Charcot Foot Deformity: Surgical Treatment Options
- Thu, 9/4/08 - 11:52am
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With longer survival rates of patients with diabetes the incidence of Charcot arthropathy has been noted to be increasing in occurrence within the last several years.1 Charcot arthropathy is a noninfective progressive process that was first reported by Jean-Martin Charcot in 1868.2 It was originally described in neuropathic patients with tertiary syphilis, although it is now most commonly associated with diabetes mellitus. It has also been associated with peripheral neuropathy caused by alcoholism, syringomyelia, rheumatoid arthritis, leprosy, multiple sclerosis, and trauma. It has been reported that 30%–50% of patients with diabetes have neuropathy, but only 0.2%–2.5% will develop Charcot arthropathy.3
Charcot arthropathy is usually characterized by painless joint destruction, fracture, and eventual dislocation. Men and women are equally affected, and it occurs bilaterally in 30% of cases.4 The exact etiology remains controversial, but two main theories exist.
Charcot proposed the neurovascular theory stating that the cause was the damaged trophic centers of the spine that control bone and joint nutrition, resulting in a neurally initiated increase of blood flow to bone;5 this is known as the French theory. The neurotraumatic theory, or German theory, proposed by Volkmann and Virchow, states that decreased protective sensation allows repetitive trauma to result in fracture and dislocation.6 Continued weight bearing causes mechanical failure and collapse. Indeed it is a commonly held opinion that the etiology is most likely a combination of both.
Clinical Evaluation
Clinically, the acute Charcot foot usually presents with erythema, edema, and varying degrees of loss of protective sensation. It is often mistaken for cellulitis. Laboratory tests, radiographs, and clinical suspicion may help rule this out. Often, elevating the involved extremity for 10 minutes may provide a way to help distinguish between edema associated with infection versus Charcot changes, as swelling associated with infection will often remain.7 Edema that subsides with elevation may be more indicative of Charcot arthropathy.
When ordering radiographs, it is best to image the foot and ankle in a weight bearing position to evaluate the stage of deformity and biomechanical malalignments including plantar prominences. Further diagnostic imaging may be needed to help rule out infection. Magnetic resonance imaging may be helpful when looking for abscess and when evaluating for osteomyelitis. Possibly the best imaging tool available to help distinguish between osteomyelitis and Charcot arthropathy is an indium-labeled white blood cell scan.8
It is important to evaluate all patients for Achilles tendon contracture who present with a possible diabetic Charcot foot. Achilles tendon contracture may lead to increased plantar foot pressures, in particular across the plantar forefoot and midfoot.9 Increased plantar pressures may lead to soft tissue compromise and ulceration. Ankle equinus deformity must be corrected to alleviate these stresses.
Charcot Foot Staging
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18. Catagni MA, Ottaviani G, Combi A, Elhence A. External circular fixation: a comparison of infection rates between wires and conical half-pins with threads outside or inside the skin. J Trauma. 2006;61(5):1186–1191.
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Just wondering, can anyone tell me what the life expectancy is for a person with a below the knee amputation? Can this cause other problems, such as congestive heart failure?
I was told by a doctor that the life expectancy is 3-5 years because the blood that normally flows to the extremities is flowing back to the heart too quickly causing heart problems. Is this true? I always thought amputees lived mostly normal lives after amputation.
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