General overview. Good starting point.

1. Charcot Foot
Miss Sheweidin Aziz – ST3 T&O
Boston Pilgrim Hospital
June 2016

2. HISTORY
• In 1703 William Musgrave first described a neuropathic joint
as an arthralgia caused by venereal disease
• In 1868 Jean-Martin Charcot gave the first detailed
description of the neuropathic aspect. He noted this disease
process as a complication of syphilis (most common cause
until 1936 when Jordan linked it to Diabetes)

3. DEFINITION
• Neuropathic (Charcot) osteoarthropathy is a non infective,
destructive, lesion of a bone and joint resulting from a
fracture or dislocation or both in a patient who has
peripheral neuropathy

4. • A chronic and progressive joint disease following loss of
protective sensation and leads to destruction of joints and
surrounding bony structures. May lead to amputation if left
untreated

5. RISK FACTORS
• Diabetic neuropathy
• Alcoholism
• Leprosy
• Meningomyelocele
• Tabes dorsalis/syphilis
• Syringomyelia
• Any condition that causes sensory or autonomic neuropathy

6. EPIDEMIOLOGY
• In diabetic patients: 0.1-1.4%
• In diabetics with neuropathy 7.5%
• Bilateral disease occurs in <10%
• Type 1 DM: 20-25 years post diagnosis
• Type 2 DM: 5-10 years post diagnosis
• Gender ?Male predominance

7. PATHOPHYSIOLOGY
Neurotraumatic theory: German theory 1946
• Peripheral neuropathy  loss of protective sensation 
increase susceptibility to injuries (repeated minor or acute)
 progressive destruction and damage to bone and joints

8. PATHOPHYSIOLOGY
Neurovascular theory: French theory 1868
• Spinal cord lesion  autonomic neuropathy  AV shunting
 increased blood flow (warm foot and dilated veins) 
Increased osteoclast activity  bone resorption and
mechanical weakening  fractures and deformity

9. PATHOPHYSIOLOGY
Molecular biology
• Inflammatory cytokines may cause destruction IL-1 and TNF
– alpha  increased production of transcription factor - kB

10. CLINICAL PRESENTATION
• Symptoms
• Swelling foot and ankle
• Pain 50%
• Loss of function

11. CLINICAL PRESENTATION
• Acute Charcot
• Swelling
• Warmth (3.3° warmer)
• Erythema (will decrease with Charcot but not with
infection on elevation)

12. CLINICAL PRESENTATION
• Chronic Charcot
• Structurally deformed foot
• Rocker bottom deformity
• Collapsed medial arch

13. CLASSIFICATION

16. Stage 0: Joint oedema. Negative radiographs.

17. Stage 1: Fragmentation. Joint oedema. Bone
resorption. Dislocations. Fractures

18. Stage 2: Coalescence. Decreased local oedema.
Sclerosis. Fracture healing. Debris resorption.
Decreased joint mobility.

19. Stage 3: Reconstruction. No joint oedema.
Consolidation and remodelling of fracture
fragments. Ulcers may develop.

20. INVESTIGATION
• Inflammatory markers: Elevated in Osteomyelitis and
Charcot
• Bone scan: useful in presence of superimposed osteomyelitis
• Technetium bone scan: maybe positive in infection or
Charcot
• Indium WBC scan: Negative in Charcot. Positive in
osteomyelitis

21. • MRI: differentiate between abscess and soft tissue swelling
• Biopsy: to guide antibiotic therapy
• Histology: Synovial hypertrophy and detritic synovitis

22. MANAGEMENT
• Non-operative
• Total contact casting every 2-4 weeks for 2-4 months
• Orthotics – Charcot restraint orthotics walker (CROW)
boot can be used after TCC
• Shoe modifications to reduce ulcerations

23. • Operative
• Resection of bony prominences (exostectomy) and
Achilles Tendon lengthening
• Braceable foot with equinus deformity and focal bony
prominence causing skin breakdown
• Aim to achieve plantigrade foot that allows ambulation
without skin compromise

24. • Deformity correction, arthrodesis +/- osteotomy
• Severe deformity that is not braceable
• High complication rate up to 70%
• Amputation
• Failed surgery. Unstable arthrodesis. Recurrent infection
• Aim is for partial or limited amputation if vascularity allows

25. Sohn et al performed a retrospective study to compare the risks of
lower-extremity amputation
• Charcot patients had a 4.1 amputations per 100 person-years vs ulcer
patients 4.7
• In patients under 65 years amputation risk 7x in ulcer only vs. 12x for
Charcot and ulcer

26. THANK YOU