The natural history of Charcot's neuroarthropathy

Considerations in Charcot Reconstruction

Charcot deformity is a challenging condition often leading to foot and ankle deformity that subsequently causes decreased function, ulceration, infection, and limb loss. There are various treatment measures to take into consideration when managing these patients. Treatment approaches range from conservative casting to surgical reconstruction. The authors believe that when faced with deformity, aggressive reconstruction to maintain a plantigrade foot and prevent loss of function is critical. Because of the nature of the Charcot condition, timing and fixation are often debated. This article discusses the authors' approach to Charcot reconstruction in a large integrated health care system.

Conservative Management of Charcot Neuroarthropathy

Charcot can be a difficult clinical entity to diagnose in the acute phase, and clinicians should have a high clinical suspicion in neuropathic patients who present with erythema, edema, and warmth of the foot or ankle. Immobilization and nonweight-bearing should be immediately initiated when the diagnosis of Charcot has been made and patients should remain nonweight-bearing until the affected bones/joints have coalesced. Educating patients and managing expectations is crucial to improve compliance with the conservative treatment of Charcot and avoid the long-term sequelae including severe deformity, ulceration and infection, and amputation.

Success and Survivorship Following Charcot Reconstruction: A Review of 151 Cases

Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal deformity and pedal ulceration in the insensate foot. Results are often poor and no clear guidelines for surgical management exist. Additionally, amputation rates vary widely making it difficult to accurately inform patients of risks. Few studies have assessed outcomes to identify patients for whom reconstruction is likely to fail. The literature is limited, with small sample sizes and mortality infrequently addressed. We performed a retrospective observational study of patients with Charcot neuroarthropathy to assess overall amputation and mortality rates at 30 days, 1 year, and 3 years postreconstruction and evaluated associated risk factors. Rates of infection, re-ulceration, and return to walking were also assessed. We identified 151 patients over a 5-year period. Demographic and clinical characteristics were collected. Descriptive statistics, Cox proportional hazard model, and logistic regression were used. Overall, 22 (14.6%) patients died, and 23 (15.2%) patients advanced to limb amputation postoperatively. End-stage renal disease, peripheral vascular disease, reconstruction during active phase Charcot process, and reconstruction at the ankle or subtalar joint were all associated with poor outcomes. The risk of mortality was 2.5 times higher in patients with end-stage renal disease, and 3.4 times higher among patients with peripheral vascular disease. Patients with ankle or subtalar joint reconstruction were 70% less likely to return to walking compared to medial column reconstruction. Due to these findings, we suggest that patients with such comorbidities be advised of increased risk for complications including failure to return to walking, amputation, and death.

A comprehensive review of the treatment and management of Charcot spine

Charcot spine arthropathy (CSA), a result of reduced afferent innervation, is an occurrence of Charcot joint, a progressive, degenerative disorder in vertebral joints, related mostly to spinal cord injury. The repeated microtrauma is a result of a lack of muscle protection and destroys cartilage, ligaments, and disc spaces, leading to vertebrae destruction, joint instability, subluxation, and dislocation. Joint destruction compresses nerve roots, resulting in pain, paresthesia, sensory loss, dysautonomia, and spasticity. CSA presents with back pain, spinal deformity and instability, and audible spine noises during movement. Autonomic dysfunction includes bowel and bladder dysfunction. It is slowly progressive and usually diagnosed at a late stage, usually, on average, 20 years after the first initial insult. Diagnosis is rarely clinical related to the nature of nonspecific symptoms and requires imaging with computed tomography (CT) and magnetic resonance imaging (MRI). Conservative management focuses on the prevention of fractures and the progression of deformities. This includes bed rest, orthoses, and braces. These could be useful in elderly or frail patients who are not candidates for surgical treatment, or in minimally symptomatic patients, such as patients with spontaneous fusion leading to a stable spine. Symptomatic treatment is offered for autonomic dysfunction, such as anticholinergics for bladder control. Most patients require surgical treatment. Spinal fusion is achieved with open, minimally-open (MOA) or minimally-invasive (MIS) approaches. The gold standard is open circumferential fusion; data is lacking to determine the superiority of open or MIS approaches. Patients usually improve after surgery; however, the rarity of the condition makes it difficult to estimate outcomes. This is a review of the latest and seminal literature about the treatment and chronic management of Charcot spine. The review includes the background of the syndrome, clinical presentation, and diagnosis, and compares the different treatment options that are currently available.

