Charcot Arthropathy.

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Charcot Arthropathy.

• Dr. Saima Hashim Khan
• Dept. of Diabetes Endocrinology
• HMC. PGMI

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Case History 1

• 55yrs old married female
• Type2 diabetic 25yrs
• HTN 7yrs
• Swelling right foot gt1month, treated as
  cellulitus with antibiotics

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INVESTIGATION

• Hb 10.8g/dl, TLC 9900/cmm
• S.creatinine 0.7mg/dl
• S.uric acid 4.0mg/dl
• X ray foot.

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MRI Foot
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Case History 2

• 45yrs old married female
• DM2 15yrs (Retinopathy PRP, Nephropathy crt
  clr 103 )
• HTN 5yrs
• Post amputation RT big toe 3yrs
• Swelling LT foot 2 months, treated as cellulitis
  with antibiotics

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Investigations

• Hb9.5 gm/dl, TLC 9600/cmm
• URIC ACID 4.2mg/dl
• CREATININE 1.02mg/dl
• DOPPLER U/S LT FOOT no DVT normal arterial flow
  and subcutaneous edema.
• Xray Foot

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X Ray Foot
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Tragic Rule of 15

• 15 of diabetes Foot ulcer in
  lifetime of patients
• 15 of foot ulcers Osteomyelitis
• 15 of foot ulcers Amputation
• Clinical Care of the Diabetic Foot, 2005

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Tragic Rule of 50

• 50 ofamputations
• 50 of patients
• 50 of patients

Transfemoral/transtibial level 2nd amputation
in? 5 years Die in ? 5 years
Clinical Care of the Diabetic Foot, 2005
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History of charcot foot

• Mitchell,1831 The first association between
  joints and neurological diseases.
• Charcot 1868 Arthropathy and tabes dorsalis.
• Jordan 1936 Neuritic manifestation of DM

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Charcots Foot A Neuropathic Arthropathy

• Caused by repetitive trauma in the setting of
• Diminished sensation proprioception
• Motor neuropathy results in muscle imbalance
  abnormal weight bearing.
• Rocker Bottom Deformity
• a convex deformity of the foots plantar
  aspect caused by the collapse of metatarsal
  bones

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Etiology

• Peripheral sensory neuropathy is always present
  /- motor.
• Autonomic neuropathy leads to increased blood
  flow.
• Trauma may be an important precipitating factor,
  although 2/3rd of patients dont remember any
  injury.
• Bone metabolism both osteoblastic and
  osteoclastic activities are increased.

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Epidemiology

• Incidence 0.1 0.5 . General
• Increased in patients with neuropathy.
• Diabetics 3-5
• Common in the 4th or 5th decades of life.
• Bilateral in 30 of patients.
• Sex difference No
• Type 1 or type 2 Both are at risk.
• Majority in the mid foot but any bone or joint
  in the foot or ankle can be affected.

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Clinical Features and Diagnosis

• Acute Charcot
• Warm, inflamed and swollen.
• Misdiagnosed as cellulitis, osteomyelitis or
  inflammatory arthropathy as gouty or septic.
• Although sensory neuropathy, pain is common
  feature followed by discomfort.
• Diagnosis by exclusion as investigations in early
  stages are negative.

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Clinical Features and Diagnosis

• High index of suspicion is necessary so that
  appropriate treatment is immediately instituted
  to prevent severe deformity!

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Clinical Features and Diagnosis

• Chronic Charcot, may be months, painless, without
  temperature difference and deformed.
• Reactivation by further trauma is frequent.
• Patients are at high risk of ulceration and
  amputation, so long term follow up is
  recommended.

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Investigations

• X-ray Early absent or subtle finding.
• Late bone and joint destruction, fragmentation.
• bone scan Increased bone uptake.
• In labeled leucocytes scan to differentiate from
  osteomyelitis.
• MRI Bone marrow edema is the earliest sign.

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Treatment

1. Immobilization
2. Pharmacological Treatment.
3. Surgical Treatment.

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Treatment

• Immobilization
• Almost 16 weeks (3-6 months) but may be
  more.
• (temp gradient less than 1 on 2 occasions or
  serial radiology).

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Treatment

• Immobilization
• Bed rest
• Half-shoes
• Crutches, Walkers and Wheelchairs
• Total contact cast (TCC) -gold standard
• Prefabricated pneumatic walking brace ( Air cast
  )

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Total contact cast
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Air cast
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Half shoe
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Modified/custom shoes/orthoses
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Treatment

• 3. Pharmacological Treatment.
• Pilot study first using pamidronate,1994.
• Other Bisphosphonates were used to decrease
  disease activity and bone turnover markers.
• Calcitonin were also used.
• Given for 12 weeks or till temp gradient is less
  than 2 on 2 consecutive visits.

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Treatment

• Surgical treatment
• No role in acute.
• Later may be to remove bony deformities or
  constructive surgeries to achieve a stable shape.
  
• Techniques include Arthrodesis,
  exostectomies, reconstruction and Achilles
  tendon lengthening.

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Take Home Message

• High degree of suspicion to diagnose acute
  Charcot arthropathy.
• High risk categorization.
• Immobilization
• Bisphosphonate.
• Customized Foot Wear

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Thank You