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