Charcot Neuroarthropathy

Transcription

1 Charcot Neuroarthropathy Jeffrey D. Lehrman, DPM, FACFAS, FASPS, AAPWCA Diplomate, American Board of Foot and Ankle Surgery John Scheland, DPM FACFAS

2 Important Points Recognize Charcot (Patient, Presentation, Stages) Differential Diagnosis Diagnostic Strategies Non-Surgical Modalities Understand Surgical Challenges Management in Long-Term

3 Charcot Statistics 60-70% diabetics neuropathic Often misdiagnosed, overlooked! Duration of diabetes >10 years B/L 6-40% Progressive deformity, ulceration, infection, amputation, death

4 Etiology Diabetes most common cause Tabes dorsalis Syringomyelia Leprosy Polio Pernicious Anemia Spinal chord tumors Paraplegia Alcohol abuse Extrinsic compression of spinal cord MS Chemo-Therapy Spina Bifida Pott s Disease

5 French Neurovascular Theory Neurally initiated vascular reflex. Autosympathectomy High rate of flow produces AV shunting Bone demineralization and breakdown. Bone resorption by osteoclasts. Hyperemia with secondary pathologic fractures With continued WB on insensate foot, the Neurotraumatic mechanism occurs.

6 German Neurotraumatic Theory Bone and joint changes caused by repetitive foot trauma on an insensate foot. Trauma (Minor/Major) Repetitive moderate stress Repetitive impulse loading Trabecular microfractures Inadequately protected fractures/sprains Surgery

7 What Factors Contribute to Charcot? NEUROPATHY: 100% Increased local blood flow (A-V Shunting) Increased plantar foot pressures (Deformity/Equinus) Non-Enzymatic Glycosylation Continued repetitive stress/trauma

8 The Natural History of Charcot s Neuroarthropathy. Nielson, D. and Armstrong, D. Lack of perception of 4/10 sites (SWMF), carries 97% sensitivity and 83% specificity in identifying patients at highest risk for diabetic foot ulcers. Vibration perception, yielding 90% sensitivity and 84% specificity in detecting neuropathy. When both of these used the sensitivity increased to 100% and specificity 77%. 8

9 Motor Denervation of intrinsic muscles Contractures Deformities, digital deformities Gait Abnormalities; Drop foot, EQUINUS Non-Enzymatic Glycosylation Autonomic (Sudomotor) Etiologic factor in soft tissue and bony lesions Abnormalities in regulation of temperature and sweating AV-Shunting Hypothesis: Autosympathectomy Sensory: Most Important! Leading factor in fractures, ulcers, injuries

10 Recognition of Charcot Must have high index of suspicion PMH History of trauma/surgery Symptoms Clinical Presentation

11 Charcot Joint Disease The Medical History General Patient Profile Diabetes 15 years Poor Control Renal Failure 5 th or 6 th Decade Sex predilection? Bilateral 6 40 % Primary Risk Factors Retinopathy Nephropathy Neuropathy Secondary Risk Factors Obesity Biomechanics Lifestyle Trauma

12 Acute Charcot Presentation Clinical Presentation Extremity Clinical Erythema Warmth Swelling/Edema Labs WBC Possibly Slightly Elevated Differential: no Left Shift Glucose normally elevated ESR/CRP normally elevated Alkaline Phosphatase normally elevated Creatinine usually elevated Blood Cultures negative if only Charcot Venous Doppler negative if only Charcot

13 Charcot Joint Clinical Presentation Extremity Relatively painless Neurologic deficit Progressive May have adequate circulation Long Standing Charcot does not Guarantee Continued Adequate Blood Flow Lack of protective sensation Microtrauma Ligamentous instability

14 Differential Diagnosis of Charcot Foot Osteomyelitis Cellulitis DVT Gout Septic Arthritis Pes planus Bone Tumor DJD Osteomyelitis / Cellulitis more likely if there is an ulcer or history of an ulcer

15 Probe to Bone Test Posivitive predictive value 53% - 95% Negative predictive value 85% - 98% May be more useful in excluding osteomyelitis than diagnosing it. Sensitivity 60%-98% Specificity 78% - 91% Grayson, 1995 Lavery, 2007 Shone et al, 2006

