Charcot Neuroarthropathy: Conservative Management

APMA 2019 Annual Scientific Meeting

Kristin Kirby, DPM Huntersville, North Carolina

Charcot Neuroarthropathy

Charcot • Deforming and destructive

process • increased patient morbidity • gross instability • recurrent ulceration • high risk for amputation

• Diagnosed cases associated with diabetic patients ranges from 0.08% to 7.5%

• Associated with DM, Leprosy, Polio, RA and etc.

Etiology ● “Neurotrophic theory” Charcot and Féré (1883):

○ neurogenic deficit in bone nutrition ● “Neurovascular theory” Johnson (1966):

○ hypervascular reflex ○ overactive bone resorption ○ mechanical weakening

○ “Neurotraumatic theory” Virchow, Rotter and Volkman (1886) ○ Repetitive trauma to neuropathic joint ○ Reduced BMD in Charcot ○ reduced bone strength

● Jeffcoate (2004) RANK-L/OPG pathway: regulates bone turnover and vascular calcification

● Sanders & Frykberg (2007) with Monckeberg’s arteriosclerosis

Acute Charcot ● Early recognition &

treatment ○ Improve symptoms, reduce

sequalae, and improve quality-of-life ○ Optimize glucose control with team

approach ○ Educate ○ Identify at risk patients ○ Immobilization ○ Custom orthosis or shoes

Staging

● Eichenholtz (1966): Charcot based on radiographic appearance and physiologic course

● Shibata (1990): stage 0

Classifications

● Sanders and Frykberg (1991)

Classifications

● Brodsky (1993)

60% 30-35%

9%

<2%

Classifications

● Schon (1998)

CN Treatment Considerations

● Diagnosis & Stage ● Joint of involvement ● +/- ulceration ● +/-infection ● Health, A1c, vascular

status, BMI, family support

● Compliance

Conservative Treatment

● Goals: ○ Maintain or

achieve structural stability

○ Prevent ulceration ○ Preserve

plantigrade foot

The gold standard of acute CN is

immobilization in a total contact cast.

Total Contact Casting

● Pressure relief ○ Offloads forefoot and midfoot by 80%

● Non-removable ● Avg time DFU healing of 43

days in 88% of patients (Shaw, Jensen)

● Offloaded in CN 1 until reduction of erythema, edema and signs of osseous consolidation; 5 weeks up to 12 months

CROW

● Initially developed for Stage 1 CN

● Pressure reduction at the site

of ulceration ranging from 64-92%

● Reduces patient’s activity

level

Patellar Tendon Bearing Brace ● Foot in suspension without use

of crutches ● Extra-depth shoe with a steel

shank is recommended

● Addition of padding with PTBB (alone entire foot reduced by 15%)

○ Decreased the mean peak force to the entire foot by 19%, to the hindfoot by 37%, and to the midfoot by 20%. (Saltzman)

Stage 0, I & II Charcot

● Limited to partial WB

● TCC

● CROW

0 & I

II

● Recognition of acute stages

● Immobilization

● TCC, AFO, Splinting

● 9 patients ● Acute stage

○ Biweekly WB TCC ● Successful treatment of Stage I CN using

the weight bearing TCC with an average return to depth inlay shoes and custom orthoses in 9.2 weeks

Stage III Charcot

III

● CROW

● Double Upright AFO

● DM shoes with CMO

● Eleven (91.7%) patients had initiation of treatment with a WB-TCC

● Acute stage ● One patient was not diagnosed and thus treatment was not

initiated until 22 weeks following symptom onset. ● Average duration of casting for all patients was 17.8 weeks

(range: 8–52) ● All 11 patients who were diagnosed and immobilized early

did not progress to fracture formation during the follow-up time (range: 12–26 months).

○ 1 patient who was diagnosed late progressed to Charcot fracture of the foot during their 3-month follow-up time

● 6-year period, 198 patients (201 feet) were treated DM CN ● Location: midfoot in 147 feet, in the ankle in 50, and in the forefoot in 4 ● Results: At a minimum 1-year follow-up, 87 of the 147 feet with midfoot

disease (59.2%) achieved the desired endpoint without surgical intervention. Sixty (40.8%) required surgery. Corrective osteotomy with or without arthrodesis was attempted in 42, while debridement or simple exostectomy was attempted in 18 feet.

● Using a simple treatment protocol with the desired endpoint being long-term management with commercially available, therapeutic footwear

and custom foot orthoses, more than half (59.2%) of patients with Charcot arthropathy at the midfoot level can be successfully managed without surgery.

