Charcot Joint

 Rapidly progressive and destructive, neuropathic arthropathy arising from loss of pain sensibility and position sense
 Usually minimal or no trauma
 Especially weight bearing joints
 Charcot 1868 - Changes in jt 2° to damage to CNS trophic centres that control bone & joint nutritio (all his patients had tabes
dorsalis)

Prevalence/Epidemiology Pathogenesis – combination of both

 Poorly controlled DM in West Neurotraumatic Theory
 Usually affects foot  Repetitive microtrauma due to loss of normal reflex safeguards
o TMTJ 70% o Protective joint sensitivity
o Forefoot 15% o Proprioception
o Hindfoot 15%  Florid joint damage due to
 Bilateral in 35% o Resultant fracture
 Average 14 years duration of o Continued weight bearing with misuse
DM at onset of neuropathy Neurovascular Theory
Aetiology/DDx  Neurally initiated vascular reflex due to autonomic dysfunction
 Spina Bifida o Leads to increased blood flow & active bone resorption by osteoclasts
 Alchoholism o Secondary fracture & joint damage
 DM
 Tabes dorsalis Unlike OA it is largely destructive with few if any signs of repair
 Syringomyelia 20-40% Classification - Eichenholtz
 Leprosy 3 stages of development (“fragmented coal consolidates”)
 Cong Indifference to pain 1. Acute (Fragmentation)
 Peripheral nerve lesions –  Clinical
toxic, traumatic, infectious, o Rapid onset of red hot swollen joint
neoplastic damage o May be mild-moderate pain
o Differential diagnosis from – cellulitis, OM, Septic arthritis, gout
SAD TULIP o  Erythema in Charcot foot classically decreases with elevation of foot
 XR
Important Points o Generalized osteopaenia & dissolution
 DM most common cause o Periarticular fragmentation of bone ± dislocation
 Syringomyelia most common o Soft tissue swelling
cause in UL
o Te99 of little help in differentiating from infection
 Leprosy 2nd most common in
o Te99-labelled WBC better
UL  MRI - May be of use
 In exam you don’t operate  Laboratory - ESR & WCC are Normal
unless only alternative is
amputation 2. Subacute (Coalescence) Clinical appearance suggests it
Deformity  Clinical should be agonising – the
Foot o Redness & swelling decrease paradox is diagnostic
o TMTJ & STJ collapse  Pes o Pain decreased
Planovalgus o Early deformity
o Forefoot deformity leads to  Usually Pes Planovalgus
claw toes  XR
Ankle o New bone formation
o Less commonly affected  Fracture of differing ages
o Usually preceded by fracture  Due to callus formation
o Leads to subluxation & o Prolific
dislocation of ankle o Abundant cartilage/ bone

Semmes-Weinstein Monofilament 3. Chronic (Consolidation)

o 5.07 = non-protective  Clinical
sensation o Redness & swelling settled
o Progressive deformity
o Ulcer over bony prominences
o Especially head of talus
 XR
o Fracture healed & consolidated
o Residual gross disorganization of joints
Management
Principles
o Prevention Specific
o Education Forefoot
o Protect joints from trauma/ overuse o Most problems are ulceration
o Due to exostosis
Treatment o Due to infection
o Aims o Treat with debridement
o Control foot position & shape o Pretreat associated ulcer with
o Maintain plantigrade foot  Debridement
o Watch for ulcers  Antibiotics
o Acute o Exostectomy
o Rest joint  Use full thickness flap to bone
o Protect from weight bearing  Remove bone prominence
o Backslab if swelling  Do not remove so much bone
that joint is destabilised
o Then Total Contact Cast
Midfoot & Hindfoot
 Avoid overpadding the cast
o Rarely treat surgically
 Felt over bony prominences
o +++ Debride of necrotic bone
 Changed weekly
o Crutches o Instability/ deformity
o Lasts for 1-2/12 o Occasionally performed are
o Subacute o Mid/ Hindfoot osteotomy
o Once acute swelling decreases o Fusion of selected joints
o Protect from deformity o Aim is shoe-able plantigrade foot
 Total Contact Orthosis Ankle
o Treatment nonoperative
 TCO
 Charcot Retaining Orthotic Walker o Unless so severe considering amputation  KEY
 CROW o Can then justify arthrodesis
 Front-Back Boot with Rocker Bottom
o Minimal weight bearing initially Knee
o Lasts for 2-6/12 o Poor results with TKR (Hugh English does TKR)
o Chronic o Arthrodesis is the operation of choice
o Once healing has occurred o Charnely Clamp 50% union
o Brace indefinitely
Hip
o Forefoot
o Surgery not indicated except in severe disability
 Extra depth shoes
o ORIF NOF  Failure
 Molded insoles
 Steel shanks o Hemi NOF  Dislocates/ fails
 Rocker bottom soles o Arthrodesis  Nonunion
o Mid/ Hindfoot o THR not indicated
 Double upright PTB AFO
Spine
Surgery o Destructive changes in 10-15%
o Seldom contemplated o Both central & lateral joints
o Contraindications
o Uncontrolled DM
o PVD
o Acute Disease
o Recurrent ulcer from bony prominence may benefit from removal
o Heal ulcer 1st if possible
o Then exostectomy
o Unbraceable foot may require arthrodesis
o Difficult to obtain
o Avoid during acute stages 1 & 2
 Associated with osteopaenic bone
o When performed, principles are
 Resect sclerotic bone
 Firm apposition of fragments
 Bone graft where indicated
 Efficient & long immobilization