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

Charcot Joints

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

Clinical Presentation

• Ulceration• Painless swelling• Neuropathic pain unrelated

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

Stage 1: Fragmentation

Stage 3: Consolidation

Anatomic Classification

• I: Midfoot 60%

• II: Hindfoot 10%

• IIIA: Ankle 20%

• IIIB: Calcaneal Tubercle

Type 0

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)

Type 3B

• Os calcis

• Pathologic fracture of tubercle

• Leads to 2° collapse of foot

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

• Most Charcot treated nonoperatively

• Can take several months to years

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

• Dorsal plating - compression

Fixation Methods

• Plantar plating - tension

Fixation Methods

• Medial plating

Fixation Methods

• Ex-fix

Fixation Methods

• Screws

Fixation Methods

• Combination

Fixation Methods

• IM fixation• Hindfoot

Fixation Methods

• IM fixation• Midfoot

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

Amputation

• Indications• Failed surgeries

• Osteomyelitis

• Unstable arthrodesis

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

Thank You

RE ECT

the ankle

the foot