9/20/2017

Charcot Joints

Charcot Joints

Charcot joints occur when the ability to sense deep pain is lost or diminished. As a result of the inability to sense pain, small fractures begin to develop in areas of stress such as the arch of the foot. The normal response to a fracture is swelling and increased blood flow (reflex vasodilatation) to the affected area of bone. The increase in blood flow tends to 'wash away' calcium from the fracture site, resulting in weakening of the bone as well as more fractures. If the normal defensive mechanism, pain, stays absent, a cycle of increasing fracture activity starts with progressive fall of the supporting bone.

The description of Charcot joints dates back to 1703 when neuropathic osteoarthropathy was first described by W. Musgrave. Charcot is credited regarding his work in 1868 for describing gait anomalies of patients with syphilis (tabes dorsalis). Jordan, in was the first to describe a relationship of diabetes to neuropathic arthropathy.

  • The most frequent area of the foot to be effected by a Charcot joint may be the middle of the arch.
  • Charcot joints can also develop on the rearfoot and ankle but are much less common.
  • One of the most common cause of Charcot joints of the foot is peripheral neuropathy due to diabetes mellitus.

The development of a Charcot joint may be rapid and is dependent upon several variables. Any ability to perceive pain may lead to a more prompt diagnosis because of patient's concern relating to their abilities to complete an average day. Full loss of deep pain sensation may delay early on diagnosis. Charcot joints are easily confused with osteoarthritis, which can be treated much less aggressively than a Charcot joint.

1966 Eichenholz proposed a group of Charcot joints which is broken down into three distinctive stages. Stage one, or the development stage, shows debris surrounding the joints on xray. Stage one can develop over a period of days to weeks and it is radiographic change that occurs in response to unperceived trauma. Stage two is the coalescence stage. In stage two, the bone actually starts to heal with assimilation of debris and healing of large fracture fragments. Stage three, often called the reconstruction or reconstitution stage, note a reduction in bone turn over and reformation of stable bone structure. Stage 0 was added in 1999 by Sella and Barrette to include patients who exhibit clinical symptoms of Charcot arthropathy but have yet to show radiographic changes.

  • The classification proposed by Brodsky in 1992 includes the location of the Charcot joint and is commonly used in clinical practice today.
  • Brodsky's category is as follows;

Type 1 - Lisfrank's joint - 27-60% of all Charcot joint deformities of the feet.

Type 3A - Ankle joint - 9% of all Charcot deformities.

Type 3B - the Posterior Calcaneus.

Type 4 - Multiple instances of the feet and/or ankle.

Type 5 - the Forefoot.

Charcot joints are often not diagnosed until they create another problem that affects a patients normal activities. These may be as simple as a good inability to fit into shoes, or as severe as an infected ulceration of the foot. By this stage, the Charcot deformity has in all likelihood progressed to a point where there is massive displacement of the bones and joints in addition to numerous displaced fractures.

  • Any situation that plays a role in the loss of sensation of the foot may be considered a cause for a Charcot combined.
  • Some of the people conditions include;

Diabetes mellitus Tabes dorsalis (neuropathy caused by syphilisHansen's Disease (Leprosy) Tumors of the spinal cordDegenerative change with the spinal cord or peripheral nerveAmyloid Familial-hereditary neuropathies including Charcot-MarieToothe Disease, Hereditary sensory neuropathy andDejerine-Sottas Disease Pernicious Anemia.

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Other factors that may contribute to leading to neuropathy, and subsequently, Charcot joints include;

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Alcoholic neuropathy Genetic insensitivity to pain Pott'sDisease (tuberculosis of the spine)

The most common complicating factor of a Charcot joint of the foot is the prominence that evolves on the bottom of the foot, referred to as a 'rocker bottom' foot. This problem occurs as the bones of the arch collapse. In an advanced rocker bottom foot, the inability to feeling pain gets a complicating factor for the skin. As the bone places more pressure on the skin, the skin begins to ulcerate and becomes contaminated.

X-rays are the single most useful tool in diagnosing Charcot joints. Bone scans are helpful in the early phases of Charcot joints and are sensitive indicators of hyperemia (increased blood flow to the area of the fracture). Surface skin temperature is one of the most reliable indicator of the activity of the fractures. Most doctors do not keep the necessary equipment to measure skin temperature but merely measure with direct touch in order to sense the presence or lack of warmth.

