Nicholas J. Bevilacqua, DPM reviews the Charcot process, including predisposing factors and signs and symptoms. Dr Bevilacqua also discusses the basics of conservative and surgical treatment options. Case presentations are presented.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Nicholas Bevilacqua, DPM
North Jersey Orthopaedic Specialists
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Male Speaker: Now, we'll have Dr. Bevilacqua continue on with our surgical discussions on the Charcot foot general principles for management.
Dr. Bevilacqua: Alright. I'll do my best to stay on time. A lot of information in a short amount of time but we're going to get through it. So Charcot Foot Principles of Management. I'm sure you've heard the different nomenclature, Charcot neuropathic osteoarthropathy, most commonly just Charcot foot or Charcot ankle. Really, it's an inflammatory syndrome characterized by varying degrees of bone and joint destruction. It's progressive deformity occurs in people with neuropathy and classic rocker bottom foot deformity we showed at that previous talk, it's that hallmark sort of deformity that later stage Charcot foot, which ultimately puts the pressure at risk for skin breakdown and ultimately amputation. So it bears its name from Dr. Jean-Martin Charcot, French surgeon. You can see, this is some of his earlier work primarily on tertiary syphilis called the tabetic arthropathy and this is one of -- just from one of his early papers here. So this is in the 1850s and he ends the report with a little quote here, sera continue, which translates, to be continued. And here we are almost 150 years later and there's still a lot to learn about this condition. It wasn't until 1936 when it was associated with diabetes. Again, it occurs in people with neuropathy. Today, we know the number on cause of neuropathy is diabetes. Other causes, anything basically that causes neuropathy, it could be drugs, it could be alcohol induced, it could be diseases affecting the spinal cord or pretty much any other condition that can cause neuropathy. We've seen it in patients with HIV. So William Jeffcoate described the vicious cycle. Basically, it's uncontrolled information, you get this release of proinflammatory cytokines. Patients who have neuropathy, they continue to walk on this insensitive foot, there may be some minor trauma. It could be a surgical insults of -- that causes this increase in blood flow, they get fractures, dislocation, that causes more release of this proinflammatory cytokines and then they're neuropathic. So they're just continuing that cycle and it's really this inflammatory condition that just progresses, at least, bone and joint breakdown. The proinflammatory cytokines, basically, they cause an increase in RANKL. RANKL is important because through its pathway, it cause -- it induces preosteo [phonetic] class to mature into osteo class. And osteo class are responsible for bone breakdown. OPG is a decoy receptor and we know that there's an imbalance, and that causes this exaggerated bone loss. I'll show you that loss of balance between RANKL and OPG. So in terms now of the scope of the condition, you know, why we're here talking about it. I'm sure that anyone that seen a patient that has a Charcot foot, they know that it's -- it affects them dramatically or affects them negatively. We know these patients are in and out of wound cares and don't discount the effect it has on their family members, you know, oftentimes the family is the one driving them to wound care every week or every day to hyperbaric oxygen chamber. So there's a dramatic negative effect on the lifestyle, increases morbidity and mortality and we know that there's increased risk of amputation as a result. The diagnosis, there's -- is a clinical challenge along with the management and oftentimes there's a delay in diagnosis. Once I'm sure that the delay averaged up to 29 weeks and it sounds surprising but if you really think about it, how many patients have you seen, patient has diabetes, they have neuropathy, they have red hot swollen foot, they go to the emergency room, they are told they have cellulitis, they're given a prescription for an antibiotic and they walk right out on that insensitive foot. And they come back a week later, and now maybe its gout, maybe there's a DVT. And Charcot foot, to the non-specialized practitioners, it's very kind of low in the list of things that they think about. And oftentimes these patients -- I've had patients that were admitted into the hospital for IV antibiotics and then they go home and they were told to follow up with me for the cellulitis and then we know that they have Charcot foot. There was a taskforce, actually, Dr. Fiber [phonetic] who's the co-chair with Lee Rogers and they convened in Paris, Salpêtrière Hospital where Charcot actually practiced. And you know, you'll see there's different nomenclature, there's different classification system. Again, Dr. Fiber was involved in an anatomical classification system. We have radiographical classification system. But the taskforce, they basically decided on active versus inactive as a way that we can categorize sort of the progression of Charcot.
