1. Charcot Foot and Ankle
Selene G. Parekh, MD, MBA
Associate Professor of Surgery
Partner, North Carolina Orthopaedic Clinic
Department of Orthopaedic Surgery
Adjunct Faculty Fuqua Business School
Duke University
Durham, NC
919.471.9622
http://seleneparekhmd.com
Twitter: @seleneparekhmd
3. Jean Martin Charcot (1825-1893)
• Not 1st to describe neuropathic arthropathy
(1703 by William Musgrave)
• Syphilis
• 1936-1st described in diabetes
4. Charcot Joints
• What is it?
Progressive, noninfectious, destructive
disease of the bones and
joints in persons with sensory neuropathy
8. 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
9. 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)
13. Imaging
• X-rays
• Fractures, dislocations
• Bone compression, disintigration
• Fluffy new bone formation
• Deformity
14. • 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
15. • 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
16. Eichenholtz Stages
O: Normal radiographs
I: Dissolution/Fragmentation
• Xray – osteopenia, periarticular fragmentation, &
subluxation or frank dislocation
17. 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
18. Eichenholtz
Stage Clinical Radiography
I Development-
fragmentation
Erythema
Warmth
Swelling
Bony debris
Fragmentation
Subluxation
Dislocation
II Coalescence Decreased
erythema, warmth,
swelling
Absorption debris
New bone
Coalescence/sclerosi
s
III Consolidation Resolution of
edema
Residual deformity
Remodeling, rounding
of bone
Decreased sclerosis
23. Type 1
• Midfoot
• Require shorter immobilization
• Rocker-bottom
• Severe midfoot valgus
• Most likely to develop ulcers
24. Type 2
• Hindfoot
• “Bag of bones”
• Persistent instability
• Less likely to ulcerate (1/3)
• Longer periods of immobilization (avg. ~2 yrs)
25. Type 3A
• Ankle
• Trauma
• Similar to Type 2
• Instability & swelling leads to avg. immobilization
>1 yr
• Serious varus or valgus (ulceration @ malleoli)
26. Type 3B
• Os calcis
• Pathologic fracture of tubercle
• Leads to 2° collapse of foot
27. 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
29. 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
30. Conservative Treatment
• Prefabricated braces
• Not customized (often
will not accommodate
bony prominences)
• Do not control edema
like TCC
• Can be removed by
patient
34. 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)
35. Surgical Treatment
• Arthrodesis
• Salvage procedure
• Realign foot to relieve pressure/correct deformity
• Stabilization of instability/dislocation
• Enable brace or custom footwear w/o ulceration
36. Surgical Treatment
• Arthrodesis
• Timing
• Avoid during Stage I
• Leads to infection & loss of fixation
• Goal: Stable aligned foot
• Fibrous ankylosis may be positive result
45. 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
46. 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
47. Fixation Methods
• External Fixation
• Limb salvage rates were >90%
• New or recurrent ulceration rare
• Pin-tract infection - most common complication
49. Pharmacologic
• Bisphosphonates
• Promising short-term results in preventing bone
resorption
• Mechanism based on the promotion of osteoclast
apoptosis and the inhibition of osteoclast activity
50. 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
51. Pharmacologic
• Calcitonin
• Jude et al
• Daily dose of 200 IU intranasal calcitonin
• 3 months of treatment
• Decreased bone turnover markers
• 6 months
• No difference
