Charcot Foot Disease Prof. - PowerPoint Presentation

1. Charcot Foot Disease Prof. Ahmed M. A. KensarahDepartment of surgeryFaculty of Medicine, King Abdulaziz University Hospital,Jeddah , Saudi Arabia

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3. Charcot foot disease is commonly associated with diabetic patients . It was first described by J.M Charcot in patient of tabes dorsalis[1]. Charcot osteoarthropathy [COA] is a debilitating disease and some times can be limb threatening. Its prevalence in diabetic patients is 0.4 to 13%[3,4].Charcot Foot Disease

4. Other than diabetes rheumatoid arthritis, trauma, multiple sclerosis, leprosy, poliomyelitis, alcohol abuse, syringomyelia , heavy metal poisoning, and congenital neuropathies also contributes for the development of charcot osteoarthropathy[5,6]. Prevalence of charcot foot disease is increasing which may be due to new imaging which results in increase in diagnosis[7]. Charcot Osteoarthropathy

5. EtiologyNeurovascular theory (French): Dysregulated autonomic nervous system hyperemia. Neurotraumatic theory (German): Loss of peripheral sensation and proprioception repetitive microtrauma inflammatory resorption of traumatized bone.

6. Clinical featuresHistory of fall, sprain, trauma.May be painless because of diabetic neuropathy. Unilateral lower extremity warmth, redness, and/or edema.Rocker- bottom foot , deformity foot “Bounding” pedal pulses; no systemic signs of infection.

7. Differential diagnosesCellulitisOsteomyelitisDeep vein thrombosis

8. Joints InvolvedTarsometatarsal joint - 60% Metatarsophalangeal joint – 30% Talocrural joint (ankle) –10%

9. Loss of arch, pes deformity

10. Charcot foot

11. Rocker bottom foot

12. Treatment Off-loading devicesStabilization (casting) Custom footwear Pharmacologic therapy: Bisphosphonates – minimize bone resorption.Surgery- arthrodesis/ debridement/amputation

13. Cam/fracture walker

14. Cast

15. CROW (Charcot Restraint Orthotic Walker)

16. To evaluate Charcot neuroarthropathy in diabetic foot patients at tertiary hospitalRetrospective study of charcot foot in diabetic patients admitted from 2005 to 2015 in King Abdulaziz University hospital , Jeddah, Saudi Arabia. Sixty four patients admitted as diabetic foot disease were studied

17. Males-81.2%Females -18.8%Mean age -61.75 yrsSymptoms –Pain-25%Numbness-12.5%Foot deformity-23.4%Discharge-73.4%Difficulty in walking -12.5%HistoryHistory of trauma-10.9%Cont.

18. NIDDM-68.8%IDDM-31.2%DM more than 10 years-62.5%Uncontrolled DM-73.4%Neuropathy-59.4%Vasculopathy-56.3%Obesity-10.9%Hypertension -83.8%Dyslipidemia-31.3%Cont.

19. Clinical PicturePt. presents with swollen , red , hot, foot usually painless in diabetic patient may clinch the diagnosis.D.D However , it must be distinguished from trauma, cellulitis, sprain, acute gout, Deep vein thrombosis and osteomyelitis[10].

20. TreatmentTreatment starts with offloading which is required to prevent progression of disease, while surgery is needed in chronic cases with joint instability or deformity[11].

21. MethodsIt is a retrospective study from 2005 to 2015 of charcot foot patients in diabetic patients admitted in KAUH.Sixty four patients were admitted as diabetic foot disease and were studied.Patients admitted for diabetic foot disease in hospital were studied for Charcot joint disease.Collection of data done by reviewing patients files, OPD visits, OR notes and inpatients records.

22. Results Majority of patients were males 81.2% and females 18.8 %. Mean age was 61.75 years. Pain was reported by 25% of patients, numbness by 12.5%, foot deformity by 23.4%, discharge by 73.4%, difficulty in walking by 12.5%, and 10.9% had history of trauma.

23. Results Majority of patients were NIDDM 68.8 %, IDDM 31.2%, 62.5 % had DM more than 10 years , uncontrolled DM in 73.4%. Nephropathy in 46.3%, neuropathy in 59.4%, retinopathy in 40.6%, cardiomyopathy in 48.4% and vasculopathy in 56.3%.

24. Figure -1: Age distribution

25. Figure -2 :Complaints

26. Figure-3: Co-morbiditiesAssociated co-morbidities were obesity in 10.9%, hypertension in 83.8%, dyslipidemia in 31.3%, hypothyroidism in 14.1%, immunosuppression in 3.1, arrhythmia in 3.1% and anemia in 84.4%.