16 Charcot Joint Disease IMAGING STRATAGIES Sensitivity Specificity X-Ray 22-75% 53-80% Tc 99 ( TPBS) ` % % In111 ( Acute ) lower than Tc Higher than Tc In111 ( Chronic ) 60% > 50% Ceretec 90% 86% In111 + TPBS 100% 83% MRI 90% 79%

17 PTB test combined with X-ray in diagnosing osteomyelitis 97% sensitivity 92% specificity Positive predictive value 97% Negative predictive value 93% Aragon-Sanchez et al, 2011

18 X-Rays The 6 D s Destruction Increased density Disorganization Dislocation Disarticulation Debris

19 Arthropathy may precede the clinical onset of neurologic symptoms Freiberg like lesions Shortening of the proximal phalanx of the hallux Arthritic changes Ankylosis HYPERTROPHIC OSTEOARTHRITIS WITH A VENGEANCE ATROPHIC SUCKED CANDY

20 Patterns of Bone and Joint Forefoot: IPJ, Phalanges, MTPJ, Distal MT bones Radiographs: Pencil like tapering of metatarsal bones with sucked in candy stick appearance. Plantar ulceration common finding. Cofield and collegues: 91% Edmonds and collegues: 93% Destruction

21 Patterns of Bone and Joint Destruction Freiberg- like Lesions Phalanx Shortening Hypertrophic

22 Nuclear scans may be useful if Diagnosis of infection uncertain Clinical presentation uncertain Extent of bone involvement uncertain Presence of implants precludes use of MRI or CT scans Documentation necessary

23 MRI With contrast Low signal intensity on T1 and T2 images within bone marrow space adjacent to involved joints Visualize abscess (If Present) Observe tendon and ligament complexes for future reconstruction Charcot versus osteomyelitis findings

24 Imaging Stratagies X-ray first MRI best imaging option CT scan be useful when infection established and main concern is viability of underlying bone 3D CT Good for Reconstructive Planning

25 Charcot Joint Disease Invasive Procedures Synovial Culture/Biopsy Osteoarthritis vs Neuroarthropathy Bone Culture/Biopsy Osteomyelitis vs Neuroarthropathy

26 Bone Biopsy Synovial Biopsy Multiple shards of bone and soft tissue in the deep layers of synovium is pathognomonic for neuropathic osteoarthropathy. Bone/Synovial Cultures 1. May rules in / out presence of infection 2. Speciates Organisms for Tx 26

27 Histology vs. Culture HISTOLOGY Meyr study: 39 specimens, Unanimous agreement in only 33.33% of specimens. CULTURE Possible Contamination On Antibiotic? Improper sampling Stop antibiotic 48 hrs prior 27

28 Charcot

29 Eichenholtz Classification Stage 0 Joint edema Radiographs are negative Bone scan may be positive in all stages

30 Eichenholtz Classification Stage 1: Developmental/Fragmentation Acute destructive period Joint effusion Soft tissue edema Bone resorption Dislocation/Subluxation Increased joint mobility Bone, cartilage debris Intraarticular fractures Fragmentation of bone NWB TCC

31 Eichenholtz Classification Stage 2: Coalescence Lessening of edema Absorption of fine debris Healing of fractures Fusion, coalescence Loss of vascularity Sclerosis of bone PWB TCC CROW Bivalved AFO

32 Eichenholtz Classification Stage 3: Reconstruction/Resolution Bone repair and remodelling Residual deformity Diminution of sclerosis Restoration of stability Increased bone density Exuberant ossification CMO with rocker soles CROW, Diabetic shoes

33 Sanders and Frykberg Classification Zone 1: distal and proximal interphalangeal joints and metatarsophalangeal joints Zone 2: tarsometatarsal joints (Lisfranc) Zone 3: naviculo-cunieform joints talo-navicular joint calcaneocuboid joint Zone 4: ankle joint subtalar joint Zone 5: calcaneus

34 Sanders and Frykberg Classification Zone 3 Zone 5 Zone 4 Zone 1 Zone 2

35 Patterns of Charcot (Sanders/Frykberg) MPJ/IPJ 15% Tarsal/Metatarsal 40% Ulcer MPJ/Toe Ulcer Styloid/Cuboid

36 Patterns of Charcot (Sanders/Frykberg) Midtarsal joint 30% Ankle 10% Ulcer CC/Cuboid/Medial Arch (late) Unstable Ulcer Head of Talus and Medial Malleolus

