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A 56-year-old male with uncontrolled diabetes presents for follow up of a recurrent midfoot ulceration. He has been placed into a total contact cast for extended periods without resolution of the ulcer. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. He has an equinus contracture. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. What is the next best option at this point?
Below the knee amputation
Exostectomy with placement into a protective brace
Exostectomy & achilles tendon lengthening with placement into a protective brace
Select Answer to see Preferred Response
The clinical presentation is consistent with a diabetic associated Charcot neuroarthropathy that has failed conservative management with total contact casting. Given the presence of a bony projection, in the setting of a stable deformity, exostectomy is a reasonable option. An equinus contracture is indicative of a tight Achilles tendon and as such a lengthening is warranted.
The first line of treatment of Charcot arthropathy is conservative measures; total contact casting is the gold standard. Surgical intervention may be considered in patients for whom ulceration persists despite total contact casting. Increasing deformity, with evidence of joint instability is another indication for surgery. For this patient, who does not appear to have evidence of major instability on examination, the preferred treatment is an exostectomy with protective bracing. The Silverskiold test, which differentiates between a tight gastrocnemius muscle vs. a tight Achilles tendon complex, can be used to determine if what kind of lengthening procedure should be considered. With a positive Silverskiold test, the gastrocnemius is tight. For this patient, an exostectomy can be combined with an Achilles lengthening to help prevent ulceration in the forefoot.
Van der Ven A et. al review the current concepts for evaluation and management of Charcot arthropathy. The article delineates that ulceration is often the result of malpositioning of tarsal bones after joint collapse. Chronic ulceration that fails to resolve with conservative measures (i.e. contact casting) can be managed with exostectomy and protective bracing, with successful limb salvage in up to 90%. Concomitant Achilles tendon lengthening should be considered for those with contracture in the setting of recurrent plantar ulceration.
Figure A demonstrates an ulcer commonly identified in the midfoot region as a result of Charcot arthropathy. Figure B shows a lateral x-ray of a patient with radiographic evidence of midfoot joint collapse with soft tissue abutment.
Illustration A demonstrates the Silverskiold test; passive dorsiflexion is completed with knee in flexion & extension to differentiate between Achilles tendon tightness or gastrocnemius tightness.
Answer 1: External Fixation would not address this problem.
Answer 2: At this time the patient has viable tissue and an amputation is not indicated.
Answer 3: Observation would not be indicated as this patient is having persistent ulceration that has not resolved with conservative measures.
Answer 4: As this patient has an equinus contracture he will require a lengthening procedure as well.
van der Ven A, Chapman CB, Bowker JH.
J Am Acad Orthop Surg. 2009 Sep;17(9):562-71. PMID: 19726740 (Link to Abstract)
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Average 3.0 of 18 Ratings
A 65-year-old male with insulin-dependent diabetes and chronic kidney disease presents for follow-up care for issues in his right lower extremity. He has been treated for the past four months with the modality seen in Figure A (Panel A) for the condition seen in Figure A (Panel B). He has currently has no ulcerations on his foot. Which shoe modification, shown in Figure B-F, is most appropriate to prevent potential future skin breakdown by offloading the affected area in this patient?
This question describes a patient with diabetic neuropathy and right foot Eichenholtz stage 3 charcot neuroarthropathy. Following total contact casting for a total of two to four months, patients with intact skin and without evidence of active infection may be placed in a charcot restraint orthotic walker (CROW) boot, and ultimately normal footwear with a double rocker sole modification.
Treatment for Charcot neuropathy depends on the stage and clinical presentation. The first-line treatment is nearly always total contact casting for a full two to four months followed by the use of a CROW boot. To offload areas of increased pressure, shoe modifications such as the double rocker sole, which decreases pressure from plantar midfoot prominences, are used in an effort to prevent future/worsening ulceration.
Janisse et al. described a variety of shoe modifications and orthoses for use in foot and ankle pathology. While several types of modifications were described, the authors noted the double rocker sole modification as the correct option for treating midfoot pathology.
Van der Ven et al. provide an expert opinion review presentation and management of charcot neuroarthropathy. The authors describe the typical progression of non-operative management (when indicated) including total contact casting for Stage 1 disease, followed by CROW boot use for Stage 2 disease, followed by appropriate accommodative footwear in Stage 3 disease.
Figure A demonstrates an example of total contact casting (a) and radiographic evidence of Eichenholtz stage 3 charcot neuroarthropathy (b).