Active is that red hot swollen foot. Inactive is once you start getting that consolidation and the coalescence and the remodeling and where you get that late stage rocker bottom deformity. And acute fracture in a patient that has neuropathy should be treated as a Charcot event and this is because that fracture, that dislocation was also not released of those proinflammatory cytokines and that can start the whole -- the event process. So oftentimes, you know, whether it be a mid-foot injury, same criteria. If there's displacement, malalignment, you're going to treat them surgically and oftentimes I'll go right to effusion. Diabetic ankle fractures, you can have a whole lecture, you know, just on that. Usually, in supplemental fixation, whether it be external fixation, used walking plates and you're going to, you know, increase the duration of non-weight bearing. I just included this because this is sort of like an insuffiency fracture where a lot of these patients have decreased bone mineral density and they can get these cranial tuberosity avulsion fractures. And oftentimes, in this population, the bone quantity is so poor that if doesn't involve the posterior facet there, I'll just excise the fracture fragment, reattach the Achilles tendon. So in terms of diagnosis, initially, that red hot swollen foot should be -- you know, it's a clinical diagnosis. If a patient comes in with this rocker bottom, it's broken down, misshapen foot, unfortunately, it was probably misdiagnosed which was not treated. Maybe the patient didn't seek medical care. And then when they have these deformities, they have these concurrent ulcerations, you have to rule out underlying osteomyelitis. Sometimes the imaging gets a little confusing. This was a little algorithm that Lee Rogers and I put together and just all it's meant to do is just help guide the practitioner in ways that we could sort of either rule in or out osteomyelitis or Charcot. So if we look, here's a patient with red hot swollen foot. Initially, we take an x-ray. We can see that there's a little fragmentation under the navicular there. So let's just say for sake of argument that we don't see any changes in bone. So if we just look at our algorithm here, the question is bone destruction on bone. If you actually recognize that, which hopefully you do, you would just say, yes, open wound, no, then a Charcot. But let's say we didn't see that or let's say, you know, that that actually wasn't there, just for the sake of demonstration. So then we go to another advanced imaging that could be either a Tech 99 bone scan or sometimes an MRI, which is very useful to sort of, you know, uncover some of these hidden injuries and you can see in this case, it does, where you have that bone marrow edema in the navicular. Are we considering osteomyelitis in this case? No, there's no open wound and we know that greater than 90 percent of the times, osteomyelitis, there's a concurrent ulceration that causes that contiguous spread. So pretty much red hot swollen foot, patient has neuropathy, should be considered Charcot until proven otherwise and it should be treated as such. This is just an interesting case, red hot swollen ankle. Patient had diabetes, neuropathy, went to the ER. Chief complaint, ankle sprain. You know, we're proactive, we said, "Let's treat this as a Charcot event. We're going to immobilize her." Initial radiographs did not show any destruction on x-ray but we did a non- -- a very sensitive but nonspecific Tech 99 bone scan and you could see that intense light up pretty localized the distal fibula fracture. Now, does she have a wound? Initially, when she went to the ER, she did not have a wound. We met -- we kept a close eye on her. And then we see here the clinical scenario is kind of changing. So don't forget, you know, it's great to order these fancy tests but always use your clinical judgment. You can see here, she has a ruptured bulla with kind of angry erythema there. So now, we're considering osteomyelitis. And then we did a white blood cell label scan that lit up and now we know we're dealing with more an infectious process. And in fact, this went on to require emergent incision and drainage where she did have osteomyelitis in the distal fibula. So that had to be excised. I put this right before dinner just to get your appetites going. And then she went onto requiring an ankle fusion. So just one last example, how about Charcot foot possibly complicated with osteomyelitis, unfortunately, any time you have that long standing ulcer, probes the bone, we're highly suspicious of osteomyelitis. Or was there destruction on x-ray, obviously, yes. Is there an open wound? Yes. So we did a white blood cell labeled bone scan, as you could see here, it lights up right at navicular head there. So we know that this is a Charcot complicated by osteomyelitis. And that's going to affect the treatment, whether it be a staged procedure, remove the infected bone and then maybe go onto a more definitive arthrodesis. Just an algorithm, you know, we ruled -- rule out infection treated, if there is infection obviously. So acute Charcot. The treatment is going to focus on immobilization and offloading. So if we look at the medical management, also antiresorptive therapy, we'll talk quickly about it. We can use these little skin thermometers just to help us diagnose the condition where there's greater, you know, difference between the contralateral limb and also to assess the progression of the deformity as those temperature between the two normalize.
