Charcot Ankle Neuroarthropathy Pathology, Diagnosis and Management: a Review of Literature

MOJ Orthopedics & Rheumatology Charcot Ankle Neuroarthropathy Pathology, Diagnosis and Management: A Review of Literature Keywords: Ankle charcot Arthropathy; Ankle arthrodesis; Ankle external fxation arthrodesis; Total contact cast; Ankle Review Article neuroarthropathy Volume 6 Issue 2 - 2016 Key Points: Charcot ankle neuroarthropathy is a common hard to treat condition, early diagnosis and proper management is the key point of treatment. Non- surgical options are feasible in certain stages, but surgical intervention is required in advanced 1Orthopaedic surgery specialist, Nasser institute for research disease. and treatment, Egypt 2Foot and ankle surgery fellow, Schmerzklinik Basel, Introduction Switzerland 3Lecturer of Orthopaedic surgery, Ain Shams University, Egypt Charcot neuroarthropathy can be described as a non-infective, destructive process activated by an isolated or accumulative *Corresponding author: neuro-traumatic stimulus that manifests as dislocation, peri- Ahmed E Galhoum, Orthopedic articular fracture or both in patients rendered insensate by Department, Schmirzklinik, Basel, 11-15 Hirschgasslein, peripheral neuropathy [1]. 4010 Basel, Switzerland, Email: Received: October 01, 2016 | Published: November 03, The ankle has swelling, warmth, and erythema, and the 2016 The bones and joints develop fractures, ligamentous laxity, dislocations,syndrome may cartilage initially damage, be difficult bone to erosions, distinguish and from hypertrophic infection. repair [2]. The resulting bone and joint deformities may be is present in 22% to 53% of patients with Charcot Arthropathy [6,14,15]. or braces. Furthermore, ulceration may result from instability or bonyassociated prominence with instability and may and cause may chronic compromise or recurrent the fitting soft of tissueshoes Classification infection and osteomyelitis. Amputation may be required for Modified eichenholtz stages management of infection or instability [2]. Almost all affected individuals have a dense sensory peripheral an earlier stage prior to “development. “ Several authors have neuropathy. The neuropathy is most commonly associated with Shibata T et al. [16] modified the Eichenholtz system to include diabetes, but may also be associated with leprosy, alcoholism, called “Charcot in situ,” “pre-stage 1,” or “stage 0 Charcot” [17-20]. tabes dorsalis (Syphilis), syringomyelia, peripheral nerve injuries, proposed that this early inflammatory phase following injury be or congenital absence of pain sensation [2]. Usually the larger foot-and-ankle physicians to Charcot arthropathy patients in the joints of the lower extremity are involved in syphilis, and the stagingThis classification of the disease is currently(Table 2). being applied by the majority of larger joints of the upper extremity are involved in syringomyelia [2]. In contrast, diabetes related Charcot arthropathy primarily Brodsky (anatomical) classification affects the foot and ankle [3]. Risk Factors foot and ankle surgeons is that based on the four most common anatomicThe most regions widely affected used anatomic[21] (Table3). classification by orthopaedic The presence of sensory peripheral neuropathy is essential for Charcot arthropathy to develop [4] (Table 1). The ankle comprises 9% of Charcot joints of the foot and ankle (Type 3A) (Figure 1). [3] Although less common than midfoot or The amount of bone and joint damage in the Charcot ankle hindfoot Charcot joints, Charcot ankles may be complicated by is determined by severity of sensory loss, mechanical stress on ulceration at the malleoli and severen uncontrollable deformity joints, and physical activity of the patient [2]. Vibration sensation and cardiovascular autonomic function are andThe hypermobility diagnosis of that Charcot may preclude arthropathy fitting is ofprimarily a brace. reliant on similar in patients with Charcot neuroarthropathy and diabetic clinical presentation, but a physician’s high index of suspicion patients with ulcers [5]. Obesity is present in at least two-thirds should not be underappreciated [7]. A thorough patient history of patients with Charcot neuroarthropathy [6]. is essential to any assessment; however, a neuropathic patient’s Trauma or surgery may initiate Charcot arthropathy [7-11] history can be unintentionally misleading. It is therefore up to the The trauma may be apparently minor, such as ligament sprain, clinician to know what questions to ask and what information is twisting injury, or stress fracture [7,12,13]. A history of trauma important when making an assessment. Submit Manuscript | http://medcraveonline.com MOJ Orthop Rheumatol 2016, 6(2): 00218 Charcot Ankle Neuroarthropathy Pathology, Diagnosis and Management: A Review of Copyright: 2/6 Literature ©2016 Galhoum et al. Table 1: Risk factors for the development of Charcot Arthropathy [5]. Neuropathy (sensory, autonomic, motor) Age Obesity Trauma Physical activity Ulceration Peripheral vascular disease Instability Achilles tendonPlantar / gastro pressure soleus contracture Table 2: Modified EichenholtzStage Stages [19,20].Clinical Radiography Differential Diagnosis Frequently, stage 0 patients are Charcot swelling Diagnosis of this stage with MRI Stage 0: misdiagnosed as cellulitis, gout, or deep vein LocalizedRedness or technetium bone scan thrombosis Warmth (Inflammatory) Arthropathy Fragmentation of subchondral Stage I: Development- Marked swelling Bone debrisbone at joints Fragmentation IncreaseErythema warmth Subluxation Dislocation Decrease erythema Decrease New bone formation Stage II: Coalescence swelling CoalescenceAbsorption of oflarge fine fragments debris Decrease Sclerosis of bone ends warmth Resolution of Stage III: Reconstruction- edema Remodling, rounding of bone Consolidation Residual Decrease sclerosis deformity Table 3: Charcot arthropathy of the footType and 1ankle: Brodsky anatomical classification [21]. Type 2 TarsometatarsalChopart’s/ subtalar (Lisfranc's) Type 3A Ankle Calcaneus Type 3B Multiple regions : Type 4 Sequential Concurrent Type 5 Forefoot Special attention must be given to the patient especially if history of any trauma, history of neuropathy, recent swelling, arthropathy. The loss of protective sensation may leave the patient redness in the limb. Counter intuitively, the history may include unawarerecall some of anyspecific particular traumatic event event or reoccurring prior to the minor onset events of Charcot [23]. pain sensations in an insensate limb but no recollection of It is important to investigate any previous history of infection any sustained trauma. In a study of 55 patients with Charcot or ulcers to role out a recurring acute or chronic infection. The arthropathy, more than 75% complained of pain in the foot and usual presentation of Charcot arthropathy involves, a warm, ankle upon presentation even though all subjects had a clinical swollen, erythematous foot or ankle in an insensate patient loss of protective sensation to the 10-g Semmes-Weinstein mono- and, because of its similarity to an acute soft-tissue infection, heightened awareness is needed when dealing with the diabetic filamentRepetitive wire [22].trauma to the foot and ankle may be entirely neuropathy patient population [22]. Most infection in the diabetic absent from verbal history even though clinical symptoms prove foot and ankle involve a direct source of inoculation through an otherwise. The study found that only 22% of patients were able to opening in the skin, usually caused by neuropathic ulcers [24,25]. Citation: Orthop Rheumatol 6(2): 00218. DOI: 10.15406/mojor.2016.06.00218 Galhoum AE, Abd-Ella MM (2016) Charcot Ankle Neuroarthropathy Pathology, Diagnosis and Management: A Review of Literature. MOJ Charcot Ankle Neuroarthropathy Pathology, Diagnosis and Management: A Review of Copyright: 3/6 Literature ©2016 Galhoum et al. III. Charcot Restraint Orthotic Walker (CROW) IV. Antiresorptive Drugs V.VI. ElectricalUltrasound Bone Stimulators B.I. OperativeDebridement Treatment of Ulcer. including II. Ostectomy. III. Arthrodesis with Internal Fixation. IV.V. ArthrodesisAmputation: with with External uncontrolled Fixation. infection and VI. Uncontrolled deformity. Non operative therapies and medical management Figure 1: The goals for every patients undergoing treatment for an acute or quiescent Charcot process should be to maintain or achieve Brodsky anatomical classification (22). structural stability of the foot and ankle, to prevent ulceration, When this initial stage is suspected but not proven, the patient and to preserve a plantigrade foot [15]. should be prevented from incurring any additional injury to the Total contact cast protected while awaiting the results of further investigation. suspected limb. With immobilization and offloading, the patient is Most cases of acute Charcot ankle especially stage 0 or stage Radiographs of the foot and ankle that are taken in the non-weight-bearing position can have obvious variability in surgically with pressure-relieving methods such as total contact image quality and may not show subtle instability compared to casting1 Eichenholtz (TCC), Charcotwhich is neuroarthropathy believed to be thecan goldbe treatedstandard non- of radiographs in the weight-bearing position. It is recommended treatment [32]. that all foot-and-ankle radiographic examinations be obtained in a weight-bearing position if possible. TCC was developed in the 1950s. Most of the cast padding is eliminated for exact conformity to the lower extremity, with the MRI examination are increasingly being

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