Exostectomy ● No accepted protocol to quantify how much bone to

resect ● Increased risk of complications related to plantar

lateral midfoot ulcerations following an exostectomy

○ Lateral healing rate: 38% vs. medial 92%

Realignment Arthrodesis

● High rate of incomplete bony union ○ Fusion rates of 71-84% for

diabetics and ranging from 33-84% for Charcot patients

■ Grant, 2009

Post Op Complications ● Pin tract infections

○ 0.9-100%

● Stress Fractures ○ 6.5% with DM experienced a tibia

fracture

● Osteomyelitis ● Psychosocial issues ● Major Amputation

○ CN related wound-> major amp increased likelihood by factor of 6; Wukich 2017

My Concerns

● DM Statistics

● Timeline

● Multiple trips to OR & hospital

● Costs & Socioeconomic factors

● Post op Complications

● Quality of life

References ● American Diabetes Association. (2016) http://www.diabetes.org/ ● American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care 2016.

● Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk

for ulceration of the foot. J Bone Joint Surg Am 1999;81(4):535-538.

● Baumhauer, J. F., O'Keefe, R. J., Schon, L. C., & Pinzur, M. S. (2006). Cytokine-induced osteoclastic bone resorption in charcot arthropathy: an immunohistochemical study. Foot & ankle international, 27(10), 797-800.

● Bevan WP, Tomlinson MP. Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ankle Int 2008;29(6):568-573.

● BRODSKY, J. W.,, A. M. (1993). Exostectomy for symptomatic bony prominences in diabetic Charcot feet. Clinical orthopaedics and related research, 296, 21-26.

● Charcot, J. M., & Féré, C. H. (1883). Affections osseuses et articulaires du pied chez les tabétiques (Pied tabétique). Publications du Progrès Médicale.

● Eichenholtz, S. N. (1966). Charcot joints. Charles C. Thomas. ● Herbst, S. A., Jones, K. B., & Saltzman, C. L. (2004). Pattern of diabetic neuropathic arthropathy associated with the peripheral bone

mineral density.Bone & Joint Journal, 86(3), 378-383.

● Jeffcoate, W. (2004). Vascular calcification and osteolysis in diabetic neuropathy—is RANK-L the missing link?. Diabetologia, 47(9),

1488-1492.

References

● Raikin SM, Parks GBG, Noll KH, Schon LC. Biomechanical evaluation of the ability of casts and braces to immobilize the ankle and hindfoot. Foot Ankle Int. 2001; 22(3):214-219.

● Rogers, L. C., Frykberg, R. G., Armstrong, D. G., Boulton, A. J., Edmonds, M., Van, G. H., ... & Jude, E. (2011). The Charcot foot in diabetes. Diabetes Care, 34(9), 2123-2129

● Saltzman CL, Johnson KA, Goldstein RH, Donnelly RE. The patellar tendon-bearing brace as treatment for neurotrophic arthropathy: a dynamic force monitoring study. Foot Ankle. 1992; 13(1):14-31.

● Sanders, L. J., & Frykberg, R. G. (1991). Diabetic neuropathic osteoarthropathy: the Charcot foot. The high risk foot in diabetes mellitus, 325-333.

● Sanders, L. J., & Frykberg, R. G. (2007). Levin and O'Neal's the diabetic foot. ● Schon, L. C., Easley, M. E., & Weinfeld, S. B. (1998). Charcot neuroarthropathy of the foot and ankle. Clinical

orthopaedics and related research, 349, 116-131. ● Shibata, T. O. H. R. U., Tada, K., & Hashizume, C. (1990). The results of arthrodesis of the ankle for leprotic

neuroarthropathy. J Bone Joint Surg Am,72(5), 749-756. ● Tan, P. L., & Teh, J. (2014). MRI of the diabetic foot: differentiation of infection from neuropathic change. The

British journal of radiology. ● Wukich, D. K., & Sung, W. (2009). Charcot arthropathy of the foot and ankle: modern concepts and management

review. Journal of diabetes and its complications, 23(6), 409-426. ● Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Post operative rates in foot and ankle surgery: A comparison

of patients with and without diabetes mellitus. J Bone Joint Surg Am 2010;92(2):287-295. ● Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am

2008;90(7):1570-1578 ● Wukich DK, Raspovic KM, Hobizal KB, Sadoskas D. Surgical management of Charcot neuroarthropathy of the

ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev. 2016; 32(Suppl 1):292–296.

Thank You