Treatment of Charcot Joints

The hallmark of treatment of Charcot joints is early diagnosis and prevention. The signs and symptoms and findings of Charcot joints vary so that each case requires careful evaluation. Remedy ofCharcot joints of the feet may include rest, casting as well as non-weight bearing to allow adequate time for fracture healing. Total contact casting or the use of a Charcot Restraint OrthoticWalker (CROW) tend to be popular in stages one and two. The goal is to limit weight bearing to enable progression to stage three. This progression can take from weeks up to 6 months. Electrical stimulation, or bone excitement, is a popular adjunct to non-weight bearing or sending your line.

Surgical procedures for Charcot joints are often challenging not only due to the complexity of this condition but also due to the fact that these patients are usually bad surgical applicants due with health problems (co-morbidity). Surgical procedure may include reconstruction of the arch and/or shared fusion. Usually, surgical procedures are used to come back the foot to a shape that can be accommodated by typical base wear. Stage threeCharcot deformities often result in piles, bump and unusually shaped feet due to bone tissue modifications. Reshaping the foot may be used to eliminate a boney prominence on the top or bottom of the foot.

Nomenclature: reflex vasodilitation - increased blood circulation to an area inside response to inflammation

Rocker bottom foot - a prominence in which forms on the sole or even bottom of the foot as a result of the collapse of the arch

Symptoms:

The symptoms of Charcot joints vary based on the location and severity of the problem. The sign is localized edema swelling) of the joint or joints. The actual edematous area may exhibit increased temperature change. Often, the first apparent sign that a patient with advanced sideline neuropathy will notice is the fact that their shoes have become tighter or they will have difficulties fitted into a pair of shoes that have fit well for some time.

The concern in diagnosing this condition is the lack of signs and symptoms that are due to peripheral neuropathy. Peripheral neuropathy makes it impossible for the patient to be able to speak in terms that would be understood by the general population such as 'my toes hurt'. As a result, the physician needs to rely more on testing and less on the history and physical examination.

Differential Diagnosis:

The differential diagnosis for this condition should include;

  • Bone tumor.
  • Fracture.
  • Idiopathic edema
  • Pseudogout.
  • Soft tissue tumor

Additional References Include;

Grady, J.F., et al: The use of electrostimulation in the treatment of diabetic neuroarthropathy J. Am. Podiatric Med. Assoc. 90(6): 287-294, 2000

  • Sinha, S., Munichoodappa, C.S., Kozak, G.P: NeuroarthropathyCharcot Joints) in diabetes mellitus.
  • Medicine (Baltimore)

Saltzman, CL, Johnson KA, Goldstein RH, et al: The patellar tendon-bearing brace as treatment for neuropathic arthropathy: a dynamic force monitoring study. Foot Ankle 13: 14, 1992

  • Sticha RS, Frascone ST, Werthheimer SJ: Major arthrodesis in patients with neuropathic arthropathy.
  • J Foot Ankle Surg 35:
  • Eichenholtz SN: Charcot Joints, Charles C.
  • Thomas, Springfield,Il 1966
  • Giurini JM: Applications and use of in-shoe orthoses in the conservative supervision of Charcot foot deformity.
  • ClinPodiatric Med Surg 11: 271, 1994
  • Pinzur Ms, Sage R, Stuck R, et al: A treatment algorithm for neuropathic (Charcot) midfoot deformity.
  • Foot Ankle 14: 189, 1993

Lavery La, Armstrong DG, Walker SC: Therapeutic rates of person suffering from diabetes foot ulcers associated with midfoot fracture due to Charcot's arthropathy. Diabet Med 14:46, 1996

  • Cleveland M: Surgical fusion of unstable joints due to neuropathic disturbance.
  • Am J Surg 43: 580, 1939
  • Wilson M : Charcot foot osteoarthropathy in diabetes mellitus.
  • Mil Med 156: 563, 1991
  • Reinherz RP, Cheleuitte ER, Fleischle JG: Identification and treatment of the diabetic neuropathic foot.
  • J Base ankle Surg
  • Pap J, Myerson M, GirardP, et al: Save you with arthrodesis in intractable diabetic neuropathic arthropathy of the foot and ankle.
  • J Bone Joint Surg Am 75:1056, 1993
  • Lavine LS, Grodinsky AJ: Current ideas review: electrical stimulation of repair of bone tissue.
  • J Bone Joint Surg Am 69: 626, 1987
  • Bassett CA, Mitchell SN, Norton L, et al: Repair of non-unions by pulsing electromagnetic fields.
  • Acta Orthop Belg 44: 706,

About the actual author:Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.

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Domenic is a head content marketing specialist at musclenstress.com, a collection of articles on health issues. In the past, Domenic worked as a post curator for a well-known health site. When he's not writing posts, Domenic enjoys drawing and rock climbing.