A radiological severity scale to measure the impact of Charcot's Neuroarthropathy: an observational study

Background

Charcot’s Neuroarthropathy (Charcot foot) is a debilitating and destructive disorder resulting from neurological changes in the foot. Whilst the majority of cases are painless, as a result of disruption to sensory function, a common outcome is severe deformity that impacts considerably on foot function. The purpose of this study was to develop and validate a radiological severity scale to quantify resultant damage from acute mid foot Charcot’s. This in turn can be used to evaluate clinical outcomes related to different degrees of offloading.

Methods

A four round Delphi process was used to develop five tool items. Level of consensus and agreement was set at 80%. Inter-rater and intra-rater reliability was evaluated using 3 raters and 24 plain x-rays of chronic mid-foot Charcot’s. Strength of agreement of individual items and overall scores was calculated using weighted Kappa coefficients (S.E). Cronbach’s α was used to determine internal consistency. Floor (> 15% score 0) and ceiling (> 15% score 11) effects were examined at each time point. Spearman’s correlation coefficient was used to assess construct validity using Mobility and Usual Activity scores taken from the EQ-5D-5 L.

Results

Twenty two patients participated. The five item severity scale demonstrated a Cronbach’s α of 0.91. Intra-rater Kappa coefficients (SE) for total scores ranged from 0.84 (0.20) to 0.86 (0.20). Inter rater coefficients (SE) ranged from 0.72 (0.14) to 0.83 (0.14). Distribution was normal and no floor or ceiling effects were identified.

Conclusion/interpretation

This study suggests it may be possible to quantify resultant damage from mid foot Charcot’s. Given the physical and emotional impacts from long periods of complete immobilisation defining a minimum standard would be an important development in the management of Charcot foot.

Bilateral Total Knee Arthroplasty for Charcot Arthropathy After Cauda Equine Syndrome: A Case Report

Charcot arthropathy of the knee is a relatively rare and poorly understood condition. Diagnosis requires detailed history of the patient, radiological investigation and exclusion of other causes of arthropathy. Conservative treatment is sufficient only in early stages. In late stages, either arthrodesis or total knee arthroplasty is the treatment of choice. We report a case of a 65-year-old woman who presented with Charcot arthropathy in both knees, after a spinal fracture 35 years ago, which caused cauda equine syndrome with diminished sensation of both legs. She underwent bilateral total knee arthroplasty using hinged knee prosthesis.

New Concepts in the Management of Charcot Neuroarthropathy in Diabetes

Charcot Neuroarthropathy (CN) is an uncommon, debilitating and often underdiagnosed complication of chronic diabetes mellitus though, it can also occur in other medical conditions resulting from nerve injury. Till date, the etiology of CN remains unknown, but enhanced osteoclastogenesis is believed to play a central role in the pathogenesis of CN, in the presence of neuropathy. CN compromises the overall health and quality of life. Delayed diagnosis can result in a severe deformity that can act as a gateway to ulceration, infection and in the worst case, can lead to limb loss. In an early stage of CN, immobilization with offloading plays a key role to a successful treatment. Medical therapies seem to have limited role in the treatment of CN.In case of severe deformity, proper footwear or bracing may help prevent further deterioration and development of an ulcer. In individuals with a concomitant ulcer with osteomyelitis, soft tissue infection and severe deformity, where conservative measures fall short, surgical intervention becomes the only choice of treatment. Early diagnosis and proper management at an early stage can help prevent the occurrence of CN and amputation.

Charcot arthropathy of the diabetic foot in a sub-Saharan tertiary hospital: a cross-sectional study

Background

Charcot foot arthropathy is a potentially limb-threatening condition that leads to progressive destruction of the bones and joints in the neuropathic foot. One of its main causes is diabetes mellitus whose prevalence is steadily increasing. The acute phase is often misdiagnosed thus leading to foot deformity, ulceration and increased risk of amputation. There is a paucity of literature on this condition from sub-Saharan Africa. This study aimed at determining the extent of Charcot foot arthropathy, the radiological patterns of Charcot foot arthropathy and patient’s factors associated with Charcot foot arthropathy among adult patients with longstanding diabetes in an African setting.

