CHARCOT NEUROARTHROPATHY

1. Definition
Pathophysiology
Classification
Clinical
Imaging
Management
Outline

2. • Progressive, non-infective, destructive inflammatory
process
• Protective sensation
• Peripheral neuropathy
Definition

3. Deformity
Poor shoe fitting + Altered foot loading
Ulceration
Why is Charcot foot important?

4. Ulceration
Portal for infective agent
Osteomyelitis

5. AMPUTATION

6. Rocker bottom Deformity
• Ulcer on skin beneath bony prominences

8. Neurotraumatic theory
Germany – Volkman/Virchow
Neurovascular theory
French – Charcot/Mitchell
Pathogenesis

9. •Due to loss of protective sensation
•Microtrauma or fracture
Neurotraumatic theory

10. • Sympathetic vascular denervation
• Increased in blood flow
Neurovascular theory

11. • Anatomical - Brodsky
• Stage (radiological) - Eichenholtz 1966
• Stage, grade (MRI) - Chantelau 2014
Classification

12. • 3 types + 2
• Joint involvement
• Distal to proximal
Brodsky

14. Brodsky Type 1
• Tarsometatarsal, navicularcuneiforms
• 60 %
• Fixed rocker-bottom deformity presentation

16. Type 1

18. Type 1

19. Type 1

20. Type 1

21. Brodsky Type 2
• Subtalar, transverse tarsal joints (TN, CC)
• 10 %
• Unstable and requires prolonged immobilization

23. Type 2

25. Brodsky Type 3
• Type 3A
• Type 3B

26. Brodsky Type 3A
• Ankle joint
• 20 %
• Late varus / valgus deformity

27. Brodsky Type 3B
• Calcaneal tuberosity fracture
• < 10 %
• Migration of tuberosity

28. Type
3A

29. Type
3A

30. Type
3A

31. Type
3A

32. Brodsky Type 4
• Combination
• < 10 %

33. Brodsky Type 5
• Forefoot
• < 10 %

34. • Radiological
• Stage 0 -3
• FCR
Eichenholtz

35. Eichenholtz Stage 0
• Joint edema
• Radiograph Normal
• Bone scan positive (all stages, not specific)

36. Eichenholtz Stage 1
• Fragmentation phase
• Fragmentation and dislocation

37. Eichenholtz Stage 2
• Coalescence phase
• Decreased edema
• Fragments absorption of debris

38. Eichenholtz Stage 3
• Reconstruction phase
• No edema
• Consolidated and remodeling

39. • History
• Usually presents at 4th to 6th decade of life
• Redness, warmth, swelling, loss of function
• Pain
Clinical

40. • Physical examination : ACUTE PRESENTATION
• Swollen, warm
• Erythema, decreased with elevation
• 3.3 degrees Celsius warmer
• Neuropathy

41. • Physical examination : CHRONIC PRESENTATION
• Deformity
• Bony prominences, ulcerations

42. • Clinical diagnosis
• Definitive diagnosis, guide treatment
• Plain radiograph, CT, MRI, bone scan
Imaging

43. Plain Radiograph
• Focal demineralization
• Periosteal destruction
• Cortical destruction of multiple joints

44. CT
• Bony abnormalities
• Intraarticular fractures

45. MRI
• Soft tissue edema
• Joint effusion
• Bone marrow changes

46. Bone Scan
• Bone turnover
• Technetium99
• Indium111 leukocytes labelled

47. PET-CT
• FDG
• Costly

48. Biopsy
• In presence of ulcer with unclear diagnosis
• Pathognomonic features – multiple particles of
bone and soft tissue embedded in deep layer of
synovium

49. Differential diagnosis
• Cellulitis
• Abscess

50. • Nonoperative
• Operative
Management

51. Goals
• Prevent structural abnormalities
• Plantigrade, stable coronal alignment
• Prevent / Treat ulceration
• Keep patient as ambulatory as possible

52. Nonoperative
• Immobilization (Eichenholtz stage 0, 1)
• Off-loading with non weight bearing
• Using crutches, wheelchair and walking frame
• Until edema and skin temperature normalised

53. Total Contact Cast
• Allow protective weight bearing once edema resolved
• Reduce mechanical force
• Arrest progression of deformity
• Patient is allow to weight bear during consolidation phase
Strotman et al 2016

55. Charcot Restraint Orthotic Walker
• CROW (alternative to TCC)
• Custom molded polypropylene shell lined
• Attached to rocker sole

57. Pharmacological
• Antiresorptive
• Monitor bone turnover markers
Jude et al 2001

58. Operative
• Goals
• Stable, painless
• Plantigrade foot
• Treat / Prevent ulcer
• Eradicate OM
• Limb salvage

59. Early
• TA lengthening
• Arthrodesis
• Realignment

60. TA Lengthening
• Reduces foot pressure
• Improves alignment of the ankle and foot

61. Arthrodesis
• Arthrodesis of ankle, TC and midfoot
• In patient with instability, pain and recurrent
ulceration that fail conservative mx

62. Late
• Exostectomy
• Extensive realignment
• Arthodesis
• Debridement
• TA lengthening
• Amputation

65. Case Series of operative treatment
• Sammarco et al 2009 – 22 patients, good result at 2
years, no amputation
• Assal and Stern 2009 - 15 patients ; 1 amputated,
others success

66. Our own study
• THE QUALITY OF LIFE AND FUNCTIONAL
OUTCOME OF CHARCOT FOOT PATIENT TREATED
WITH RECONSTRUCTIVE FOOT SURGERY
• 30 patients in total – 2 patients had complication
• Reconstruction of stage 4 Brodsky with Hindfoot
arthrodesis nail (HAN)
• Outcome measured using SF-36 and AOFAS score
• Significant results

67. Studies Number of samples SF-36 pre and post AOFAS pre and post
Mittlmeier et al
(2010)
26 - P<0.001
Budnar et al (2010) 45 SF-12
P<0.001
P<0.001
Rammelt et al
(2013)
38 P<0.001 -
Brodsky, Verschae,
and Tenenbaum et
al (2014)
30 p<0.001 p<0.001
Hijaz, Adham and
Aminudin (2018)
30 p<0.0001 p<0.001

68. Results comparison
Studies Number of samples SF-36 pre and post AOFAS pre and post
Mittlmeier et al
(2010)
26 - P<0.001
Budnar et al (2010) 45 SF-12
P<0.001
P<0.001
Rammelt et al
(2013)
38 P<0.001 -
Brodsky, Verschae,
and Tenenbaum et
al (2014)
30 p<0.001 p<0.001
Hijaz, Adham and
Aminudin (2018)
30 p<0.0001 p<0.001

69. Take Home Message
• Do not miss CN
• Prevention is better then cure
• Understand the concept of management
Thank you