37 Patterns of Charcot (Sanders/Frykberg) Calcaneus 5%

38 NONOPERATIVE MANAGEMENT RESOLVE EDEMA PROLONGED NWB CAST IMMOBILIZATION BRACING TERMINATE PROCESS PREVENT PROGRESSION ELECTRICAL BONE STIMULATION FOSEMAX, CALCITONIN STIMULATE BONE PRODUCTION RETARD OSTEOCLASIS SURGICAL INTERVENTION MINOR OR MAJOR

39 Non Operative Protocols Standard BK cast Bivalved AFO walker CROW: Charcot Restraint Orthotic Walker PTB: Patellar Tendon Brace

40 Non Operative Management Goals Create and maintain plantigrade foot Heal ulcer Prevent infection Bony healing Prevention of deformity

41 Conservative Treatment Treatment is prolonged and challenging Strict NWB 8-12 weeks (Brace, TCC, CROW) Immobilization continued to consolidation stage. Newer Options: Bisphosphonates, calcitonin, antiinflammatories Bone stimulators useful Midfoot charcot: Keep immobilized 4-6 months Ankle charcot: 9 months to 1 year

42 Surgical Intervention Controversy: When to intervene with surgery? When bracing is ineffective and deformity may compromise skin by ulceration. Unbraceable due to severe deformity Goals: Limb salvage and prevention of amputation. Avoid during Acute and Subacute stage High risk of failure fixation and complications

43 PREOPERATIVE ESSENTIALS Stabilization of Diabetes Gait training for NWB status Prophylactic Bracing of contralateral limb Optimize local factors ( edema, skin etc. ) Know all surgical options

44 Considerations Prior to Surgery In Charcot foot with ulceration: Must check for OM Bone Biopsy MRI, Ceretec scan Plain films CT scan to fully evaluate cross sectional anatomy prior to arthrodesis and reconstruction

45 SURGICAL TREATMENT OPTIONS SOFT TISSUE Tendoachilles Lengthening Tendon Release or Transfer Ulcer excision & coverage OSSEOUS Relocation Osteotomy Relocation Arthrodesis Exostectomy Reconstruction with Grafting AMPUTATION Partial, Segmental, Full

46 When to operate? Chronic ulceration Recurrent ulceration Joint instability Osteomyelitis Avascular Necrosis Pain Acute Fractures

47 Goals Restore stability Restore alignment Prepare for Bracing and appropriate shoe gear Prevent inevitable amputation Community Ambulation

48 Timing Eichenholz Classification ( Temporal) If possible best done in Reconstruction Phase, Stage 3

49 Impediments to repair Soft Tissue Infection Bone Infection Uncontrolled Diabetes Malnutrition Eichenholz I Peripheral Vascular Disease Smoking Insufficient Bone Stock Non-compliance

50 Equinus 90% of DM with Charcot Major contributing factor to diabetic complications. Increased plantar foot pressures Ulcers Instability at midfoot Weakness of anterior crural muscles Drop foot gait force of FF Contracture triceps-surae from unopposed ankle DF stress TMTJ, MTJ

51 Equinus. Increased Plantar Foot Pressures 10 degrees required for proper gait If contracture identified can perform Tendo achilles lengthening Beware of over-lengthening can cause Calcaneal gait

52 Stable Charcot Foot Recurrent ulceration. Goal: Remove bony prominence predisposing to ulceration or difficulty with shoe gear. Offloading procedure designed to accommodate deformities that are not amenable to WB or shoe gear. Exostectomy

53 Arthrodesis Unstable CF or so severe that integrity of the foot is jeopardized Key to success: adequate rigid fixation, whether internal or external.

