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 login to view 1 more bullet type 2 diabetes login to view 1 more bullet 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 login to view 2 more bullets neurovascular login to view 2 more bullets molecular biology inflammatory cytokines may cause destruction login to view 3 more bullets 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 login to view 6 more bullets chronic Charcot neuropathy inspection login to view 4 more bullets motion login to view 1 more bullet neurovascular login to view 2 more bullets Imaging Radiographs views obtain standard AP and lateral of foot, complete ankle series findings early changes login to view 1 more bullet late changes login to view 6 more bullets Bone scan indications useful to help determine presence of superimposed osteomyelitis type of study technetium bone scan login to view 1 more bullet indium WBC scan login to view 1 more bullet 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 login to view 1 more bullet 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 login to view 1 more bullet technique login to view 11 more bullets outcomes login to view 1 more bullet Operative resection of bony prominences (exostectomy) and TAL indications login to view 1 more bullet technique login to view 1 more bullet deformity correction, arthrodesis +/- osteotomies indications login to view 1 more bullet outcomes login to view 1 more bullet amputations indications login to view 2 more bullets technique login to view 1 more bullet Techniques Arthrodesis technique fixation techniques login to view 4 more bullets post-operative care minimal weight-bearing for three months cons high complication rate (up to 70%) login to view 5 more bullets