By Rafi Mahandaru \ 212

CHARCOT FOOT

By Rafi Mahandaru \ 212

CHARCOT FOOT

Jean-Marie Charcot• 29 November 1825 – 16 August 1893

• The father of neurology

• Charcot triad-1 MS• Charcot triad-2 AC• Charcot joint, known

as Charcot neuroarthropathy (CNA)/charcot osteoarthropathy (COA) / charcot foot/ neuropathic joint

DEFINITION

Charcot footCharcot foot can be defined as a relatively painless, progressive and degenerative

arthropathy of single or multiple joints caused by an underlying neurological deficit.

It was a limbthreatening condition, wich can lead to amputation

ETIOLOGY

Firstly describes 1868Tabes Dorsalis late manifestation of shypilis

Bilateral degeneration of axons in BOTH dorsal columns• Pain, parestethic, sensory loss• Muscle stretch reflex also messed up

because the sensory input to those reflexes have been lesioned

• usually occurs at lumbar levels

Recent common cause

• Complication of diabetes melitus

• is estimated to affectbetween 1-2.5% of people with diabetes (2003)

• It is estimated to affect 0.8%-8% of diabetic populations (2011)

• At least 10 years suffer

Another rare cause

PATHOPHYSIOLOGY

French Theory• Charcot 1868 neurovascular theory• “…the arthropathy of ataxic patients seems to

always start after the sclerotic changes have taken place in the spinal cord.”

• Spinal cord lesion autonomic neuropathy arterious venous shunting increase blood flow increase osteoclast activity bone resorption and mechanical weakening fractures and deformity

• Increase blood flow warmth foot and dilated veins

German theory (1946)

• Volkman and Virchow neurotraumatic theory• “ peripheral neuropathy leading to loss of

protective sensation may render the foot susceptible to injury from either repeated or acute trauma “

• Insensitive joint• Allow mechanical trauma normaly prevented by

pain• Spontaneous fracture, subluxation and dislocation

Other Contributed Factor

• Bone pathology• Atypical neuropathy• Non-enzymatic collagen glycation• Increased plantar pressures• Excessive local inflammation

Acute Charcot Foot

Acute Charcot Foot

• H : Hminor trauma• L : Swollen, erythem,

deform• F : Warmth – hot• M : Crepitation• Discomfort

considerably less than might be expected from the pathology seen

Chronic Charcot foot

Chronic Charcot foot• L : pemanent deform,

no erythem, reducing swollen

• F : warmth or hot temp., subside

• M : no crepitation, gait tabes dorsalis,

• Sometimes with unoticed ulcer

Clinical Course• People risk for Charcot foot stage 0• Acute Charcot foot stage I Dev-fragmentation

– Swollen, hyperemia, bone fragmentation, join dislocation and destruction

– Radiological still looks normal, bone debris, joint subluxation and dislocation subsequently develop

• Chronic Charcot foot stage II coalescence– Decreasing erythem, hot, swelling– X-Ray :absorption of fine debris,formation of new bone,

coalescence of larger fragments and sclerosis of bone ends– Decrease joint mobility

Clinical Course

• Stage III reconstruction - consolidation– edema, erythema and warmth are not present,– unless fractures have not healed– Ulcers may develop at– sites of residual deformity, while X-rays reveal

bony remodeling,– rounding of bone ends and decreased sclerosis

Diagnose

Clinically

• Have been describe above• Investigation should be make on early stage

and to differentiate between another disease like Osteomyelitis, Gout, Arthritis– History – Predisposising factor– Physical Examination– Complication

X - Ray• Atrophic changes :

“pencil pointing or sucked candy “

X-Ray• Hypertropic

changes :– Bone proliferation– Bone destruction– Subcondral sclerosis

and– Osteophtes may be

seen

Treatment

Conservative

Immobilization and off loading• Reducing swelling and mechanical stress

elevation, bed rest, whell chair• TCC Total Contact Cast

Conservative

• Biphosphonat inhibit Osteoclastic activity– N-Containing

• Sodium alendronat (fosamax)• Riserdonat (actonel)

– Non N-Containing• Etidronat (didronel)• Tiludronic (skelid)

INTRANASAL CALCITONIN

Surgery

• Acute Charcot Foot Contraindicated• Chronic Ulcerated and fixed deformity

indication of surgery remove bony prominent and correct the deformity– Exostectomy– Arthrodesis– Tendon Lengthening

THANX … !