Charcot Foot

Candidate:

This is a clinical photograph of a grossly deformed foot and ankle, possibly due to Charcot arthropathy.

Candidate:

Charcot arthropathy can occur in any patient with a sensory disturbance, with over 90% of cases in the UK being related to diabetic neuropathy. Other causes can include alcoholic peripheral neuropathy, post-traumatic sensory deficits, tertiary syphilis, spina bifida, hereditary motor and sensory neuropathy, and congenital insensitivity to pain. Diabetes, especially when poorly managed, can lead to peripheral neuropathy – damage to the nerves in the limbs, often in the feet. This neuropathy, in turn, causes a loss of sensation that prevents the patient from perceiving pain and trauma, leading to unrecognized injuries and progressive damage and deformity in the joint.

Candidate:

Eichenholz has classified the progression of Charcot arthropathy into three stages:

Collapse: The foot becomes painful, swollen and warm. X-rays may show fractures or dislocations, making it difficult to differentiate from an acute infection. Over weeks, the swelling and redness may settle, but the foot can change shape due to continued bone fragmentation.

Coalescence: The foot continues to settle, starts to stiffen, and deformities become fixed. X-rays show coalescence of small fracture fragments and adsorption of fine bone debris.

Consolidation: Over months, the swelling and redness completely settle. X-rays show consolidation and remodeling of fracture fragments. The timeline for these stages varies with the forefoot taking around 6 months, midfoot around 12 months, and hindfoot around 18 months.

Candidate:

The treatment approach to Charcot arthropathy involves several principles:

Prevention: Optimum management of co-morbidities like diabetes is crucial to prevent the onset of this condition.

Early diagnosis: It is important to maintain a high index of suspicion, particularly in patients who have lost protective sensation. This loss can be tested using the Semmes-Weinstein monofilament test.

Supporting the foot during the early phase: In the initial phase, the foot should be supported to maintain its shape and prevent gross deformity. Weight-bearing should be limited, and care should be taken to avoid ulceration since patients often lack protective sensation.

Post-consolidation management: Once consolidation is well underway, the patient can gradually return to some form of shoe wear. This can take several months, and often, life-long specially made orthotics will be required. It is crucial that patients are made aware of the risks of skin breakdown and encouraged to inspect their feet closely every day.

Candidate:

A patient with Charcot arthropathy reporting skin breakdown is a serious concern as it can lead to infection, including cellulitis, osteomyelitis or even septic arthritis. This patient requires immediate evaluation. Treatment might include antibiotics, wound care, off-loading, and possibly surgical intervention. If there is an underlying infection, it needs to be identified and treated promptly to avoid further complications. Multidisciplinary input may be necessary, involving specialists in diabetic medicine, infectious disease, wound care, and orthopedics. The patient would also require education about appropriate foot care, the importance of regular foot inspection, and controlling their underlying conditions such as diabetes.

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Charcot Foot

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