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- It is the progressive, non-infectious destructive disease of joint
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- Congenital -
- CMT, spinal dyrsaphism (myelodysplasia)
- syringomyelia [can also cause LL charcot; case report for hip charcot]
- Acquired -
- DM, alcohol,
- Infection - syphillis, leprosy
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- 3 theories - neurotraumatic, inflammatory, Neurovascular
- Neurotraumatic - Loss of sensory protection, repeated trauma
- Neurovascular - autonomic dysfunction ➔ hypervascular ➔ increased resorption
- Inflammatory - inflammatory cytokines activate osteoclasts
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- Due to midfoot collapse
- The prominence can either be plantar subluation of talus, cuboid
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- Triple assessment to confirm diagnosis, rule out infection, elicit severity
- Hx
- Symptoms - duration, fever, pain
- Risk factors - DM, leprosy, syphilis, CMT,
- PE
- Differentiate from OM –
- Sensation - monofilament
- Claw toes - imbalance in intrinsics vs extrinsic. Intrinsics tend to be less functional; so excess FDL activity
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- blanching on elevation > 5-10min (erythema due to hyepervascularity)
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- Invx – to differentiate infection vs Charcot
- Bloods - FBC, CRP ESR
- Imaging –
- XR,
- MRI (TRO Deep collections),
- WBC labelled scan [hot in OM, cold in neuropathic joints]
- CT scan to evaluate for consolidation?
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- By stage = Eichenholtz FCC
- 1 = Fragmentation (1-6 month),
- 2 = Coalescence,
- 3 = Consolidation/ remodelling
- By joints involved = Brodsky
- 1 = midfoot - Lis franc joints +
- 2 = Peritalar - Talocalcaneal, Chopart joints (TN and CC) (same joints as triple fusion)
- 3 = Tibiotalar
- 3A = tibio talar
- 3B = calcaneum
- 4 = mixed
- 5 = forefoot
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- Goal = Aim is to achieve a consolidated stage 3 foot while preventing deformity
- Total Contact Cast (increases total surface area to distribute WB forces) ➔ Need repeat casting weekly/ 2 weekly ➔ until swelling subside Then convert to Charcot Restraint Orthotic Walker (CROW)
- Bisphosphonates – no evidence
- F/U for temperature (2 degree cut off. If > 2 ° , still active. If < 2 °, can withdrawal immobilization. ), serial XR
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- Need to rule out infective ulcer ➔ Bloods and MRI to look for OM or deep collections
- Infected ➔ Op to debride ➔ eradicate infection ➔ Plan for definitive op.
- Can consider TA release at same time to reduce plantar loading
- Non Infected ➔
- Not recommended to do exostectomy at acute stage as it can lead to further mid foot collapse
- Offload and protect ulcer with TCC until consolidation stage (assess clinically with temperature or CT scan for fusion) ➔ Exostectomy and deformity correction
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- Aim = Achieve a plantigrade, functional, stable, painless foot
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- Accomodative shoe wear to accommodate deformities e.g. rocked bottom
- Op
- Indications – Foot at risk– deformity that threatens skin and is unstable.
- Planning for Op
- Check Vascular supply
- Surgical options:
- Soft tissue procedures ➔ TAL lengthening (very good to reduce plantar loading
- Exostectomy/ bumpectomy
- Deformity correction and fusion
- extension of fusion beyond zone of injury
- include joints not affected;
- ‼️ adequate bone resection to improve soft tissue envelope ; minimal soft tissue dissection
- 1 plantar plates,
- 2 multiple locked plates,
- 3 axial screw fixation
- External fixation – standalone or combined with IF (circular fixator)
- TTC nailing
- Amputation
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- As high as 35%
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- Internal fixation – superconstructs described by Sammarco et al. – 3 principals and 3 fixation techniques
- 3 principles
- extension of fusion beyond zone of injury
- include joints not affected;
- adequate bone resection to improve soft tissue envelope ; minimal soft tissue dissection
- 3 fixation techniques –
- plantar plates,
- multiple locked plates,
- axial screw fixation
sammarco2009.pdf652.6KB
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- Syme = Transmalleolar amputation
- Pirigoff = Talectomy, Distal calcaneum osteotomy; flipped such that the calcaneum tuberosity now faces down
- Boyd = Talectomy, Excision of anterior and superior articularting surfaces, calcaneotibial fusion
- Chopart = Chopart joint (TN and CC) disarticulation
