Charcot Arthropathy of the Foot & Ankle. MTAPA Annual Meeting June 2018 Emily Harnden, MD

Transcription

1 Charcot Arthropathy of the Foot & Ankle MTAPA Annual Meeting June 2018 Emily Harnden, MD

2 Background

3 Disclosures None

4 Learning Objectives Define the disease Recognize presenting signs/symptoms for proper diagnosis Understand basics of management

5 What is it? Chronic & progressive joint disease resulting in destruction of joints & surrounding bone structures Due to loss of protective sensation

6 What is it? Can occur at any joint Most common: Foot & Ankle Shoulder Elbow Knee

7 Risk factors DM (type 1 and 2) EtOHism Myelomeningocele Tabes dorsalis/syphilis Leprosy Syringomyelia Shoulder

8 Epidemiology 1.4% of patients with DM 7.5% of patients with DM + Neuropathy 9-35% bilateral disease 7% risk of amputation With associated ulceration: 28% risk of amputation

9 Pathophysiology Neurotraumatic Neurovascular Insensate joints Autonomic dysfunction Repetitive microtrauma Increased blood flow Bone resorption & weakening

10 Pathophysiology Neurotraumatic Neurovascular Insensate joints Autonomic dysfunction Bone & Joint Breakdown Repetitive microtrauma Instability Increased blood flow Deformity Bone resorption & weakening

11 Types (Brodsky Classification) 90-95%

12 Stages (Eichenholtz Classification) Stage 0: Joint swelling Radiographs NEGATIVE

13 Stages (Eichenholtz Classification) Stage 1: Fragmentation

14 Stages (Eichenholtz Classification) Stage 2: Coalescence

15 Stages (Eichenholtz Classification) Stage 3: Reconstruction

16 Learning Objectives Define the disease Recognize presenting signs/symptoms for proper diagnosis Understand basics of management

17

18 Diagnosis: History +/- History of trauma Can be PAINLESS: Pain in ~50% Swelling & redness in foot and/or ankle +/- Difficulty ambulating Difficulty with shoe wear

19 Diagnosis: Exam ACUTE Charcot Warm, swollen foot Erythema: Will DECREASE with elevation In acute infection, erythema will not change Ankle or foot instability Neuropathic Test with 5.07 monofilament (10 grams)

20 Diagnosis: Exam CHRONIC Charcot No erythema, warmth, or swelling Foot and/or ankle deformity Rocker-bottom Medial arch collapse Ankle/Hindfoot deformity Callous or ulceration Neuropathic Test with 5.07 monofilament

21 Diagnosis: Imaging Normal Foot Xrays: 17-32

22 Diagnosis: Imaging Normal Ankle X-rays:

23 Diagnosis: Imaging Charcot X-rays

24 Diagnosis: Imaging Charcot X-rays Mann s Foot and Ankle 2014, 4 th ed., Ch. 27

25 Diagnosis: Advanced Imaging Bone Scan: Rule out superimposed osteomyelitis Indium WBC scan: Negative (cold) in Charcot Positive (hot) in Osteomyelitis Technetium scan: Positive in both

26 Diagnosis: Advanced Imaging MRI Look for abscess with soft tissue swelling Osteomyelitis and Charcot look the SAME

27 Diagnosis: Labs Not very useful WBC, ESR, CRP can be elevated in both infection and Charcot

28 Diagnosis: Biopsy Gold standard for distinction between osteomyeiltis and Charcot Charcot pathognomic pathology: Bone particles embedded in synovium Osteo: Inflammatory cells in marrow + cultures Osteonecrosis in marrow

29 Learning Objectives Define the disease Recognize presenting signs/symptoms for proper diagnosis Understand basics of management

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31 Treatment: GOALS Prevent deformity Achieve bone & joint stability by stopping destruction Maintain a planti-grade, neutrally aligned foot Prevent ulceration Allow continued ambulation during healing

32 Non-Operative Treatment PRIMARY treatment for Charcot Appropriate non surgical treatment: 3% amputation rate Critical factor: maintain soft tissue integrity

33 Non-Operative Treatment Can require months to years of treatment At initial diagnosis discuss potential complications: Severe deformity Ulceration Infection Amputation

34 Non-Operative Treatment Treatment steps roughly follow stages of the disease

35 Non-Operative Treatment Step 1: Total Contact Casting (TCC)

36 TOTAL CONTACT CAST Acute/Stage 1 Early initiation of casting ensures more favorable outcome Non-weight bearing** Rest, elevation Change every week initially Change every 2-4 weeks as transition to stage 2

37 TOTAL CONTACT CAST Complications: Secondary skin breakdown from cast Frequent cast changes important Can briefly d/c cast if this occurs Mann s Mann s Foot Foot and and Ankle Ankle 2014, 2014, 4 th th ed., ed., Ch. Ch

38 Non-Operative Treatment Stage 1: Do NOT use prefabricated walker boots

39 Non-Operative Treatment Step 2: Transition to WB brace Timing: based on clinical exam and radiographs Resolution of redness, swelling, and warmth Stability at involved joints on exam Xray: new bone formation & callous

40 Non-Operative Treatment Step 2: CROW (Charcot restraint orthotic walker) boot Custom removable brace Initiate WB Continue until stage 3 May take months F/u every 3-4 weeks Skin X-rays Alter brace as needed

41 Non-Operative Treatment

42 Non-Operative Treatment Step 3: Transition to shoe Custom-molded, dualdensity accommodative insole May require extra-depth shoes Can also use well-fitted athletic or walking shoe May require custom modification for deformity Mann s Foot and Ankle 2014, 4th ed., Ch. 27

43 Non-Operative Treatment Stage 3 Alternative: Custom AFO (ankle foot orthosis) More severe deformity or residual instability Several types based on severity and location of deformity Posterior shell Solid AFO w/ foot orthosis Double upright calf-lacer AFO with in-depth shoe Ankle Gauntlet Lacer, aka Arizona AFO

44 Non-Operative Treatment Summary: TCC CROW custom accommodative insole in shoe or AFO Close follow up for: Relapse (30%) Occurrence in other extremity Soft tissue breakdown

45 Surgical Treatment INDICATIONS: Deformity or instability not amendable to custom bracing or footwear Chronic, recurrent ulceration or impending ulceration Wait until Stage 3

46 Surgical Treatment GOALS: Preserve function Allow safe footwear or bracing Prevent amputation

47 Surgical Treatment TECHNIQUES: Exostectomy: excision of bony prominences Arthrodesis: realign and fuse deformity to reconstruct plantigrade foot +/- ulcer debridement Amputation

48 Surgical Treatment EXOSTECTOMY: Isolated bony prominence causing ulceration or risk of ulceration Otherwise braceable or plantigrade foot

49 Surgical Treatment Arthrodesis More severe deformity correction Internal or external fixation High complication rate (up to 70%) Mann s Foot and Ankle 2014, 4 th ed., Ch. 27

50 Surgical Treatment AMPUTATION Non-reconstructable vascular disease Extensive open wound(s) Extensive or recurrent osteomyelitis Multiple comorbidities or non-ambulatory patient Psychiatric disease precluding compliance Failure of other surgical techniques

51 Learning Objectives Define the disease Recognize presenting signs/symptoms for proper diagnosis Understand basics of management

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53 Summary: Charcot Most common cause: DM2 Most common location: Foot & Ankle High index of suspicion for diagnosis Successful non-surgical treatment in MOST cases if done correctly Preserve soft tissue Prevent deformity Prevent infection

54 THANK YOU