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 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 (5.07) 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 most sensitive in diagnosing soft tissue and/or osteomyelitis 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 modifications 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
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Percutaneous Achilles Tendon Lengthening Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults
QUESTIONS 1 of 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.92) A 55-year-old man is referred to you for management of a recalcitrant diabetic foot ulcer. He had previously undergone 2 cycles of total contact casting and several bedside debridements. A current clinical photograph is seen in Figure A. Recent midfoot and hindfoot weightbearing radiographs are seen in Figure B. After formal debridement, which of the following is the next best treatment step? Tested Concept QID: 4727 FIGURES: A B Type & Select Correct Answer 1 Charcot restraint orthotic walker 19% (527/2758) 2 Achilles tendon lengthening 11% (303/2758) 3 In-situ tibiotalocalcaneal fusion using an intramedullary device 11% (295/2758) 4 Midfoot osteotomy and Lisfranc joint fusion using plates and screws 9% (247/2758) 5 Reduction and arthrodesis of the Chopart joint using a ring fixator 50% (1373/2758) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 4367 FIGURES: A B Type & Select Correct Answer 1 External fixation 1% (52/4742) 2 Below the knee amputation 19% (910/4742) 3 Continued observation 2% (89/4742) 4 Exostectomy with placement into a protective brace 4% (198/4742) 5 Exostectomy & achilles tendon lengthening with placement into a protective brace 73% (3457/4742) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (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? Tested Concept QID: 4467 FIGURES: A B C D E F Type & Select Correct Answer 1 Figure B 7% (257/3908) 2 Figure C 3% (102/3908) 3 Figure D 50% (1956/3908) 4 Figure E 16% (627/3908) 5 Figure F 24% (926/3908) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 3013 FIGURES: A Type & Select Correct Answer 1 Osteomyelitis 1% (17/2144) 2 Charcot-Marie-Tooth disease 1% (31/2144) 3 Lisfranc fracture-dislocation 1% (18/2144) 4 Charcot arthropathy 96% (2067/2144) 5 Freiberg's Disease 0% (4/2144) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 458 FIGURES: A B C Type & Select Correct Answer 1 Cardiovascular disease 0% (13/2664) 2 Hypertension 0% (4/2664) 3 Diabetes mellitus 97% (2582/2664) 4 Spinal stenosis 1% (15/2664) 5 Rheumatoid arthritis 1% (39/2664) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ07.193) A 65-year-old diabetic female presents with a two-month history of mild ankle pain. 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 and her radiographs are shown in Figures A and B. What is the most appropriate initial treatment at this time? Tested Concept QID: 854 FIGURES: A B Type & Select Correct Answer 1 Modification of shoe wear 9% (234/2581) 2 Use of a total contact cast 80% (2056/2581) 3 Ankle arthrodesis 8% (215/2581) 4 Spanning external fixation of the ankle and hindfoot 1% (36/2581) 5 Below-knee amputation 1% (35/2581) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (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? Tested Concept QID: 796 FIGURES: A B Type & Select Correct Answer 1 Custom orthotics with first ray recession and lateral heel posting 2% (46/1917) 2 Total contact cast and non-weight bearing 88% (1689/1917) 3 Intravenous antibiotics 3% (67/1917) 4 Talonavicular and tarsometarsal arthrodeses 5% (90/1917) 5 Transtibial amputation 1% (21/1917) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ06.130) 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? Tested Concept QID: 316 FIGURES: A Type & Select Correct Answer 1 Carbon fiber shank insole 0% (11/3086) 2 Custom orthotic with Jones bar and medial posting 7% (214/3086) 3 AFO (ankle foot orthosis) with posterior leaf spring 1% (35/3086) 4 Total contact casting 76% (2341/3086) 5 Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes 15% (473/3086) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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 2.6 (normal range of <6.0). Which of the following is the most likely diagnosis? Tested Concept QID: 1133 Type & Select Correct Answer 1 Navicular stress fracture 1% (27/2750) 2 Neuropathic arthropathy 94% (2595/2750) 3 Osteomyelitis 2% (60/2750) 4 Embolic ischemia 2% (47/2750) 5 Rheumatoid arthritis 0% (11/2750) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (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? Tested Concept QID: 963 FIGURES: A Type & Select Correct Answer 1 Thompson test 1% (8/1001) 2 Cotton test 4% (40/1001) 3 Syndesmosis squeeze test 7% (71/1001) 4 Babinski test 0% (3/1001) 5 Semmes-Weinstein monofilament testing 87% (872/1001) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (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: Tested Concept QID: 970 FIGURES: A B Type & Select Correct Answer 1 Diabetes mellitus 8% (161/1937) 2 Syringomyelia 11% (210/1937) 3 Leprosy 12% (236/1937) 4 Neurosyphilis 5% (99/1937) 5 Reiter's syndrome 63% (1224/1937) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept
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