Answer 1: (Figure B) - This figure shows a severe angle rocker sole which is helpful in reducing weight-bearing pressures distal to the ball of the foot (severe toe tip ulcerations)
Answer 2: (Figure C)- This figure shows a mild rocker sole, which provides a rocking mechanism at the heel and toe to produce mild metatarsal head relief and to assist in gait via forward propulsion.
Answer 4: (Figure E)- This figure shows a negative heel rocker sole, which forces the heel height to be lower than that of the ankle, and is designed both for patients with fixed dorsiflexion and for patients with forefoot pressures as this sole transfers pressure to the midfoot and heel.
Answer 5: (Figure F)- This figure shows a heal-to-toe rocker sole, which is helpful in assisting with gait by increasing propulsion at toe-off; this modification is helpful for patients after ankle/subtalar fusion or patients with fixed lesser toe deformities (hammer, claw toes).
Janisse DJ, Janisse E
J Am Acad Orthop Surg. 2008 Mar;16(3):152-8. PMID: 18316713 (Link to Abstract)
Average 2.0 of 30 Ratings
A 50-year-old male with long-standing type 1 diabetes presents with redness, swelling and crepitus in his foot two weeks after a twisting injury. Elevation of the extremity reduces the hyperemia. A radiograph is shown in Figure A. What is the most likely diagnosis?
This is a classic presentation of Charcot arthropathy in a diabetic patient after sustaining a relatively minor trauma. In addition, hyperemia that regresses with elevation is classic for Charcot. Neuropathy has the greatest affect on diabetic foot pathology and the most sensitive test is the Semme's Weinstein monafilament testing.
Guyton et al's ICL on the diabetic foot presents a comprehensive review of this topic.
Guyton GP, Saltzman CL.
Instr Course Lect. 2002;51:169-81. PMID: 12064102 (Link to Abstract)
Average 3.0 of 19 Ratings
You are seeing a 62-year-old male for ankle and foot swelling (Figures A-C). There is no history of trauma and he has never seen a physician before. In addition to his lower extremity care, what other medical condition should he be evaluated for?
This patient is presenting with Charcot arthropathy, a known complication of diabetes mellitus. Clinical photograph and radiographs show the characteristic appearance of the Charcot foot with complete arch collapse and multi-joint end stage degenerative joint disease through the entire hind, mid, and fore-foot.
As described by Guyton and Saltzman, there is a complex pathophysiology by which diabetes contributes to the foot deformities seen in Charcot arthropathy. This pathophysiology includes alterations in peripheral nerves, bones/soft tissue, gait kinematics, microscopic/macroscopic vascularity, immune system, and mechanisms of wound healing. To treat, one must address the mechanical and biologic aspects of the disease.
Average 3.0 of 11 Ratings
A 62-year-old gentleman with a 10-year history of Type II diabetes complains of warmth, swelling, and pain in his right foot that has progressively worsened over the past 6 weeks. He denies fevers or chills, and states that the swelling and warmth dissipates each night after he sleeps with his foot elevated on pillows. A clinical photograph of the foot is provided in Figure A. The midfoot is hot to touch and mildly tender with palpation. A radiograph is provided in Figure B. Which of the following is the most appropriate management?
Custom orthotics with first ray recession and lateral heel posting
Total contact cast and non-weight bearing
Talonavicular and tarsometarsal arthrodeses
The clinical presentation, photograph, and radiograph are consistent with diabetic charcot neuropathy of the midfoot.
The lack of systemic symptoms and resolution of erythema with foot elevation rule against the presence of infection. This patient appears to be in the fragmentation phase of the pathologic process given the osteopenia, fracture, and collapse of the midfoot. This is followed by the coalescence and reconstitution phases. The goal of treatment in the first phase is to prevent further collapse and deformity. Given there is no ulceration, and/or deep infection present, this is best accomplished through protected weight bearing and total contact casting. A CROW walker could also be considered.
Examples of total contact casting and a CROW walker are demonstrated in Illustrations A and B. The objective is to prevent high contact stress points and subsequent ulceration in the insensate foot. Surgical intervention should be reserved for debridement of a deep infection from open wounds or arthrodesis of arthritic joints following the consolidation that occurs during the reconstitution phase.
Average 3.0 of 17 Ratings
A 65-year-old diabetic female presents with a two-month history of mild ankle pain and subjective instability. She denies any specific injury and she does not have any foot ulcerations or wounds; her foot and ankle are edematous with erythema that resolves upon elevation. Her ESR, CRP, and WBC levels are within normal limits. Her radiographs are shown in Figures A and B. What is the most appropriate initial treatment?
