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Diabetic Foot Charcot Neuropathy

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Topic updated on 08/03/14 1:10pm
Introduction
  •  A chronic and progressive joint disease following loss of protective sensation
    • leads to destruction of joints and surrounding bony structures
    • may lead to amputation if left untreated
  • Epidemiology
    • incidence
      • 0.1-1.4% of patients with diabetes
      • 7.5% of patients with diabetes and neuropathy
    • demographics
      • age bracket
        • type 1 diabetes
          • typically presents in 5th decade (20-25 years following diagnosis)
        • type 2 diabetes
          • typically presents in 6th decade (5-10 years following diagnosis)
    • location
      • foot and ankle (diabetic Charcot foot)
        • 9-35% have bilateral disease
      • shoulder and elbow
      • knee  
        • often leads to ligamentous instability and bone loss
    • risk factors
      • diabetic neuropathy
      • alcoholism
      • leprosy
      • myelomeningocele
      • tabes dorsalis/syphilis
      • syringomyelia
  • Mechanism and pathophysiology
    • theories
      • neurotraumatic
        • insensate joints subjected to repetitive microtrauma
        • body unable to adopt protective mechanisms to compensate for microtrauma due to abnormal sensation
      • neurovascular
        • autonomic dysfunction increases blood flow through AV shunting
        • leads to bone resorption and weakening
    • molecular biology
      • inflammatory cytokines may cause destruction
        • IL-1 and TNF-alpha lead to increased production of
          • transcription factor-kB
          • RANK/RANKL/OPG triad pathway post
  • Associated conditions
    • orthopaedic manifestations
      • foot ulcerations
Classification
 
Brodsky Classification
Type 1  • Involves tarsometatarsal and naviculocuneiform joints
 • Collapse leads to fixed rocker-bottom foot with valgus angulation
60%
 
Type 2  • Involves subtalar, talonavicular or calcaneocuboid joints
 • Unstable, requires long periods of immobilization (up to 2 years) 
10%
 
Type 3A  • Involves tibiotalar joint
 • Late varus or valgus deformity produces ulceration and osteomyelitis of malleoli
20%
Type 3B  • Follows fracture of calcaneal tuberosity
 • Late deformity results in distal foot changes or proximal migration of the tuberosity
< 10%
Type 4  • Involves a combination of areas < 10%
Type 5  • Occurs solely within forefoot < 10%
 
Eichenholtz Classification
Stage 0
 • Joint edema
 • Radiographs are negative
 • Bone scan may be positive in all stages
  
Stage 1 fragmentation  • Joint edema
 • Radiographs show osseous fragmentation with joint dislocation 
  
Stage 2 coalescence  • Decreased local edema
 • Radiographs show coalescence of fragments and absorption of fine bone debris
  
Stage 3 reconstruction  • No local edema
 • Radiographs show consolidation and remodeling of fracture fragments
  

 

Presentation
  • Symptoms
    • swollen foot and ankle 
    • pain in 50%, painless in 50%
    • loss of function
  • Physical exam
    • acute Charcot neuropathy
      • inspection
        • swollen
        • warm
          • average of 3.3 degrees C warmer than contralateral side
        • erythema
          • often confused with infection
          • erythema will decrease with elevation in Charcot arthropathy, but is unchanged in infection
    • chronic Charcot neuropathy
      • inspection
        • structurally deformed foot
        • bony prominences
        • rocker bottom deformity
        • collapse of medial arch
      • motion
        • may be ligamentously unstable
      • neurovascular
        • Semmes-Weinstein monofilament testing
Imaging
  • Radiographs
    • views
      • obtain standard AP and lateral of foot, complete ankle series 
    • findings
      • early changes
        • degenerative changes may mimic osteoarthritis
      • late changes
        • obliteration of joint space
        • fragmentation of both articular surfaces of a joint leading to subluxation or dislocation
        • scattered "chunks" of bone in fibrous tissue
        • surrounding soft tissue edema
        • joint distension by fluid
        • heterotopic ossification
  • Bone scan
    • indications
      • useful to help determine presence of superimposed osteomyelitis
    • type of study
      • technetium bone scan
        • may be positive for a neuropathic joint and osteomyelitis
      • indium WBC scan
        • negative (cold) for neuropathic joints and positive (hot) for osteomyelitis
  • MRI
    • indications
      • best for differentiating abscess from soft-tissue swelling
    • limitations
      • difficult to differentiate infection from Charcot arthropathy on MRI
Studies
  • Laboratory
    • inflammatory markers
      • ESR and WBC
        • elevated in both infection and Charcot arthropathy
    • wound healing levels
      • absolute lymphocyte count >1500/mm3
      • serum albumin >3.0g/dL
  • Biopsy
    • may be used to guide antibiotic therapy in cases of associated osteomyelitis or soft tissue abscess
  • Histology
    • synovial hypertrophy
    • detritic synovitis (cartilage and bone distributed in synovium)
Treatment
  • Nonoperative 
    • total contact casting, shoewear modifications, medications   
      • indications
        • first line of treatment
      • technique
        • contact casting
          • casts changed every 2-4 weeks for 2-4 months
        • orthotics
          • Charcot restraint orthotic walker (CROW) boot can be used after contact casting  
        • shoe modifcations
          • in Eichenholtz stage 3 double rocker shoe modifications will best reduce risk for ulceration at the plantar apex of the deformity 
        • medications
          • bisphosphonates
          • neuropathic pain medications
          • antidepressants
          • topical anesthetics
      • outcomes
        • 75% success rate
  • Operative
    • resection of bony prominences (exostectomy) and TAL
      • indications
        • "braceable" foot with equinus deformity and focal bony prominences causing skin breakdown
      • technique 
        • goal is to achieve plantigrade foot that allows ambulation without skin compromise
    • deformity correction, arthrodesis +/- osteotomies  
      • indications
        • severe deformity that is not "braceable"
      • outcomes
        • very high complication rate (up to 70%)
    • amputations
      • indications
        • failed previous surgery (unstable arthrodesis)
        • recurrent infection
      • technique
        • goal is for a partial or limited amputation if vascularity allows
Surgical Techniques
  • Arthrodesis
    • technique
      • fixation techniques
        • internal fixation
          • screw, pins, plates, tibiocalcaneal nail
        • external fixation
          • used when bone quality is poor or soft tissues are compromised
    • post-operative care
      • minimal weight-bearing for three months
    • cons
      • high complication rate (up to 70%)
        • infection
        • hardware malposition
        • recurrent ulceration
        • fracture

