Charcot Foot Disease Prof Ahmed M A Kensarah
- Slides: 54
Charcot Foot Disease Prof. Ahmed M. A. Kensarah Department of surgery Faculty of Medicine, King Abdulaziz University Hospital, Jeddah , Saudi Arabia
Charcot Foot Disease • Charcot foot disease is commonly associated with diabetic patients. • It was first described by J. M Charcot in patient of tabes dorsalis[1]. • Charcot osteoarthropathy [COA] is a debilitating disease and some times can be limb threatening. • Its prevalence in diabetic patients is 0. 4 to 13%[3, 4].
Charcot Osteoarthropathy �Other than diabetes rheumatoid arthritis, trauma, multiple sclerosis, leprosy, poliomyelitis, alcohol abuse, syringomyelia , heavy metal poisoning, and congenital neuropathies also contributes for the development of charcot osteoarthropathy[5, 6]. �Prevalence of charcot foot disease is increasing which may be due to new imaging which results in increase in diagnosis[7].
Etiology • Neurovascular theory (French): Dysregulated autonomic nervous system hyperemia. • Neurotraumatic theory (German): Loss of peripheral sensation and proprioception repetitive microtrauma inflammatory resorption of traumatized bone.
Clinical features � History of fall, sprain, trauma. � May be painless because of diabetic neuropathy. � Unilateral lower extremity warmth, redness, and/or edema. � Rocker- bottom foot , deformity foot “Bounding” pedal pulses; no systemic signs of infection.
Differential diagnoses �Cellulitis �Osteomyelitis �Deep vein thrombosis
Joints Involved �Tarsometatarsal joint - 60% �Metatarsophalangeal joint – 30% �Talocrural joint (ankle) – 10%
Loss of arch, pes deformity
Charcot foot
Rocker bottom foot
Treatment � Off-loading devices � Stabilization (casting) � Custom footwear � Pharmacologic therapy: Bisphonates – minimize bone resorption. � Surgery- arthrodesis/ debridement/amputation
Cam/fracture walker
Cast
CROW (Charcot Restraint Orthotic Walker)
To evaluate Charcot neuroarthropathy in diabetic foot patients at tertiary hospital � Retrospective study of charcot foot in diabetic patients admitted from 2005 to 2015 in King Abdulaziz University hospital , Jeddah, Saudi Arabia. � Sixty four patients admitted as diabetic foot disease were studied
Cont. � Males-81. 2% � Females -18. 8% � Mean age -61. 75 yrs � Symptoms – � Pain-25% � Numbness-12. 5% � Foot deformity-23. 4% � Discharge-73. 4% � Difficulty in walking -12. 5% � History of trauma-10. 9%
Cont. �NIDDM-68. 8% �IDDM-31. 2% �DM more than 10 years-62. 5% �Uncontrolled DM-73. 4% �Neuropathy-59. 4% �Vasculopathy-56. 3% �Obesity-10. 9% �Hypertension -83. 8% �Dyslipidemia-31. 3%
Clinical Picture � Pt. presents with swollen , red , hot, foot usually painless in diabetic patient may clinch the diagnosis. � D. D � However , it must be distinguished from trauma, cellulitis, sprain, acute gout, Deep vein thrombosis and osteomyelitis[10].
Treatment �Treatment starts with offloading which is required to prevent progression of disease, while surgery is needed in chronic cases with joint instability or deformity[11].
Methods � It is a retrospective study from 2005 to 2015 of charcot foot patients in diabetic patients admitted in KAUH. � Sixty four patients were admitted as diabetic foot disease and were studied. � Patients admitted for diabetic foot disease in hospital were studied for Charcot joint disease. � Collection of data done by reviewing patients files, OPD visits, OR notes and inpatients records.
Results � Majority of patients were males 81. 2% and females 18. 8 %. � Mean age was 61. 75 years. � Pain was reported by 25% of patients, numbness by 12. 5%, foot deformity by 23. 4%, discharge by 73. 4%, difficulty in walking by 12. 5%, and 10. 9% had history of trauma.
Results � Majority of patients were NIDDM 68. 8 %, IDDM 31. 2%, 62. 5 % had DM more than 10 years , uncontrolled DM in 73. 4%. � Nephropathy in 46. 3%, neuropathy in 59. 4%, retinopathy in 40. 6%, cardiomyopathy in 48. 4% and vasculopathy in 56. 3%.
Figure -1: Age distribution
Figure -2 : Complaints 80 70 pain 60 numbness 50 foot deformity 40 discharge 30 difficulty in walking 20 history of trauma 10 0
Figure-3: Co-morbidities 90 80 obesity 70 hypertension 60 dyslipidemia 50 hypothyroidism 40 30 arrhythmias 20 immunosuppression 10 0 anemia Associated co-morbidities were obesity in 10. 9%, hypertension in 83. 8%, dyslipidemia in 31. 3%, hypothyroidism in 14. 1%, immunosuppression in 3. 1, arrhythmia in 3. 1% and anemia in 84. 4%.