Modification of shoe wear
Use of a total contact cast
Spanning external fixation of the ankle and hindfoot
Charcot arthropathy is a devastating bone and joint disease. While it most commonly occurs in those with diabetes and neuropathy, it has been known to occur with other non-diabetic neuropathies as well.
Figures A and B show severe Charcot changes to the hindfoot, leading to the patient's reports of pain and instability. Initial treatment should include bracing and frequent skin checks to monitor for development of ulcerations or other skin lesions. Neuropathic osteoarthropathy, otherwise known as Charcot neuroarthropathy, is a chronic, degenerative arthropathy and is associated with decreased sensory innervation. Typical findings include joint destruction, disorganization, and effusion with osseous debris. Progression of Charcot neuroarthropathy often follows a predictable clinical and radiographic pattern and is described by the Eichenholtz classification found in Illustration A.
Hatzis et al reviewed a case series of neuroarthropathy of the shoulder (radiograph shown in Illustration B), and found that syringomyelia is the most common etiology of this disorder in the shoulder.
The referenced article by van der Ven is a review of the etiologies, pathogenesis, treatments, and outcomes of Charcot neuroarthropathy of the foot and ankle.
Hatzis N, Kaar TK, Wirth MA, Toro F, Rockwood CA
J Bone Joint Surg Am. 1998 Sep;80(9):1314-9. PMID: 9759816 (Link to Abstract)
Average 3.0 of 14 Ratings
A 57-year-old woman with type 2 diabetes presents with right foot pain resulting in gait disturbance for the past 6 months. Medical comorbidities include renal insufficiency and hypertension. A radiograph is provided in Figure A. What initial management is most appropriate?
Carbon fiber shank insole
Custom orthotic with Jones bar and medial posting
AFO (ankle foot orthosis) with posterior leaf spring
Total contact casting
Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes
Initial treatment of Charcot arthropathy includes a total contact cast (TCC) continued for up to 4 months. When the active disease phase has ended, the patient can be fitted with a CROW (charcot restraint orthotic walker) and, later with a custom shoe with orthoses.
Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. Treatment is focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses.
The Charcot Restraint Orthotic Walker (CROW) seen in Illustration A is a custom, bivalved, total contact AFO with full foot enclosure, rigid rocker sole, and custom insole. The CROW usually is used after an initial period in a TCC to enable reduction of edema before fabrication of the CROW. The total contact design simulates a TCC, but the CROW allows better hygiene and comfort because it is removable. The CROW controls edema, enables ambulation, and prevents deformity as coalescence proceeds. Disadvantages of the CROW include the high costs of fabrication and maintenance.
Average 2.0 of 27 Ratings
A 43-year-old male presents with painless swelling and erythema of his ankle which resolves with elevation. He has begun to have trouble ambulating because he reports his ankle feels "floppy" since a fall several weeks ago. His x-ray is shown in Figure A. What physical exam test is most appropriate?
Syndesmosis squeeze test
Semmes-Weinstein monofilament testing
This is the classic scenario for Charcot arthropathy, also known as neuroarthropathy. Semmes-Weinstein monofilament testing is an important test to confirm the diagnosis.
Charcot arthropathy is characterized by rapid destruction of joints secondary to repetitive loading or single episode of trauma in the presence of poor sensory feedback. Theories regarding the pathophysiology include the neurotraumatic theory which is based on unrecognized repetitive microtrauma in a sensory impaired extremity, and the neurovascular theory which is based on bone destruction and ligamentous weakness secondary to an unregulated hyperemia that occurs in an autonomic peripheral neuropathy. Patients with diabetic neuropathy are at a higher risk of developing complications, especially Charcot arthropathy. The catastrophic effect as seen in this gentleman demonstrates the importance of early diagnosis and intervention.
Holmes et al retrospectively evaluated the occurrence of Charcot joint changes in diabetic patients after fractures of the foot and ankle and noted that of the 11 fractures in which there was a delay in diagnosis and treatment, 8 developed Charcot changes.
Graves et al report patients with diabetic neuropathy are at a higher risk of developing Charcot arthropathy and early diagnosis and intervention is the key to optimizing outcome. They recommend diabetic patients with a lower extremity injury should be screened with sensory testing using a 5.07 monofilament.
Feng et al demonstrated variations in sensitivity of Semmes-Weintein testing due to different methodology, but it is clearly a vital part of detection and prevention of peripheral neuropathy complications.