 

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Qbank (11 Questions)

TAG
(OBQ12.7) 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? Topic Review Topic
FIGURES: A   B        

1. External fixation
2. Below the knee amputation
3. Continued observation
4. Exostectomy with placement into a protective brace
5. Exostectomy & achilles tendon lengthening with placement into a protective brace

PREFERRED RESPONSE ▶
TAG
(OBQ12.107) 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? Topic Review Topic
FIGURES: A   B   C   D   E   F

1. Figure B
2. Figure C
3. Figure D
4. Figure E
5. Figure F

PREFERRED RESPONSE ▶
TAG
(OBQ09.200) 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? Topic Review Topic
FIGURES: A          

1. Osteomyelitis
2. Charcot-Marie-Tooth disease
3. Lisfranc fracture-dislocation
4. Charcot arthropathy
5. Freiberg's Disease

PREFERRED RESPONSE ▶
TAG
(OBQ08.72) 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? Topic Review Topic
FIGURES: A   B   C      

1. Cardiovascular disease
2. Hypertension
3. Diabetes mellitus
4. Spinal stenosis
5. Rheumatoid arthritis

PREFERRED RESPONSE ▶
TAG
(OBQ07.135) 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? Topic Review Topic
FIGURES: A   B        

1. Custom orthotics with first ray recession and lateral heel posting
2. Total contact cast and non-weight bearing
3. Intravenous antibiotics
4. Talonavicular and tarsometarsal arthrodeses
5. Transtibial amputation

PREFERRED RESPONSE ▶
TAG
(OBQ07.193) 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? Topic Review Topic
FIGURES: A   B        

1. Modification of shoe wear
2. Use of a CROW walker boot
3. Ankle arthrodesis
4. Spanning external fixation of the ankle and hindfoot
5. Below-knee amputation

PREFERRED RESPONSE ▶
TAG
(OBQ06.130) A 57-year-old woman with type 2 diabetes has had the plantar foot ulcer shown in Figure A for 2 months. Medical comorbidities include renal insufficiency and hypertension. A radiograph is provided in Figure B. Following ulcer debridement, what initial management will provide the best long term function? Topic Review Topic
FIGURES: A   B        

1. Carbon fiber shank insole
2. Charcot restraint orthotic walker (CROW)
3. AFO (ankle foot orthosis) with posterior leaf spring
4. Total contact casting
5. Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes

PREFERRED RESPONSE ▶
TAG
(OBQ05.77) 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? Topic Review Topic
FIGURES: A          

1. Thompson test
2. Cotton test
3. Syndesmosis squeeze test
4. Babinski test
5. Semmes-Weinstein monofilament testing

PREFERRED RESPONSE ▶
TAG
(OBQ05.84) 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: Topic Review Topic
FIGURES: A   B        

1. Diabetes mellitus
2. Syringomyelia
3. Leprosy
4. Neurosyphilis
5. Reiter's syndrome

PREFERRED RESPONSE ▶
TAG
(OBQ05.247) 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 elevated with a result of 6. Which of the following is the most likely diagnosis? Topic Review Topic

1. Navicular stress fracture
2. Neuropathic arthropathy
3. Osteomyelitis
4. Embolic ischemia
5. Rheumatoid arthritis

PREFERRED RESPONSE ▶



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