Methods

This was a cross-sectional study that was carried at a national referral and university teaching hospital in Kampala, Uganda. One hundred patients with longstanding diabetes mellitus were consecutively recruited. Patients with a history of having diabetes mellitus for at least seven years since diagnosis were considered to have a longstanding disease. Clinical assessment of both feet was done. Weight-bearing radiographs of the selected foot were taken and evaluated using the Sanders and Frykberg and modified Eichenholtz classifications. A blood sample was taken for glycosylated haemoglobin (HbA1c). Data were summarized using descriptive statistics and student t-test.

Results

The proportion of Charcot foot arthropathy among patients with longstanding diabetes was 12% of which one-third (4 out of 12) were acute cases. Fifty percent of the lesions were in the forefoot and 50% in the midfoot. Seventeen percent of lesions were at the inflammatory stage of the modified Eichenholtz classification, 50% at the developmental stage, 25% at the healing stage, and 8% at the remodelling stage. An abnormal foot radiograph was significantly associated with Charcot foot arthropathy among patients with longstanding diabetes.

Conclusion

Charcot foot arthropathy is fairly common in patients with longstanding diabetes mellitus in these settings with one third of patients presenting in the early acute phase. An abnormal weight-bearing radiograph was an associated factor of Charcot foot arthropathy among this specific group of patients. To reduce on the morbidity and limb threatening sequelae of this condition, clinicians are therefore advised to routinely examine the feet of patients with diabetes and send those with suspicious signs and symptoms for radiographic assessment.

Risk Factors Associated With Major Lower Extremity Amputation After Osseous Diabetic Charcot Reconstruction

Patients with diabetic Charcot neuroarthropathy (CN) are at high risk for ulcerations and major lower extremity amputations (LEAs). Osseous reconstruction is an important component in ulcer healing and prevention; however, despite such efforts, major LEAs remain a serious postreconstruction concern. The aim of this study was to identify risk factors for major LEA in patients who underwent osseous Charcot reconstruction. A retrospective review was performed on 331 patients with the diagnosis of CN in the foot and ankle treated over a 16-year period. Two hundred eighty-five patients were included after exclusion of those without diabetes. Demographic data, anatomic wound location, surgical interventions, wound healing status, and the level of eventual amputation were recorded. Multivariate logistic regression and Fisher's exact test were used for analysis. All patients had diabetes, neuropathy, or CN and required osseous reconstruction. Risk factors and their respective odds ratios (ORs) are as follows: postoperative nonunion (OR 8.5, 95% confidence interval [CI] 2.2 to 33.5, 0.0023), development of new site of CN (OR 8.2; 95% CI 1.1 to 62.9; p = .0440), peripheral arterial disease (OR 4.3; 95% CI 1.7 to 11.0; p = .0020), renal disease (OR 3.7; 95% CI 1.6 to 8.8; p = .0025), postoperative delayed healing (OR 2.6; 95% CI 1.1 to 6.5; p = .0371), postoperative osteomyelitis (OR 2.4; 95% CI 1.0 to 5.9; p = .0473), or elevated glycated hemoglobin (OR 1.2; 95% CI 1.0 to 1.4; p = .0053). Independent risk factors found to be statistically significant for major LEA in diabetic CN in the setting of osseous reconstruction must be mitigated for long-term prevention of major amputations.

A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.

The Effect of Charcot Neuroarthropathy on Limb Preservation in Diabetic Patients with Foot Wound and Critical Limb Ischemia after Balloon Angioplasty

OBJECTIVE

The aim of this article is to investigate one-year limb preservation rates after below-the-knee angioplasty in patients with diabetic foot wound who only have critical limb ischemia (CLI) and those who have Charchot neuroarthropathy (CN) accompanied by CLI.

METHODS

This single-center, retrospective study consists of 63 patients with diabetic foot wound who had undergone lower extremity balloon angioplasty of at least 1 below-the-knee (BTK) vessel. Only those patients with postprocedural technical success of 100% were selected from the database. All patients were classified into two groups as patients with CLI and CN and patients with CLI only without CN. The Kaplan-Meier method was used to compare the limb preservation rates for the two groups.

RESULTS

There was no statistically significant difference between patient age, gender, diabetic disease duration, and comorbid disease such as chronic renal insufficiency, hypertension, and coronary artery disease of the two groups (p > 0.05). Limb preservation in the 12 months was 59.1% in the CN group and 92.7% in the group without CN. Also, limb preservation rates between the two groups displayed statistically significant differences (p < 0.005).

