Charcot Arthropathy.
Hanan El-Soutouhy Gawish.
Prof Int Med, Diabetes Unit,Mansoura University
International Working Group of Diabetic Foot
Egypt Representative
Charcot Arthropathy
Mansoura 2nd International DF Training Course
History
Mitchell,1831: The first association between joints
and neurological diseases.
Charcot 1868: Arthropathy and tabes dorsalis.
Jordan 1936: Neuritic manifestation of DM
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot’s 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 foot’s plantar
aspect caused by the collapse of
metatarsal bones
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Aetiopathogenesis
Peripheral sensory neuropathy is always
present +/- motor.
Autonomic neuropathy leads to increased blood
flow.( plethysmography & uptake of isotopes).
Trauma may be an important precipitating
factor, although 2/3rd of patients don’t
remember any injury.
Bone metabolism both osteoblastic and
osteoclastic activities are increased.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Epidemiology
Incidence : 0.1 – 0.5 % .
Increased in patients with neuropathy.
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.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
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.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Clinical Features and Diagnosis
High index of suspicion is necessary so that
appropriate treatment is immediately
instituted to prevent severe deformity!
Charcot Arthropathy
Mansoura 2nd International DF Training Course
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.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Investigations
X-ray : Early; absent or subtle finding. Late;
bone and joint destruction, fragmentation.
Tc bisphosphonate bone scan: Increased
bone uptake.
In labeled leucocytes scan to differentiate
from osteomyelitis.
MRI: Bone marrow oedema is the earliest
sign.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Treatment
1.
2.
3.
4.
Immobilization
Radiotherapy and Ultrasound.
Pharmacological Treatment.
Surgical Treatment.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Treatment
1. Immobilization:
Total Contact Cast (TCC), Removable Cast
Walker (RCW).
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Removable Cast Walker
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Treatment
1. Immobilization:
Almost 16 weeks (3-6 months) but may be
more. (temp gradient less than 1 on 2
occasions or radiology).
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Treatment
2. Radiotherapy and Ultrasound:
May be useful in conjunction to offloading but
only few small studies.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
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.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
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.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Conclusion
High degree of suspicion to diagnose
acute Charcot arthropathy.
High risk categorization.
Immobilization and Bisphosphonate.
Charcot Arthropathy
Mansoura 2nd International DF Training Course
Thank You
Charcot Arthropathy
Mansoura 2nd International DF Training Course