We can use the roll-about. So one of the gentlemen in the back has it. So you're all familiar with that. Total contact cast is the gold standard. Sometimes, you know, if you don't have the personnel to apply, you can use the instant total contact cast. And really, they should be non-weight bearing, whether it be crutches, wheelchair, roll-about. Bisphosphonates, I put a line through. You know, when I was a resident we did a lot of bisphosphonates, you know, that works directly against that osteo class. But there was a study just recently published in diabetes care that showed that it actually may prolong that inflammatory state and that active Charcot. So there's questionable use of it now. Intranasal calcitonin works directly on that rancal [phonetic] pathway. So that may play a role. Nonsurgical care is not without -- you know, it's headaches, it requires a long duration of casting. One study showed that it was 18 weeks plus or minus ten weeks. Return to shoes almost took about six months or so. And then you can see this other study looked at complications from nonsurgical care. These were treated with a total contact cast on weight bearing with crutches or a wheelchair and add 30 percent control hour Charcot recurrence or ipsilateral episode and 30 percent ulcer formation. So it's been the same thing, 50 percent re-ulceration rate after intensive non-operative care. So on the inactive, this is more of the -- you know, we go from the active to more of that inactive. You can see here, we get the bone remodeling and now we basically have our result and deformity. Hopefully, you catch it early enough where they're offloaded, they immobilized, where you get to reduce or eliminate the deformity. But unfortunately, most often they end up with the deformity because the delay in diagnosis. And then the question is can you -- is it stable or not? Can you accommodate it? If you can oftentimes to choose rocker bottom, sometimes they have to be in a brace. If you cannot accommodate it, this example here, you could see a very unstampled deformity there, has this chronic non-healing wound. Then we're going to start thinking surgical management. Surgical management could be something, you know, simple as a TAR or a gastroc [phonetic] which could be done very early in the process by itself or often in combination. Exostectomy, sometimes, you know, that's the lump and bump just to remove that boney prominence to allow that to fit better in shoes or a brace. So we talked about equinus and its role in Charcot formation. And we can address that with the triple hemisection that we spoke about, exostectomy. There was, you know, the study out of West Penn showed that there was increased complications with plantar lateral exostectomy versus the medial just because, you know, you have to be careful you don't excise too much bone and then make it more unstable. But it's often performed in combination with the TAL or a gastroc recession to help offload. Reconstruction, again, this -- Dr. Laporto [phonetic] is going to talk more about the pearls of the actual surgical procedure. I'm just going to talk basically the goals. Stable plantar grade foot, we want to increase function. Obviously, we can use it to help augment healing or we can -- with the hopes of this unstable midfoot, you catch it early enough where you prevent ulcer formation. The goal is obviously osseous fusion. Although, there's been studies showing that, you know, a good stable pseudofusion is acceptable. You can use internal, external fixation. I'm sure Dr. Laporto will get into that. So I'm just going to finish off with just a case study. This was actually a bilateral Charcot foot echo. You could see on the top, this is her right side, on the bottom, this is her left. She was 59 years old. She's been in a wheelchair for three years. So she had not walked in three years. She had diabetes for 20 years and you can see she's had some sort of history of previous procedure on the right side. She had unstable ankle and midfoot bilaterally ulcers despite weekly wound care hyperbaric, custom bracing. And I think have it in here also. She was basically, right here, scheduled for bilateral BKA. She was -- she had the date and she was scheduled for it and mentally she was preparing herself for it. Her daughter made her seek second opinion. Just to give you sort of a contrast of what a normal, you know, foot looks like. You can see that large ulceration beneath the plantar foot there. So this was treated actually with an ankle and a midfoot fusion. I just put this in. Dr. Fiber is going to talk about complications. You know, I put this in just to remind that, you know, this -- there's basically 100 percent complication rate. We just hope that it's a simple complication whether it be like pin breakage or pin tract infection as opposed of complex complication requiring, you know, hospitalization or return trip to the operating room. So she -- you know, she had a post-op infection that required some adjustment and debridement, negative pressure would therapy with the skin graph. But here she is at 12 weeks from when we took the frame off. And then we actually tackled the left during the post-operative phase for the right.
So she actually had, you know, these devices on both sides. But here she is in six months walking for the first time. So you know, this is great to show the success, you know, there's complication that doesn't always go well, you know, that can always result in below-knee amputation. But I think in the right patient, in the right situation, it's definitely a viable option. So take home points, early diagnosis is critical, effective nonsurgical management really focuses on offloading and immobilization, surgical management for the deformed foot. And just a shameless plug for co-chair, Dr. Fiber, this was 15 minutes. This was just to get your appetite whet. So go out, get this book. He's the editor of the Diabetic Charcot Foot that I had the privilege of participating in. Thank you.