Charcot Arthropathy.
Dr. Saima Hashim Khan
Dept. of Diabetes & Endocrinology
HMC. PGMI
Case History : 1
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55yrs old married female
Type2 diabetic 25yrs
HTN 7yrs
Swelling right foot >1month, treated as
cellulitus with antibiotics
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INVESTIGATION
Hb 10.8g/dl, TLC 9900/cmm
S.creatinine 0.7mg/dl
S.uric acid 4.0mg/dl
X ray foot.
4
5
MRI Foot
7
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
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•
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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
lifetime of patients
Foot ulcer in
• 15% of foot ulcers
Osteomyelitis
• 15% of foot ulcers
Amputation
Clinical Care of the Diabetic Foot, 2005
Tragic “Rule of 50”
• 50% of
amputations
• 50% of patients
• 50% of patients
Transfemoral/
transtibial level
2nd amputation in
 5 years
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
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
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 don’t
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