Figure-4 ; Diabetes details Percentage Diabetes Details IDDM 68. 8 NIDDM 31. 3 More than 10 yrs 62. 5 Less than 10 yrs 36. 9 Controlled 21. 9 Not controlled 73. 4 Nephropathy 46. 3 Neuropathy 59. 4 Retinopathy 40. 6 Cardiomyopathy 48. 4 Vasculopathy 56. 3 Obesity Hypertension Dyslipidemia Hypothyroidism Anemia Immunosuppression
Figure -5; physical finding 70 60 50 40 30 20 10 0 Charcot Forefoot midfoot hind foot Charcot arthropathy was in 28. 1% of cases and forefoot was involved in 65. 5%, midfoot in 4. 7% and hindfoot/ankle in 21. 9%.
Figure-6 : x-rays findings Subluxation Dislocation Disorganized joint Bone resorption Osteommyelitis Fracture Joint collapse Articular surface destruction X-rays showed subluxation in 40. 6%, dislocation in 54. 7%, disorganized foot joints in 42. 2%, bone resorption in 23. 4%, osteomyelitis in 14. 1%, fractures in 50%, joint collapse in 39. 15 and destruction of articular surfaces in 37. 5%.
Figure -7; X-Ray findings.
Figure-8 ; charcot foot
Figure -9 ; Rocker bottom foot deformity
Figure 10: Hind foot deformity
Figure-11: hind foot deformity
Figure-12; : Surgical treatment, level of amputation
Surgical treatment, level of amputation �Debridement was done in 25% of cases while 75% of patients underwent some sort of amputation. � 14. 1% of patients underwent above knee amputation, 10. 9 % below knee amputation, 10. 9% transmetatarsal and 39. 1% toe amputation.
Discussion � Pathogenesis of Charcot foot disease is multifactorial. In diabetes polyneuropathy is one of initial event in charcot osteopathy. � Sensory neuropathy results in decreased sensations and repeated microtrauma results in hyperemia and ultimately destruction of joints. � Motor neuropathy causes decreased strength of intrinsic and extrinsic muscles resulting in deformity which further causing abnormal plantar pressures and abnormal collagen formation[12].
Discussion � Autonomic neuropathy leads to increased perfusion and increased osteoclast activity resulting in osteopenia and pathologic fractures[13]. � Incidence is equal in both sexes. � Patients who are at high risk of developing charcot arthropathy are poorly controlled diabetes more than 10 years, neuropathy and trauma[14].
Eichenholtz clssification Eichenholtz classification of neuropathy divides into three stages: � Stage 1 -development where subluxation, osteolysis and fracture occur. � Stage-2 coalescence where resorption of debris and fusion of fracture occur. � Stage-3 where healing and hypertrophic bone formation occur[15].
Sella and Barette classification Sella and Barette introduced five stages � stage-0 has pain, erythema, oedema, warm foot. � stage-1 osteopenia, erosions, diastasis, � stage-2 subluxation, � stage-3 dislocation and joint destruction and � stage-4 which is characterized by healing and hypertrophic bone formation[16].
Frykberg classification Sanders –Frykberg classified anatomically into five patterns, 1 - forefoot 2 - Tarsometatarsal joint 3 - Talonavicular, calcaneocuboid and naviculocuneiform 4 -ankle joint 5 - calcaneus[14].
Charcot Foot Disease � Mean age of our patient was 61. 75 years which is near similar to studies of Sanders et. al where it was mid fiftees[12] and 63 years in study of Min et. Al[17]. � In our study majority of patients were males 81. 2 % , and females 18. 8% while Min et. al reported males 97. 1%[17]. � This again confirms the fact that diabetic foot disease is a disease of middle age and Charcot neuroarthropathy develops in long standing diabetic foot disease.
Charcot Foot Disease (Cont. ) � Twenty five percent patients complained of foot pain in our study while Baglioni, Botek, and Petrova et. al reported pain in less than 50% of cases[18, 19, 20]. � Since patients with Charcot neuroarthropathy have neuropathy so less number of our patient reported pain. � 62. 5 % of our patients had diabetes for more than 10 years which is similar to studies of Leung et. al and Samann et. al[21, 22]. � X-rays were used to diagnose bony changes in charcot patients.
X-ray � Stage 0: Joint edema, X-ray- negative. � Stage 1: “Acute Charcot” – Osseous fragmentation and joint dislocation seen on radiograph � Stage 2: Decreased local edema, coalescence of fragments and absorption of fine bone debris. � Stage 3: No local edema, with consolidation and remodeling (deformed) of fracture fragments. The foot is now stable.
Charcot Foot Disease (Cont. ) � Initial x-rays were normal and patients had only soft tissue deformity. � 28. 1 % of diabetic patients had charcot foot disease in our patients which is quite high percentage. � Forefoot was involved in majority of our patients 65% followed by hind foot and midfoot. � Offloading was non operative management commonly it was foot wear.