27. Figure-4 ; Diabetes detailsDiabetes DetailsPercentage 68.8IDDM31.3NIDDM62.5More than 10 yrs36.9Less than 10 yrs21.9Controlled 73.4Not controlled46.3Nephropathy 59.4Neuropathy 40.6Retinopathy 48.4Cardiomyopathy 56.3Vasculopathy

28. Charcot arthropathy was in 28.1% of cases and forefoot was involved in 65.5%, midfoot in 4.7% and hindfoot/ankle in 21.9%. Figure -5; physical finding

29. Figure-6 : x-rays findingsX-rays showed subluxation in 40.6%, dislocation in 54.7%, disorganized foot joints in 42.2%, bone resorption in 23.4%, osteomyelitis in 14.1%, fractures in 50%, joint collapse in 39.15 and destruction of articular surfaces in 37.5%.

30. Figure -7; X-Ray findings.

31. Figure-8 ; charcot foot

32. Figure -9 ; Rocker bottom foot deformity

33. Figure 10: Hind foot deformity

34. Figure-11: hind foot deformity

35. Figure-12; : Surgical treatment, level of amputation

36. Surgical treatment, level of amputationDebridement was done in 25% of cases while 75% of patients underwent some sort of amputation. 14.1% of patients underwent above knee amputation, 10.9 % below knee amputation, 10.9% transmetatarsal and 39.1% toe amputation.

37. DiscussionPathogenesis of Charcot foot disease is multifactorial. In diabetes polyneuropathy is one of initial event in charcot osteopathy. Sensory neuropathy results in decreased sensations and repeated microtrauma results in hyperemia and ultimately destruction of joints . Motor neuropathy causes decreased strength of intrinsic and extrinsic muscles resulting in deformity which further causing abnormal plantar pressures and abnormal collagen formation[12].

38. DiscussionAutonomic neuropathy leads to increased perfusion and increased osteoclast activity resulting in osteopenia and pathologic fractures[13]. Incidence is equal in both sexes. Patients who are at high risk of developing charcot arthropathy are poorly controlled diabetes more than 10 years, neuropathy and trauma[14].

39. Eichenholtz clssificationEichenholtz classification of neuropathy divides into three stages:Stage 1-development where subluxation, osteolysis and fracture occur. Stage-2 coalescence where resorption of debris and fusion of fracture occur .Stage-3 where healing and hypertrophic bone formation occur[15].

40. Sella and Barette introduced five stages stage-0 has pain, erythema, oedema, warm foot.stage-1 osteopenia, erosions, diastasis, stage-2 subluxation, stage-3 dislocation and joint destruction and stage-4 which is characterized by healing and hypertrophic bone formation[16]. Sella and Barette classification

41. Sanders –Frykberg classified anatomically into five patterns, 1- forefoot2- Tarsometatarsal joint3- Talonavicular, calcaneocuboid and naviculocuneiform4-ankle joint 5- calcaneus[14]. Frykberg classification

42. Charcot Foot DiseaseMean age of our patient was 61.75 years which is near similar to studies of Sanders et.al where it was mid fiftees[12] and 63 years in study of Min et. Al[17]. In our study majority of patients were males 81.2 % , and females 18.8% while Min et.al reported males 97.1%[17]. This again confirms the fact that diabetic foot disease is a disease of middle age and Charcot neuroarthropathy develops in long standing diabetic foot disease.

43. Twenty five percent patients complained of foot pain in our study while Baglioni, Botek, and Petrova et .al reported pain in less than 50% of cases[18,19,20]. Since patients with Charcot neuroarthropathy have neuropathy so less number of our patient reported pain. 62.5 % of our patients had diabetes for more than 10 years which is similar to studies of Leung et.al and Samann et.al[21,22]. X-rays were used to diagnose bony changes in charcot patients. Charcot Foot Disease (Cont.)

44. X-ray Stage 0: Joint edema, X-ray- negative. Stage 1: “Acute Charcot” – Osseous fragmentation and joint dislocation seen on radiograph Stage 2: Decreased local edema, coalescence of fragments and absorption of fine bone debris.Stage 3: No local edema, with consolidation and remodeling (deformed) of fracture fragments. The foot is now stable.

45. Initial x-rays were normal and patients had only soft tissue deformity. 28.1 % of diabetic patients had charcot foot disease in our patients which is quite high percentage. Forefoot was involved in majority of our patients 65% followed by hind foot and midfoot . Offloading was non operative management commonly it was foot wear. Charcot Foot Disease (Cont.)

