Updated: 6/8/2021

Diabetic Charcot Neuropathy

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
5
N/A
N/A
Questions
19
0
0
0%
0%
Evidence
36
0
0
0%
0%
Cases
3
0%
Techniques
1
Topic
Images
https://upload.orthobullets.com/topic/7047/images/charcot foot_moved.jpg
https://upload.orthobullets.com/topic/7047/images/charcotfooteich1_moved.jpg
https://upload.orthobullets.com/topic/7047/images/charcotfooteich2_moved.jpg
https://upload.orthobullets.com/topic/7047/images/charcotfooteich3a_moved.jpg
https://upload.orthobullets.com/topic/7047/images/charcot shoulder.jpg
https://upload.orthobullets.com/topic/7047/images/charcot knee.jpg
https://upload.orthobullets.com/topic/7047/images/1.jpg
https://upload.orthobullets.com/topic/7047/images/2.jpg
  • Summary
    • Diabetic Charcot Neuropathy is a chronic and progressive disease that occurs as a result of loss of protective sensation which leads to the destruction of foot and ankle joints and surrounding bony structures.
    • Diagnosis can be made clinically with a warm and erythematous foot with erythema that decreases with foot elevation. Radiographs often reveal obliteration of joint space and fragmentation of both articular surfaces of a joint leading to subluxation or dislocation.
    • Treatment is a trial of total contact casting for acute charcot deformities without skin breakdown. Operative management is indicated for recurrent infections, deformities, and severe skin breakdown. 
  • 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)
    • Anatomic 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
  • Etiology
    • 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
            • sensitivity of 40-95% in diagnosing neuropathy
  • 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
  • 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 Guides (1)
Flashcards (5)
Cards
1 of 5
Questions (19)
Question locked
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?

QID: 4727
FIGURES:
1

Charcot restraint orthotic walker

19%

(546/2896)

2

Achilles tendon lengthening

11%

(325/2896)

3

In-situ tibiotalocalcaneal fusion using an intramedullary device

11%

(308/2896)

4

Midfoot osteotomy and Lisfranc joint fusion using plates and screws

9%

(261/2896)

5

Reduction and arthrodesis of the Chopart joint using a ring fixator

50%

(1442/2896)

L 4 C

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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?

QID: 4367
FIGURES:
1

External fixation

1%

(52/4860)

2

Below the knee amputation

19%

(932/4860)

3

Continued observation

2%

(90/4860)

4

Exostectomy with placement into a protective brace

4%

(201/4860)

5

Exostectomy & achilles tendon lengthening with placement into a protective brace

73%

(3549/4860)

L 2 C

Select Answer to see Preferred Response

(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?

QID: 4467
FIGURES:
1

Figure B

7%

(266/4028)

2

Figure C

3%

(103/4028)

3

Figure D

50%

(2005/4028)

4

Figure E

16%

(652/4028)

5

Figure F

24%

(962/4028)

L 4 C

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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?

QID: 3013
FIGURES:
1

Osteomyelitis

1%

(18/2245)

2

Charcot-Marie-Tooth disease

1%

(33/2245)

3

Lisfranc fracture-dislocation

1%

(18/2245)

4

Charcot arthropathy

96%

(2164/2245)

5

Freiberg's Disease

0%

(5/2245)

L 1 B

Select Answer to see Preferred Response

Question locked
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?

QID: 458
FIGURES:
1

Cardiovascular disease

1%

(14/2786)

2

Hypertension

0%

(5/2786)

3

Diabetes mellitus

97%

(2695/2786)

4

Spinal stenosis

1%

(16/2786)

5

Rheumatoid arthritis

2%

(44/2786)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 854
FIGURES:
1

Modification of shoe wear

9%

(239/2660)

2

Use of a total contact cast

80%

(2115/2660)

3

Ankle arthrodesis

9%

(227/2660)

4

Spanning external fixation of the ankle and hindfoot

1%

(38/2660)

5

Below-knee amputation

1%

(36/2660)

L 1 B

Select Answer to see Preferred Response

(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?

QID: 796
FIGURES:
1

Custom orthotics with first ray recession and lateral heel posting

3%

(56/1982)

2

Total contact cast and non-weight bearing

87%

(1734/1982)

3

Intravenous antibiotics

4%

(71/1982)

4

Talonavicular and tarsometarsal arthrodeses

5%

(94/1982)

5

Transtibial amputation

1%

(23/1982)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 316
FIGURES:
1

Carbon fiber shank insole

0%

(11/3179)

2

Custom orthotic with Jones bar and medial posting

7%

(215/3179)

3

AFO (ankle foot orthosis) with posterior leaf spring

1%

(37/3179)

4

Total contact casting

76%

(2415/3179)

5

Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes

15%

(488/3179)

L 2 D

Select Answer to see Preferred Response

(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?

QID: 1133
1

Navicular stress fracture

1%

(27/2898)

2

Neuropathic arthropathy

94%

(2732/2898)

3

Osteomyelitis

2%

(67/2898)

4

Embolic ischemia

2%

(51/2898)

5

Rheumatoid arthritis

0%

(11/2898)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 963
FIGURES:
1

Thompson test

1%

(8/1101)

2

Cotton test

4%

(41/1101)

3

Syndesmosis squeeze test

7%

(76/1101)

4

Babinski test

0%

(3/1101)

5

Semmes-Weinstein monofilament testing

88%

(966/1101)

L 1 C

Select Answer to see Preferred Response

(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:

QID: 970
FIGURES:
1

Diabetes mellitus

8%

(167/1985)

2

Syringomyelia

11%

(214/1985)

3

Leprosy

12%

(240/1985)

4

Neurosyphilis

5%

(102/1985)

5

Reiter's syndrome

63%

(1255/1985)

L 3 C

Select Answer to see Preferred Response

Evidence (36)
VIDEOS & PODCASTS (1)
CASES (3)
EXPERT COMMENTS (15)
Private Note