Charcot Foot Disease (Cont. ) � The gold standard of off-loading is the total contact cast [23, 24]. � Surgery in the form of debridement and amputation was offered. � Majority had toe amputation followed by above knee amputation.
Conclusions �Diabetic patients with Charcot joint disease poses great challenge in management. �Emphasis should be given for early detection, investigations and prompt treatment. �Treatment should be tailored according to stage of disease and patient occupation.
Thank you
References 1 -Trepman E, Nihal A, Pinzur MS. Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int 2005; 26: 46 -63. 2 -Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, Landsman AS, Lavery LA, Moore C, Schuberth JM, Wukich DK, Anderson C, Vanore JV: Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg 2006, 45(5): S 1– S 66. 3 -Frykberg RG, Belczyk R: Epidemiology of the Charcot Foot. Clin Podiatr Med Surg 2008, 25: 17– 28. 4 - Leung HB, Ho YC, Wong WC: Charcot foot in Hong Kong Chinese diabetic population. Hong Kong Med J 2009, 15(3): 191– 195.
References (Cont. ) 5 - Gupta R. A short history of neuropathic arthropathy. Clin Orthop. Relat Res 1993; 296: 43 -49 6 - Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications 2009; 23: 409 -426. 7 - Rajbhandari SM, Jenkins RC, Davies C, Tesfaye S. Charcot neuroarthropathy in diabetes mellitus. Diabetologia 2002; 45: 1085 -1096. 8 - Cofield RH, Morrison MJ, Beabout JW. Diabetic neuroarthropathy in the foot: patient characteristics and patterns of radiographic change. Foot Ankle 1983; 4: 15 -22.
References (Cont. ) 9 -Frykberg RG. Charcot foot. In: Boulton AJM, Connor H, Cavanagh PR, eds. The foot in diabetes. John Wiley Sons, Chichester, 2000: 235 -60 10 - Chantelau E. The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture. Diabet Med 2005; 22: 1707 -1712. 11 - Stefansky SA, Rosenblum BI. The Charcot foot: a clinical challenge. Int J Low Extrem Wounds 2005; 4: 183 -187. 12 -Sanders LJ, Frykberg RG. Charcot foot. In: Levin ME, O'Neal LW, Bowker JH, eds. The Diabetic Foot. St. Louis: Mosby, 1993: 149± 80.
References (Cont. ) 13 -Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot's arthropathy in a diabetic foot specialty. clinic. Diabetic Med 1997; 14: 357± 63 14 -Sanders LJ, Frykberg RG. Charcot foot. In: Levin ME, O'Neal LW, Bowker JH, eds. The Diabetic Foot. St. Louis: Mosby, 1993: 149± 80. 15 -Yu GV, Hudson JR. Evaluation and treatment of stage 0 Charcot's neuroarthropathy of the foot and ankle. J Am Podiatr Med Assoc 2002; 92: 210± 20. 16 - Armstrong DG, Peters EJG. Charcot's arthropathy of the foot. J Am Podiatr Med Assoc 2002; 92: 390± 4.
References (Cont. ) 17 - Min. W. S, Todd A. L, Rodney M. S. , Robert G. Fryberg, Elly BM ; Mortality Risk of Charcot Arthropathy Compared With That of Diabetic Foot Ulcer and Diabetes Alone Diabetes Care 2009; 32: 816– 821. 18 - Baglioni P, Malik M, Okosieme OE: Acute Charcot foot. BMJ 2012, 344(1397): 1– 4. 19 - Botek G, Anderson MA, Taylor R: Charcot neuroarthropathy: an often overlooked complication of diabetes. Cleve Clin J Med 2010, 77(9): 593– 599. 20 - Petrova NL, Edmonds ME: Charcot neuroosteoarthropathy – current standards. Diabetes Metab Res Rev 2008, 24(Suppl 1): 58– 61.
References (Cont. ) 21 -Leung HB, Ho YC, Wong WC: Charcot foot in Hong Kong Chinese diabetic population. Hong Kong Med J 2009, 15(3): 191 – 195. 22 -Samann A, Pofahl S, Lehmann T, Voigt B, Victor S, Moller F, Muller UA, Wolf G: Diabetic Nephropathy but not Hb. A 1 c is Predictive for Frequent Complications of Charcot Feet – Longterm follow-up of 164 Consecutive Patients with 195 Acute Charcot Feet. Exp Clin Endocrinol Diabetes 2012, 120: 335– 339. 23 -Stefansky SA, Rosenblum BI. The Charcot foot: a clinical challenge. Int J Low Extrem Wounds 2005; 4: 183 -187. 24 -van der Ven A, Chapman CB, Bowker JH. Charcot neuroarthropathy of the foot and ankle. J Am Acad Orthop Surg 2009; 17: 562 -571
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