46. The gold standard of off-loading is the total contact cast [23,24]. Surgery in the form of debridement and amputation was offered. Majority had toe amputation followed by above knee amputation. Charcot Foot Disease (Cont.)

47. ConclusionsDiabetic patients with Charcot joint disease poses great challenge in management.Emphasis should be given for early detection, investigations and prompt treatment.Treatment should be tailored according to stage of disease and patient occupation.

48. Thank you

49. References 1-Trepman E, Nihal A, Pinzur MS. Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int 2005; 26: 46-63.2-Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR,Landsman AS, Lavery LA, Moore C, Schuberth JM, Wukich DK, Anderson C,Vanore JV: Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg 2006, 45(5):S1–S66.3-Frykberg RG, Belczyk R: Epidemiology of the Charcot Foot. Clin Podiatr Med Surg 2008, 25:17–28.4- Leung HB, Ho YC, Wong WC: Charcot foot in Hong Kong Chinese diabetic population. Hong Kong Med J 2009, 15(3):191–195.

50. References (Cont.) 5- Gupta R. A short history of neuropathic arthropathy. Clin OrthopRelat Res 1993; 296: 43-496- Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications 2009; 23: 409-426.7- Rajbhandari SM, Jenkins RC, Davies C, Tesfaye S. Charcot neuroarthropathy in diabetes mellitus. Diabetologia 2002; 45:1085-1096.8- Cofield RH, Morrison MJ, Beabout JW. Diabetic neuroarthropathy in the foot: patient characteristics and patterns of radiographic change. Foot Ankle 1983; 4: 15-22.

51. References (Cont.) 9-Frykberg RG. Charcot foot. In: Boulton AJM, Connor H,Cavanagh PR, eds. The foot in diabetes. John Wiley Sons,Chichester, 2000:235-6010- Chantelau E. The perils of procrastination: effects of early vs.delayed detection and treatment of incipient Charcot fracture.Diabet Med 2005; 22: 1707-1712.11- Stefansky SA, Rosenblum BI. The Charcot foot: a clinical challenge.Int J Low Extrem Wounds 2005; 4: 183-187.12-Sanders LJ, Frykberg RG. Charcot foot. In: Levin ME, O'Neal LW, Bowker JH, eds. The Diabetic Foot. St. Louis: Mosby, 1993:149±80.

52. References (Cont.) 13-Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot's arthropathy in a diabetic foot specialty. clinic. Diabetic Med 1997;14:357±6314-Sanders LJ, Frykberg RG. Charcot foot. In: Levin ME, O'Neal LW, Bowker JH, eds. The Diabetic Foot. St. Louis: Mosby, 1993:149±80.15-Yu GV, Hudson JR. Evaluation and treatment of stage 0 Charcot's neuroarthropathy of the foot and ankle . J Am Podiatr Med Assoc 2002;92:210±20.16- Armstrong DG, Peters EJG. Charcot's arthropathy of the foot. J Am Podiatr Med Assoc 2002;92:390±4.

53. 17- Min.W. S, Todd A. L, Rodney M. S., Robert G. Fryberg, Elly BM ;Mortality Risk of Charcot Arthropathy Compared With That of Diabetic Foot Ulcer and Diabetes Alone Diabetes Care 2009;32:816–821. 18- Baglioni P, Malik M, Okosieme OE: Acute Charcot foot. BMJ 2012, 344(1397):1–4.19- Botek G, Anderson MA, Taylor R: Charcot neuroarthropathy: an often overlooked complication of diabetes. Cleve Clin J Med 2010, 77(9):593–599.20- Petrova NL, Edmonds ME: Charcot neuro-osteoarthropathy – current standards. Diabetes Metab Res Rev 2008, 24(Suppl 1):58–61.References (Cont.)

54. 21-Leung HB, Ho YC, Wong WC: Charcot foot in Hong Kong Chinese diabetic population. Hong Kong Med J 2009, 15(3):191–195.22-Samann A, Pofahl S, Lehmann T, Voigt B, Victor S, Moller F, Muller UA, Wolf G: Diabetic Nephropathy but not HbA1c is Predictive for Frequent Complications of Charcot Feet – Long-term follow-up of 164 Consecutive Patients with 195 Acute Charcot Feet. Exp Clin Endocrinol Diabetes 2012, 120:335–339.23-Stefansky SA, Rosenblum BI. The Charcot foot: a clinical challenge.Int J Low Extrem Wounds 2005; 4: 183-187.24-van der Ven A, Chapman CB, Bowker JH. Charcot neuroarthropathy of the foot and ankle. J Am Acad Orthop Surg 2009; 17: 562-571References (Cont.)