Figure A shows an ankle joint with obvious medial malleolar resorption and fracture, with malalignment of the ankle joint.
Feng Y, Schlösser FJ, Sumpio BE
J. Vasc. Surg.. 2009 Sep;50(3):675-82, 682.e1. PMID: 19595541 (Link to Abstract)
Graves M, Tarquinio TA.
Orthopedics. 2003 Apr;26(4):415-8. PMID: 12722914 (Link to Abstract)
Holmes GB Jr, Hill N.
Foot Ankle Int. 1994 Apr;15(4):182-5. PMID: 7951951 (Link to Abstract)
Average 4.0 of 8 Ratings
A 29-year-old male presents with left knee instability and progressive gait disturbance. He is only able to ambulate with the assistance of crutches or a walker. He has no pain with ambulation and has decreased vibratory sensation in the bilateral lower extremities. Radiographs are shown in Figures A-B. All of the following are possible etiologies for this condition EXCEPT:
The clinical presentation is consistent with neuropathic (Charcot) joint. Possible causes of neuropathic joint include diabetes mellitus, syringomyelia, leprosy, and neurosyphilis. Figure A and B shows an AP and lateral of the knee with characteristic finding of Charcot joint including fragmentation of both articular surfaces, joint subluxation, and surrounding soft tissue edema. Reiter's syndrome is not a known cause of neuropathic joint.
Neuropathic osteoarthropathy can be defined as bone and joint changes that occur secondary to loss of sensation and that accompany a variety of disorders. The pathophysiology of neuropathic arthropathy is debatable. The general consensus is that the loss of proprioception and deep sensation leads to recurrent trauma, which ultimately leads to progressive destruction, degeneration, and disorganization of the joint.
Kim et al reviewed 19 Charcot knees that underwent TKA and found at 5 year follow-up the average HSS Knee Score was double, but there was a 16% rate of loosening and 6 patients had to undergo a fusion.
Parvizi et al found that in 49 Charcot knees 75% required long-stem, constrained components secondary to ligamentous instability and 75% required bone augmentation in the form of allograft, autograft, or metal wedges. However, they found good functional outcomes at 8 years if attention was paid to the technical challenges found in this patient population.
Illustration A and B shows a severe case of Charcot neuroarthropathy of the knee.
Parvizi J, Marrs J, Morrey BF.
Clin Orthop Relat Res. 2003 Nov;(416):145-50. PMID: 14646753 (Link to Abstract)
Kim YH, Kim JS, Oh SW.
J Bone Joint Surg Br. 2002 Mar;84(2):216-9. PMID: 11922362 (Link to Abstract)
Average 2.0 of 23 Ratings
A 54-year-old diabetic man complains of swelling and erythema throughout the midfoot for 2 weeks. He denies any known trauma. The midfoot is warm, red, and swollen with no skin disruptions on physical exam. The erythema diminishes with elevation of the foot for 15 minutes. He has a temperature of 100.3 degrees Fahrenheit. The patient's CRP is 2.6 (normal range of <6.0). Which of the following is the most likely diagnosis?
Navicular stress fracture
The clinical description is most consistent with neuropathic arthropathy (Charcot) of the midfoot. Dissipation of erythema with elevation is the key finding differentiating neuropathic arthropathy from infection. A foot with osteomyelitis or a deep abscess will remain erythematous with elevation.
Van der Ven et al provide a summary of the clinical presentation, evaluation, and treatment of Charcot arthropathy. Prevention of deformity remains the hallmark goal of treatment.
Average 4.0 of 21 Ratings
HPI - Inability to walk, severe unstable hind foot with type 3 Charcot Foot underwent TTC fusion 6/12 back, failed with exposed tip of one calcaneal screw.
HPI - deformity noticed at left ankle six months back , no h\o of trauma ,deformity gradually increasing,with instability of ankle &inability to attend his daily routine, pain at leg after walk for few meters.(5m)
what is treatment of choice?(pt demand is stable ankle)
HPI - 39 y/o female presents to ER with red, hot, swollen foot. No history of trauma or open lesions/ulcers. Patient diagnosed with diabetes and admitted to hospital for cellulitic foot. Patient was re-admitted to the hospital twice over a one month period for treatment of unresolved cellulitis. During that one month period the patient's diabetes was managed by PCP. No imaging studies were ordered during this one month period by any specialists. Patient was referred to infectious disease to uncover the source of cellulitis. Infectious disease ordered radiograph which revealed charcot foot.
What would be your first line of treatment in this case?