CONCLUSION

This study showed that CLI can accompany CN in patients with diabetes. Limb preservation rates with endovascular treatment in diabetic patients with CLI only are better than in diabetic patients with CLI and CN.

Bilateral Diabetic Knee Neuroarthropathy in a Forty-Year-Old Patient

Diabetic osteoarthropathy is a rare cause of neuropathic joint disease of the knee; bilateral involvement is even more exceptional. Diagnosis is often made late due to its unspecific symptoms and appropriate surgical management still needs to be defined, due to lack of evidence because of the disease's low incidence. We report the case of a forty-year-old woman with history of diabetes type I who developed bilateral destructive Charcot knee arthropathy. Bilateral total knee arthroplasty was performed in order to achieve maximal functional outcome. Follow-up was marked by bilateral tibial periprosthetic fractures treated by osteosynthesis with a satisfactory outcome. The diagnosis of Charcot arthropathy should always be in mind when dealing with atraumatic joint destruction in diabetic patients. Arthroplasty should be considered as an alternative to arthrodesis in bilateral involvement in young patients.

Expression of the receptor activator of nuclear factor-kB ligand in peripheral blood mononuclear cells in patients with acute Charcot neuroarthropathy

Introduction. The receptor activator of nuclear factor-kB (RANK), ligand (RANK-L) and osteoprotegerin (OPG) are implicated in the pathogenesis of acute Charcot neuroarthropathy (CN). Materials and Methods. This study aimed to investigate the expression of RANK-L and OPG in peripheral blood mononuclear cells (PBMC) from patients with acute CN. Results. We found that the expression of RANK-L was lower in patients with acute CN as compared with diabetic control subjects and healthy control participants; whereas OPG expression was not detected in patients and in both control groups. RANK-L expression at the onset of disease was inversely correlated with the index of polyunsaturation (PUI), a bone marrow MRS-derived measurable index that allows evaluation of disease activity in acute CN, and recovery time. Finally, the expression of RANK-L increased at the time of healing compared with the values found during the acute phase. Conclusions. In conclusion, our preliminary data provide a first step in applying analysis of RANK-L expression in peripheral blood cells to the diagnosis of acute CN. Based on our data we also suggest that analysis of RANK-L expression could be a complementary tool that can be employed to obtain quantitative parameters that may help clinicians to monitor disease activity in patients with acute CN.

Do all Charcot Spine require surgery?

INTRODUCTION

Spinal neuroarthropathy (SNA), also called "Charcot spine", is very uncommon disease of unknown etiology. Kronig first reported this pathology in 1884 on a patient with Tabes dorsalis (also known as syphilitic myelopathy). As syphilis tends to disappear in developed countries, spinal cord lesion is the most frequent etiology of SNA.

OBJECTIVES

To describe clinical and radiographic results in 12 patients suffering from spinal neuroarthropathy (SNA).

METHODS

Twelve patients diagnosed with SNA were included in the study. All patients were wheelchair users. The average delay between the neurological disease and the diagnosis of SNA was 18 years. All patients were initially treated conservatively. Surgery was only indicated in persistent symptomatic or instable cases, and for infected SNA. Surgery was a circumferential arthrodesis.

RESULTS

From 12 patients, with a median follow-up of 4 years, five patients were operated on and 7 patients were still conservatively treated. Two patients with back pain and evolutive destruction were declined for surgery. One suffered of bilateral hip ankylosis and extensive spinal surgery would have confined him to bed, and one due to an evolutive bedsore. One patient improved with a complete regression of back pain.

CONCLUSION

Nowadays, surgical treatment is recommended with an extensive and circumferential fusion, in order to prevent relapses. Good radiographic outcome is reported but functional results have not been studied. Natural evolution of SNA remains unknown but can be less disabling than surgery. This pathologic mobility can contribute to patient's autonomy and can therefore be considered as opportune. Conservative therapy can be considered for SNA.

LEVEL OF EVIDENCE

Level IV.

Conservative and surgical treatment of the chronic Charcot foot and ankle

Charcot neuroarthropathy (CN) is a severe joint disease in the foot and ankle that can result in fracture, permanent deformity, and limb loss. It is a serious and potentially limb-threatening lower-extremity late complication of diabetes mellitus. The aim of this manuscript was to evaluate modern concepts of chronic CN through a review of the available literature and to integrate a perspective of management from the authors’ extensive experience.

Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review

BACKGROUND

Charcot Neuro-Arthropathy (CN) is one of the more devastating complications of diabetes. To the best of the authors' knowledge, it appears that no clinical tools based on a systematic review of existing literature have been developed to manage acute CN. Thus, the aim of this paper was to systematically review existing literature and develop an evidence-based clinical pathway for the assessment, diagnosis and management of acute CN in patients with diabetes.

METHODS

Electronic databases (Medline, PubMed, CINAHL, Embase and Cochrane Library), reference lists, and relevant key websites were systematically searched for literature discussing the assessment, diagnosis and/or management of acute CN published between 2002-2012. At least two independent investigators then quality rated and graded the evidence of each included paper. Consistent recommendations emanating from the included papers were then fashioned in a clinical pathway.

RESULTS

The systematic search identified 267 manuscripts, of which 117 (44%) met the inclusion criteria for this study. Most manuscripts discussing the assessment, diagnosis and/or management of acute CN constituted level IV (case series) or EO (expert opinion) evidence. The included literature was used to develop an evidence-based clinical pathway for the assessment, investigations, diagnosis and management of acute CN.

CONCLUSIONS

This research has assisted in developing a comprehensive, evidence-based clinical pathway to promote consistent and optimal practice in the assessment, diagnosis and management of acute CN. The pathway aims to support health professionals in making early diagnosis and providing appropriate immediate management of acute CN, ultimately reducing its associated complications such as amputations and hospitalisations.

Charcot arthropathy of the knee. A case-based review

The diagnosis of Charcot arthropathy in the knee is rare. However, there is an increasing number of diabetic patients, and they are living longer due to improvements in treatment. Because neuropathic arthropathy is a late effect of peripheral neuropathy, we can expect an increasing incidence of neuropathic arthropathy. Total knee arthroplasty is the preferred choice of treatment by patients, although it may also be associated with a high incidence of serious complications. This case report presents a young female with diabetes mellitus and Charcot arthropathy of the knee managed by total knee arthroplasty and a literature review. The report encompasses a 5-year follow-up of the patient, from the first contact after knee distortion through diagnosis of Charcot arthropathy and the performance of total knee arthroplasty with outpatient controls. The diagnosis was established on the basis of the rapid destruction of the medial tibial condyle after knee distortion in a patient with neuropathy. Neuropathic arthropathy was confirmed by histology. The patient refused knee fusion and total knee arthroplasty was performed. The patient quickly achieved a painless, stable knee with a 130-degree range of motion. However, a radiolucent line appeared under the tibial component due to premature weight-bearing. The patient was ordered to refrain from weight-bearing for the next 3 months, and the knee was healed. While the management of Charcot arthropathy in the knee remains controversial, total knee arthroplasty is not a contraindication. Early diagnosis, appropriate choice of implant and operative technique, and long-term weight protection are essential.

Can we predict outcome of surgical reconstruction of Charcot neuroarthropathy by dynamic plantar pressure assessment?--A proof of concept study

The joint deformity that arises as a result of Charcot neuroarthropathy, leads to gait modification. Ulceration risk associated with the deformity is generally assessed by measuring plantar pressure magnitude (PPM). However, as PPM is partially dependent on gait speed and treatment interventions may impact speed, the use of PPM to validate treatment is not ideal. This study suggests a novel assessment protocol, which is speed independent and can objectively (1) characterize abnormality in dynamic plantar loading in patients with foot Charcot neuroarthropathy and (2) screen improvement in dynamic plantar loading after foot reconstruction surgery. To examine whether the plantar pressure distribution (PPD) measured using EMED platform, was normal, a customized normal distribution curve was created for each trial. Then the original PPD was fitted to the customized normal distribution curve. This technique yields a regression factor (RF), which represents the similarity of the actual pressure distribution with a normal distribution. RF values may range from negative 1 to positive 1 and as the value increases positively so does the similarity between the actual and normalized pressure distributions. We tested this novel score on the plantar pressure pattern of healthy subjects (N=15), Charcot patients pre-operation (N=4) and a Charcot patient post-foot reconstruction (N=1). In healthy subjects, the RF was 0.46+/-0.1. When subjects increased their gait speed by 29%, PPM was increased by 8% (p<10(-5)), while RF was not changed (p=0.55), suggesting that RF value is independent of gait speed. In preoperative Charcot patients, the RF<0, however, RF increased post-surgery (RF=0.42), indicating a transition to normal plantar distribution after Charcot reconstruction.