theories (The exact nature
  remains umknown):
  Ø Neurotraumatic theory: (sensory – motor) bony destruction due to loss of pain
  sensation and proprioception with atrophy of intrinsic muscles and imbalance
  between intrinsics and extrinsics which leads to high plantar foot pressures
  combined with repetitive trauma
  Ø Neurovascular theory suggests bone and joint destruction due to hypervascularity
  that result in hyperemia and periarticular osteopenia with contributory trauma.

Question 3

what are the risk factors Charcot
arthropathy?

Answer 3

Ø DM (90% of cases are related to diabetic neuropathy)
Ø Peripheral neuropathy
Ø Alcohol
Ø Leprosy
Ø Tertiary syphilis

Question 4

How can you differentiate Charcot foot from
infection?

Answer 4

Ø Erythema will decrease with leg elevation in Charcot (for 10 mins)
Ø Lack of significant elevation of fever and WBC count
Ø Blood glucose levels usually fluctuate with infection , so normal blood glucose level should
discount infection in the differential diagnosis

Question 5

How does it evolve? (what are the stages of
Charcot arthropathy)

Answer 5

• Eichenholtz has staged this process:

ØStage 0: acute inflammatory phase: the foot becomes painful, swollen , and warm (erythematous).
X-rays may show periarticular soft tissue swelling and varying degrees of osteopenia.
Ø Stage 1: fragmentation stage. Over the following weeks the oedema and erythema settle, the bone continues to fragment.
Ø Stage 2: Coalescence: the foot starts to stiffen up and the deformities become fixed. X-rays show resorption of bone debris
Ø Stage 3: Consolidation: over many months the oedema and erythema completely settle.
X-rays
show consolidation and remodelling of fracture fragments. (As a rough guide: forefoot 6 months,
midfoot 12 months, hindfoot 18 months)

Question 6

Are you aware of any classification system?

Answer 6

Brodsky anatomic classification system:
Ø Type I: involves tarsometatarsal and naviculocuneiform joints. It is the most common type
Ø Type II: involves subtalar, talonavicular, calcaneocuboid joints
Ø Type III: involves tibio-talar joint. A: tibio-talar. B: fracture of calcaneal tuberosity.
Ø Type IV: combination of area
Ø Type V: forefoot involvement

Question 7

non operative

What are the principles of treating this
condition?

Answer 7

Ø Prevention: optimum management of co-morbidities (diabetes)
Ø Goals of treatment : to achieve plantigrade, stable foot that is able to fit into a shoe and the
prevention of recurrent ulceration
Ø TCC(total contact casting) is the gold standard of treatment.
* * 1. It allows an even distribution of the pressures across the plantar surface of the foot.
* * 2. Weight bearing should be restricted.
* * 3. Casts should be changed every 2-4 weeks until erythema and edema have resolved and the temperature has reduced.
* * TCC is commonly continued up to 4 months.
* * Ø Once the active phase has ended, the patient can be fitted with a Charcot restraint orthotic walker (CROW)and later with custom shoe orthosis.

Question 8

operative

What are the principles of treating this
condition?

Answer 8

Ø Surgery performed in the inflammatory phase has a high rate of non-union, infection, wound
complications, late deformity and amputation.

Ø Indications for surgical intervention: If a plantigrade foot cannot be achieved, recurrent ulcers and instability.
Surgical options: exostectomy, reconstruction with osteotomy and fusion, amputation