54 Fixation Options Internal fixation (Locking Plates, Solid Screws) Intramedullary nail External fixation Blade Plate Staged and/or Combination of Fixation Beaming

55 IM Rod

56 Internal Fixation

57 External Fixation

58 Indications External Fixation Open Fractures Comminuted Fractures Periarticular Fractures Osteomyelitis Deformity (length, angulation, rotation, translation, girth etc.) Soft tissue infection, Dead Space Soft tissue loss

59 Rationale of using Circular Multiplane External Fixator Wound Stabilization Limb Stabilization Fixation Away From Diseased Bone Acute Shortening or Lengthening Correction of Deformity Static Fixation Bone Transport

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62 Postoperative Protocol 3-5 months non-weightbearing TCC x 2 months Bracing x 12 months Quality of Fusion Activity level Location of Fusion Compliance

63 Postoperative Bracing MidFoot Deformity In-Depth or Extra Depth Shoe Extended steel shank STS Insole Rocker Sole HindFoot Deformity attach to double upright calf lacer or PTB AFO Significant Deformity use whatever shoe or insert accomadates foot and attach to double upright brace

64 When Bad Things Happen.

65 Pearls Know your differentials. Be able to differentiate between OM and Charcot. Understand your diagnostic studies, know when to use them and what you re looking for. Know when to use internal fixation versus external fixation and its indications. Know the indications for External fixation. Understand the principles of External fixation.

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67 Resources

68 Podiatry Institute Update 2009 Chapter 11 MRI EVALUATION OF OSTEOMYELITIS IN THE DIABETIC FOOT: Comparison with Surgical Pathology Matthew J. Takeuchi, DPM Patricia Forg, DPM J Am Podiatr Med Assoc Sep-Oct;102(5): Performance of the probe-to-bone test in a population suspected of having osteomyelitis of the foot in diabetes, Mutluoglu M, Uzun G, Sildiroglu O, Turhan V, Mutlu H, Yildiz S. Diabetes Care Oct;33(10): doi: /dc Epub 2010 Jul 9. Validating the probe-to-bone test and other tests for diagnosing chronic osteomyelitis in the diabetic footmorales Lozano R, González Fernández ML, Martinez Hernández D, Beneit Montesinos JV, Guisado Jiménez S, Gonzalez Jurado MA. Med Sci Monit Jun;15(6):CR The diagnosis of diabetic foot osteomyelitis: examination findings and laboratory values. Ertugrul BM, Savk O, Ozturk B, Cobanoglu M, Oncu S, Sakarya S. Diabetes Care Feb;30(2): Probe-to-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic?lavery LA, Armstrong DG, Peters EJ, Lipsky BA.

69 Radiol Med Feb;114(1): doi: /s Epub 2008 Oct 25. Role of magnetic resonance imaging in the evaluation of diabetic foot with suspected osteomyelitis.[article in English, Italian]Rozzanigo U, Tagliani A, Vittorini E, Pacchioni R, Brivio LR, Caudana R. J Nucl Med Technol Sep;39(3): doi: /jnmt Epub 2011 Jul 27. The diagnostic value of (99m)Tc-IgG scintigraphy in the diabetic foot and comparison with (99m)Tc-MDP scintigraphyasli IN, Javadi H, Seddigh H, Mogharrabi M, Hooman A, Ansari M, Jalallat S, Assadi M. Foot Ankle Int Mar;15(3): Magnetic resonance imaging for the diagnosis of osteomyelitis in the diabetic patient with a foot ulcer.levine SE, Neagle CE, Esterhai JL, Wright DG, Dalinka MK. Clin Infect Dis Aug 15;47(4): doi: / Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic footulcers: meta-analysis.dinh MT, Abad CL, Safdar N.

70 J Foot Ankle Surg Nov-Dec;50(6): doi: /j.jfas Epub 2011 Sep 9. Statistical reliability of bone biopsy for the diagnosis of diabetic foot osteomyelitis Meyr AJ, Singh S, Zhang X, Khilko N, Mukherjee A, Sheridan MJ, Khurana JS. J Foot Ankle Surg Mar-Apr;50(2): doi: /j.jfas Epub 2011 Jan 20. Histology versus microbiology for accuracy in identification of osteomyelitis in the diabetic foot. Weiner RD, Viselli SJ, Fulkert KA, Accetta P. Nabuurs Franssen MH, Sleegers R, Huijberts MS, et al. Total contact casting of the diabetic foot in daily practice: a prospective follow up study. Diabetes Care 2005; 28 (2): Indications/Diabetic-Foot-Ulcer.html American College of Hyperbaric Medicine. Diabetic Foot Ulcer Pathophysiology and Hyperbaric Effects J Am Podiatr Med Assoc Oct;91(9): The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study.kaleta JL, Fleischli JW, Reilly CH.