Charcot Arthropathy.

Case History : 1

55yrs old married female

Type2 diabetic 25yrs
HTN 7yrs
Swelling right foot >1month, treated as
cellulitus with antibiotics

INVESTIGATION

Hb 10.8g/dl, TLC 9900/cmm

S.creatinine 0.7mg/dl
S.uric acid 4.0mg/dl
X ray foot.

MRI Foot

Case History : 2
45yrs old married female
DM2 15yrs (Retinopathy: PRP,
Nephropathy: crt clr 103 )
HTN 5yrs
Post amputation RT big toe 3yrs
Swelling LT foot 2 months, treated as
cellulitis with antibiotics

Investigations

Hb:9.5 gm/dl, TLC 9600/cmm

URIC ACID 4.2mg/dl
CREATININE 1.02mg/dl
DOPPLER U/S LT FOOT : no DVT normal
arterial flow and subcutaneous edema.
Xray Foot:

10

X Ray Foot

11

12

13

Tragic Rule of 15
15% of diabetes
Foot ulcer in
lifetime of patients
15% of foot ulcers

Osteomyelitis

15% of foot ulcers

Amputation

Clinical Care of the Diabetic Foot, 2005

Tragic Rule of 50
50% of
amputations

Transfemoral/
transtibial level

50% of patients

2nd amputation in
5 years

50% of patients

Die in 5 years

Clinical Care of the Diabetic Foot, 2005

History of charcot foot

Mitchell,1831: The first association
between joints and neurological diseases.
Charcot 1868: Arthropathy and tabes
dorsalis.
Jordan 1936: Neuritic manifestation of DM

Charcots Foot
A Neuropathic Arthropathy
Caused by repetitive trauma in the setting
of:
Diminished sensation & proprioception
Motor neuropathy results in muscle
imbalance & abnormal weight bearing.
Rocker Bottom Deformity
a convex deformity of the foots plantar
aspect caused by the collapse of
metatarsal bones

Etiology
Peripheral sensory neuropathy is always
present +/- motor.
Autonomic neuropathy leads to increased blood
flow.
Trauma may be an important precipitating
factor, although 2/3rd of patients dont
remember any injury.
Bone metabolism both osteoblastic and
osteoclastic activities are increased.

Epidemiology
Incidence : 0.1 0.5 % . General:
Increased in patients with neuropathy.
Diabetics: 3-5%
Common in the 4th or 5th decades of life.
Bilateral in 30 % of patients.
Sex difference : No
Type 1 or type 2: Both are at risk.
Majority: in the mid foot but any bone or
joint in the foot or ankle can be affected.

Clinical Features and Diagnosis

Acute Charcot
Warm, inflamed and swollen.
Misdiagnosed as cellulitis, osteomyelitis or
inflammatory arthropathy as gouty or septic.
Although sensory neuropathy, pain is
common feature followed by discomfort.
Diagnosis by exclusion as investigations in
early stages are negative.

Clinical Features and Diagnosis

High index of suspicion is necessary so that
appropriate treatment is immediately
instituted to prevent severe deformity!

Clinical Features and Diagnosis

Chronic Charcot, may be months, painless,
without temperature difference and
deformed.
Reactivation by further trauma is frequent.
Patients are at high risk of ulceration and
amputation, so long term follow up is
recommended.

Investigations
X-ray : Early; absent or subtle finding.
Late; bone and joint destruction,
fragmentation.
bone scan: Increased bone uptake.
In labeled leucocytes scan to differentiate
from osteomyelitis.
MRI: Bone marrow edema is the earliest
sign.

Treatment
1. Immobilization
2. Pharmacological Treatment.
3. Surgical Treatment.

Treatment
1. Immobilization:
Almost 16 weeks (3-6 months) but may be more.
(temp gradient less than 1 on 2 occasions or
serial radiology).

Treatment
1.

Immobilization:
Bed rest
Half-shoes
Crutches, Walkers and Wheelchairs
Total contact cast (TCC) -gold standard
Prefabricated pneumatic walking brace ( Air cast )

Total contact cast

Air cast

Half shoe

Modified/custom
shoes/orthoses

Treatment
3. Pharmacological Treatment.
Pilot study first using pamidronate,1994.
Other Bisphosphonates were used to decrease disease
activity and bone turnover markers.
Calcitonin were also used.
Given for 12 weeks or till temp gradient is less than 2 on 2
consecutive visits.

Treatment
4. Surgical treatment:
No role in acute.
Later may be to remove bony deformities or
constructive surgeries to achieve a stable
shape.
Techniques include; Arthrodesis, exostectomies,
reconstruction and Achilles tendon lengthening.

Take Home Message

High degree of suspicion to diagnose
acute Charcot arthropathy.
High risk categorization.
Immobilization
Bisphosphonate.
Customized Foot Wear

Thank
You