Charcot Joints Diff to DDx from

Zuckerman JAAOS 1995 Cellulitis

AKA Neuropathic arthropathy OM
- For exam don't operate on these guys unless only alternative Septic arthritis
is amputation Gout
DEF XR
Chronic, progressive degen arthropathy of vert and appendic Gen osteopaenia ± New bone
jts as a result of disturbance in normal sensory innervation Soft tissue swelling
Aetiology Te 99 of little help in Dx infection
SAD TULIP Te99/ WBC better
Spina Bifida MRI may be of use
Alchoholism Atrophic vs hypertrophic
DM - No 1 cause Laboratory
Tabes dorsalis ESR & WCC = N
Syringomyelia 20-40% 2. Subacute
- No 1 cause in Upper Limb [usu 1 jt] Clinical
Leprosy - 2nd most com UL Redness / swelling dec
Cong Indifference to pain Pain dec
Peripheral nerve lesions Early def
EPIDEM Us Pes Planovalgus
- Poorly controlled DM in West XR
- Us affects foot Periarticular fragmentation of bone
TMTJ 70% # of differing ages
Forefoot 15% 2° callus formation
Hindfoot 15% Prolific
Bilat in 35% Abundant cartilage/ bone
- Av 14 yrs duration of DM at onset of neuropathy 3 Chronic
PATHOGENESIS Clinical
Of Cause Redness & swelling settled
Charcot 1868 PROG DEF & INSTABILITY
- Changes in jt 2° to damage to CNS Trophic centres that May feel bony debris
control bone & jt nutrition Ulcer over bony prominences
Neurotraumatic Theory*** Esp Head of talus
- Repetitive microtrauma due to loss of XR
1 Protective joint sensitivity # Healed
2 Proprioception Residual gross disorg of jts
- Florid jt damage due to Mx
Resultant # Principles
Continued WB ç misuse Prevention
Neurovascular Theory Education
Neurally initiated vascular reflex due to autonomic dysfn Protect jts from trauma/ overuse
Leads to inc blood flow & active bone resorption by Rx
osteoclasts Aim to :
2° # & jt damage 1 Control foot position & shape
No histol evidence for this 2 Maintain plantigrade foot
Current Theory 3 Watch for ulcers
Combination of Sensory & Autonomic Neuropathy Acute
Of Deformity Rest joint
Foot Protect from WB
- TMTJ & STJ collapse = Pes Planovalgus Backslab as if swelling
- Forefoot deformity leads to claw toes Then TCO weekly
Ankle Crutches
Less com affected Lasts for 1-2/12
Us preceded by #
Leads to subluxation & dislocation of ankle Subacute
Semmes - Weinstein Monofiliament Once acute swelling dec
> 5.07 = non protective sensation Protect from deformity
CLASS Eichenholz 1 Total Contact Orthosis
3 radiologic stages TCO
1. development/destructive 2 Charcot Restrained Orthopaedic Walker
2. coalescence/reparative CROW AFO
3. stage of reconstruction/quiescent Bivalved rocker bottom
1 Acute
Clinical - Min WB initially
Rapid onset of red hot swollen jt - Lasts for 2-6/12
May be mild - mod pain
Chronic
- Once healing has occurred Knee
- Brace indefinitely - Poor results ç TKR
- Forefoot - Arthrodesis is the op of choice
Extra depth shoes - Charnely Clamp = 50% union
Moulded insoles Usually syphilis or DM
Steel shanks Prone to progressive destruction and instability due to wt
Rocker bottom soles bearing nature and anatomy of jt
- Mid / Hindfoot Spontaneous dislocation has been reported
Double upright PTB AFO
Initially should use calliper for stability
Surgery If fails then fusion with any technique reasonable
- Seldom contemplated
- C Ind TKR should be avoided
Uncontrolled DM Hip
PVD Usually syphilis
Acute D 2 problems
- Recurrent ulcer from bony prominence may benefit from # or
removal OA type picture with destruction of jt
Heal ulcer 1st # Rx
- Unbraceable foot may require arthrodesis Notoriously difficult
Difficult to obtain High rate of failure with ORIF
Avoid during acute stages Need long term hip spica if considering
Hemi failure due to instability etc
- When performed, principles are Girdlestones probably op of choice vs non-op good option
1 Resect sclerotic bone OA picture usually gross destruction
2 Firm apposition of fragments Pain often not much of an issue
3 Bone graft where ind ROM maintained
4 Efficient & long immobi Limp and LLD and mobility is the problem
Debridement leads to instability
Arthrodesis in Eichenholtz Stage III THR huge complication and failure rate
Quiescent stage to realign foot Dislocation, loosening and periprosthetic #
Will need prolonged immobilisation Arthrodesis invariably fails due to non-union rate of 50%
Failed fusion can still be braced well as alignment improved # or OA
Some authors have attempted athroplasty Surgery not ind except in sev disability
Amputation may be necessary ORIF NOF = Failure
Specific HEMI NOF = Dislocates/ fails
Ankle Arthrodesis = Nonunion
- Rx Non-op unless so sev considering amputation = KEY THR not ind
- Can then justify arthrodesis Girdlestones or non-op
25% bilat in DM
Spine
AJ often crepitant and unstable Destructive changes in 10% - 15%
Foot shortened and thickened Both central & lateral jts
Collapse of arch with rocker bottom deformity May cause instability c nerve root irritation

Inability to fit shoes

Hammer toes and loss of fat pad below MT heads -->ulcers
and MTalgia
X-rays show #'s Peritalar dislocations, periartic calcification,
subchondral sclerosis, tibiotalar dissociation
Valgus or varus often present

Forefoot
- Most problems are ulceration ç 2° infection
Rx Aggressive debridement

Midfoot & Hindfoot

- Rarely Rx surgically
- +++ Debride of necrotic bone
= instability / deformity

Occ performed are:

1 Mid / