Charcot joint and methods of arthrodesis

1. Charcot Joint & Methods of
Arthrodesis
Presented by:
Ibrahim S. Al-Shaygy
R2

2. What to do?

3. Interoduction
• Charcot neuropathy is a progressive deterioration of weight-
bearing joints, usually in the foot or ankle.
• Historically, neuropathy of the knee was most frequently
caused by syphilis, and neuropathy of the shoulder was usually
caused by syringomyelia.

4. • Today, the Charcot foot occurs most often in patients with
diabetic neuropathy; other predisposing conditions include
alcoholic neuropathy, cerebral palsy and congenital
insensitivity to pain.
• The first description of neuroarthropathy occurring with
diabetes mellitus was published in 1936.

5. Objectives
• Pathogenesis
• Epidemiology
• Classification
• Evaluation
• Treatment options
• Surgical treatments

6. Pathogenesis
• Two theories:
 Neurotraumatic
• Attributes bony destruction to the loss of pain sensation and
proprioception combined with repetitive and mechanical
trauma to the foot.
 Neurovascular
• suggests that joint destruction is secondary to an
autonomically stimulated vascular reflex that causes
hyperemia and periarticular osteopenia with contributory
trauma.

7. Pathogenesis
 Intrinsic muscle imbalance can produce eccentric loading of
the foot, propagating microfractures, ligament laxity and
progression to bony destruction.
 In DM, the cause is high concentrations of glucose with
altered osmolarity.
 Micro vascular damage can also occur.
 Associated with increased risk of ulceration.
 Skin integrity becomes abnormal due to neuropathy.

8. Epidemiology
• Neuropathic arthropathy is prevalent in 0.8 to
7.5 percent of diabetic patients with
neuropathy.
• 9 to 35 percent of these affected patients
have bilateral involvement.
• Most of those patients have uncontrolled DM
for 15 to 20 years.

9. Epidemiology
• The (Lisfranc’s) joint is the most common site
for arthropathy.
• Initial involvement usually occure on the
medial column of the foot.
• Distribution:
– 70% at the midfoot.
– 15% at forefoot or rearfoot.

10. Learning Point
Charcot osteo-arthropathy must occur in the presence of
a neuropathy. It rarely occurs in the presence of arterial
insufficiency as high blood flow is required for osseous
resorbtion.
Charcot ankle is considered the worst among the other
Charcot because the difficulty to control the instability.

11. Classification
• Neuropathic arthropathy is
either atrophic or
hypertrophic.
• Atrophic:
 localized to the forefoot
and causes osteolysis of
the distal metatarsals. The
metatarsal heads and
shafts have a radiographic
deformity that resembles
a pencil point or “sucked
candycane”.

12. • Hypertrophic:
 usually occurs at the midfoot, rearfoot or ankle, and is
traditionally defined according to the Eichenholtz
classification system.

13. • STAGE 1
 The first stage is the developmental, or fragmentation, stage (acute
Charcot)
• Associated with: periarticular fracture and joint dislocation
leading to an unstable, deformed foot

14. Charcot Foot: Stage I
[Fragmentation]
• Initial presentation = hot,
swollen, painless foot! Early
radiographs negative!
• No fever, malaise; normal
WBC!
• Patient usually walks into
clinic
• Hyperemia precedes bony
destruction

15. • STAGE 2 “coalescence stage “
 Patients in the (subacute Charcot) present with
resorption of bone debris.
• STAGE 3 “consolidation stage”
 Reparative, stage (chronic Charcot) is associated
with re-stabilization of the foot with fusion of the
involved fragments . This leads to the return of a
stable, although deformed, foot.

16. consolidation stage Rocker-bottom foot deformity

17. Revised Eichenholtz
Classification:

18. Diagnosis
• 50 percent of patients with Charcot foot remember a
precipitating, minor traumatic event.
• Diabetic patients with neuropathy, erythema, edema,
increased temperature of the foot and normal radiographs
most likely has an acute Charcot process.
• Role out INFECTION!!!

19. Diagnosis
• Brodsky method!
• Decreased sensation light touch or vibration
Semmes-Weinstein 10-g monofilament wire.
• Decreased or absent
sensation in 4 out of 10
is an abnormal test.

21. • If a neuropathic ulcer is present, it is graded using
the Wagner classification:
• Grade Description
 1 Superficial diabetic ulcer
 2 Ulcer extension to ligament, tendon, joint capsule or
deep fascia without abscess or osteomyelitis
 3 Deep ulcer with abscess or osteomyelitis
 4 Gangrene to portion of forefoot
 5 Extensive

22. Treatment
• Stage 1:
• Immediate weight
bearing
protection!
 Severe/bilateral =
bed rest!
 Wheelchair
mobility!
 Crutch walking [if
good balance]!
 Total Contact
Casting [TCC]

23. • Goal: Prevent multiple
fractures of foot/ankle!
• TCC changed q 1-2 wks
• Unweighting for 2-3
months, or until
symptoms resolve and
radiographs show bony
stability

25. Charcot Foot: Stage II
[Coalescence]
• Maintain external foot
contours while bone
Reconstitutes.
• Controlled weight
bearing believed to
facilitate healing.
• Wean from TCC to AFO
• Custom shoe, if foot is
deformed

26. Charcot Foot: Stage III
• Consider surgical
intervention
• Arthrodesis for
severe deformities
• Exostectomy for
local prominences
with recurrent
ulceration

27. FURTHER TREATMENTS
• Alternative:
C.R.O.W or PTB
• Preferred when
control of coronal
plane ankle
instability is needed
• Usually after
erythema and
swelling subside

28. • TOTAL CONTACT CASTING:
– The gold standard of treatment when pt are picked
early.
– Most cases can be treated by pressure-relieving
methods.
– Serial x ray every 6 weeks
• conversion to a Charcot restraint
orthotic walker (CROW) after the
active phase of the condition
is complete

29. • PREFABRICATED PNEUMATIC WALKING BRACE:
• An alternative to TCC, which decrease forefoot and
midfoot plantar pressure in the treatment of
neuropathic plantar ulceration.
• Benefits include:
• easier wound surveillance, ease of application and the
ability to use several types of dressings.
 Use of the PPWB is limited in patients who have
severe foot deformity or who are noncompliant.

30. • PROPOSED TREATMENTS:
• Electrical bone stimulation
• Low-intensity ultrasonography
• Bisphosphonate

31. • SURGICAL TREATMENT:
– Exostosectomy:
• Stable chronic charcot
– Arthrodesis:
• Unstable or joint with subluxation.

32. Arthrodesis
• AIM:
 To provide a solid, painfree fusion of the ankle in
the optimum position.
 Minimise risk of complications.

33. Pre Operative
• Vascular study.
• Previous scars.
• Medical history, diabetes, smoker.
• XRs
• ? arthritis of subtalar jts or midfoot
• Increased movement in remaining joints in foot

34. Results
• 80-90% fusion rates
• Most patients satisfied with pain relief
• Hindfoot motion limited – uneven ground difficult
• Most can wear normal shoes
• Rocker bottom shoe may help gait
• Gait velocity slowed 16%
• 3% increase oxygen consumption
• Shortened stride length
• Increase ER at hip

35. Complications
• Non-union (pseud-arthrosis)
• Mal-union
• Infection
• Neurovascular injury, neuroma
• Skin necrosis

36. Non Union

37. Optimum Position
• The foot should be externally rotated 20 to 30
degrees relative to the tibia, with the ankle
joint in neutral flexion (0 degrees)
• 5 to 10 degrees of external rotation, and slight
valgus (5 degrees).
• Neutral to slight posterior displacement of
talus under tibia (minimise midfoot loading)
• Match to normal side

38. Surgery
• General or regional
• supine
• Antibiotics
• Prep for bone graft, sandbag under buttock
• +/- tourniquet
• Drape above knee (for alignment)

39. Surgical Techniques
• As a general rule, External fixators are preferred
for patients undergoing arthrodesis for a
preexisting septic joint and for those with severe
osteopenia.
• Arthroscopic arthrodesis or the “miniopen”
arthrodesis should be used only for patients with
minimal deformity.
• Open arthrodesis is appropriate for patients with
significant ankle deformity and foot and ankle
malalignment.

40. Approaches to Ankle
• Anterior
• Transmalleolar (transfibular) +/- medial
”utilitarian” approach
• Posterior behind fibular, hinged
• calcaneal osteotomy or TA divided if done for
tibio-talar-calcaneal fusion
• Mini-incision (Myerson)
• Arthroscopic

41. Fixation
• INTERNAL FIXATION:
 Screws
 Wires
 Steinman pins
 Plates
 Intramedullary rods (tibiocalcaneal)
 Bioabsorbable screws

42. INTERNAL FIXATION
• PROS
 Patient convenience
 Ease of insertion
 Good to excellent results

43. TRANSMALLEOLAR
(Mann)
• Incision 10cm above the
tip of fibula to base 4th MT
• Full thickness skin flaps
• Subperiosteal dissection
fibula and and tibia

44. • Oblique fibula osteotomy
2cm above joint
• Fibula removed (+/- as
graft)
• Distal tibia and talar neck
exposed
• Distal tibia cut – 2mm
• Talar cut 3-4mm
• Avoid excess bone
removal – loss of height

45. • Resect articular surface
medial malleolus (may
require medial incision)
• Position, temporary
Kwires
• 2 screws – sinus tarsi to
medial tibia, lat talus to
medial tibia
• Transcortical screws

46. • Practically, most of the cases with Charcot
ankle have severely deformed talus.
• Most of them need Pan talar arthrodesis.

47. Post OP
• Routine closure
• POP slabs initially
• Below knee POP & NWB 6-8weeks
• Then WB in cast further 6-8weeks

48. Screw fixation
• 6.5 – 7mm cancellous
screws
• +/- cannulated
• 2 or 3 – ( 3 screws stronger
than 2 in testing)
• Anterior, medial and central
placement
• Posterior “home-run” screw
, (inside-out technique)

49. Tibiotalocalcaneal arthrodesis
• Angled blade-plate:
 Posterior approach
 Prone position.
 Achilles tendon is osteotomized at its insertion
into the calcaneus.
 Curetting and Bone grafting
 95 degree blade plate placed posteriorly
 Achilles tendon is reattached.

50. Tibiotalocalcaneal arthrodesis

51. Tibiocalcaneal Arthrodesis with
Intramedullary Nailing
• Medial and lateral skin
incisions.
• Body of the talus removed,
and fixation of the head
and neck of the talus to
the anterior tibia
• Posterior approach used
for wide exposure.

53. Calandruccio device
• I & II
• Triplanar – more
control
• 2 pins in talus, 2 in
tibia
• Series II more
versatile and allows
XR of arthrodesis
site

54. Arthroscopic
• Entire articular surfaces denuded using shavers, burrs,
currettes ,etc
• Cannulated screws placment
• Good results:
• ? quicker union time
• Less morbidity / recovery time
• Union rates comparable to open
• Takes longer
• More difficult

55. Bone graft
• Some reports
indicate faster and
higher union rates
• Adaptable to
different situations,
esp with bone loss
• Iliac crest or fibula/
tibia

56. Long term
• Coester et al –JBJS am 2001(mean 22 yr FU on
post traumatic OA arthrodesis)
 Increased risk of arthritis in subtalar and midfoot
areas
 No increased risk of knee OA

57. Foot Arthrodesis
• Mostly for Lisfranc’s
joint.
• Two dorsal insicion
medial and lateral.
• Fixation with screws or
LP plates.
• Most of the cases will
need BG.
• Long time needed till
complete healing

58. Summary
• Charcot osteo-arthropathy is a potentially
catastrophic complication of neuropathy.
• However it most commonly presents in the foot and
ankle in the diabetic population.
• Early recognition and prevention of deformity make a
lot of difference.
• Arthrodesis is meant for unstable severely deformed
and painful ankle.

59. That’s
All Folks