Charcot

Definition

It is a non infectious,destructive process culminating in dislocations and periarticular fractures in patients with peripheral neuropathy and loss of protective sensations

0.1 to 29% incidence

50% need one operation in life time

15-67% chance of amputation

Clinical features

  • Pain
  • Local rise of temparature >3-50 compared to normal
  • Swelling
  • Deformity

Charcot vs Infection

Charcot Infection
Limb elevation decreases inflammation No
No Increased ESR,CRP,IL6
No Istope (In +Tc)scan positive, PET positive

Classification

Eichenholtz
Stage Name Features
0 Prefragmentation Inflammation
1 Fragmentation Subluxation,dislocation
2 Coalascence decreased inflammation
3 Consolidation No inflammation

Progression

0-1 in 6 months and 2-3 in 12-14 months

Causes

  • Endocrine: DM, Renal failure, Alcohol
  • Infection: Leprosy, syphilis
  • Neurogenic: CP, Syrinx,Myelomeningocele, cord injury
  • Idiopathic

Theories

  • Neurotraumatic
  • Neurovascular ( Autonomic dysfunction causing bone resorption)
  • Inflammatory theory (Favored, Here injury lead to inflammation and activate RANK-RANKL pathway leading to bone resorption)
  • ADA, 2011 suggests a hybrid of all theories

Clinical examination

Look

Stand the patient and look for deformity. Most common are Rocker bottom and Planovalgus

Walk the patient and look for Clawing and also have a look at the foot wear

Sit the patient and look for deformity, ulceration and inflammation

Feel

Temperature, tenderness, pulse and sensation

Move

The joints

Special tests

Silfverskiöld test, Vibration, offer probing the ulcer

Management principles

  1. Stop inflammation
  2. Protect and maintain foot architecture
  3. Relieve pain
  4. Arrest or reverse de-mineralisation
  5. Prevent/limit deformity
  6. Control DM

Suspect Charcot if there is a deformity associated with inflammation, perepheral neuropathy with or without renal failure

Suspected a/c Charcot: always take a weight bearing X Ray, if negative take MRI

Immediatly refer to MDT

MDT approach

  1. Non removable offloading device
  2. No Bisphosphonates
  3. Monitor by Foot Skin temperature assessment and seriel xrays until inflammation resolves

When will you say that inflammation is resolved?

  • Temperature difference of < \(2^0\) between the feet
  • Seriel xrays show no progression
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