Charcot arthropathy (Charcot Foot) is a progressive disease of neurologic origin. It is a key concern for diabetics.
Jean-Martin Charcot, a French neurologist, is given credit for first describing this disease in the 1800's, although he primarily attributed it to complications of syphilis. The first published report of diabetes as a causative factor in Charcot arthropathy was reported in 1936. And today, Charcot arthropathy is primarly associated with diabetes.
Charcot arthropathy usually affects the foot and the ankle joints. Type II diabetics in particular are most prone to the ravages of neuropathic changes in the lower extremities. Neuropathy is prevalent in up to 7% of diabetic patients.
Neuropathic arthropathy is either atrophic (wasting away or decrease in size of the body part) or hypertrophic (growing abnormally large).
The atrophic form is usually localized to the forefoot and causes degeneration of bone tissue of the distal metatarsals. The hypertrophic form usually occurs at the mid tarsal joints (center joint of the foot) usually referred to as the Lisfranc articulation. Less commonly but equally destructive is the ankle articulation including the subtalar joint. Patience and the subacute Charcot phase present with resorption of bone debris. The consolidation or repaired of stage which is the chronic Charcot type foot is associated with stabilization of the foot with fusion of the involved fragments.
The first step in treating in Charcot arthropathy is obviously making the correct diagnosis. This is not always easy to do. Trauma is not usually a precipitating event, and charcot arthropathy usually presents as a slow and gradual onset, characterized by increased warmth, edema and sometimes increased temperature. The symptoms of Charcot arthropathy are often confused with cellulitis. Cellulitis is an infectious condition that usually affects the foot, ankle and legs and has the same characteristics. But with Charcot arthropathy there is no infectious agent that can be identified and it is not amenable to antibiotic therapy. However, many Charcot arthropathies have ulceration associated.
In the beginning phases of this disease, plain film x-rays are usually not helpful. Magnetic resonance imagine is the best diagnostic tool. Other tests that are helpful include white blood counts and sedimentation rate.
The underlying condition of Charcot arthropathy lies in the neurologic diagnosis: loss of sensation which is characterized by decreased sensitivity to light touch, cold, heat and pressure. The monofilament test which measures how much pressure loss has taken place is a good screening device to detect degenerization of the the nerves in diabetics. However, if the diagnosis is in question, quantitative sensory testing is the best diagnostic tool. Also used for diabetic Charcot arthropathy is an older technique called bone scanning. Indium radionucleotide sometimes can help differentiate infection from Charcot arthropathy.
What can YOU do?
- Institute complete non-weight bearing for the affected extremity - that means keep your weight off the foot
- Maintain good glycemic control
- Guarding against infection
- and educate yourself about total outcome of this severe disease.
Newer techniques to re-establish sensitivity to the extremity have been pioneered by Johns Hopkins University professor Dr. A. Lee Dellon. This technique decompresses multiple peripheral nerves in the lower extremity and 85% of the cases have been shown to have excellent results. However, this technique needs to be instituted before complete bony destruction has ensued. If the neuropathy is not reversed, outcomes are poor.
In advanced cases of Charcot arthropathy where bone destruction has taken place, reconstructive surgery can be performed. This technique usually requires extensive surgical reconstruction with either internal or external fixators.
In the interim, before surgical care is instituted, non-weightbearing full-contact casting is employed. But even with these techniques, amputation of the extremity is still inevitable in a large percentage of cases. It is estimated that 100,000 non-traumatic amputations occur every year in the United States.
In summary, Charcot arthropathy is a devastating disease that is difficult to diagnose, usually has poor outcomes, and is extremely expensive to treat.
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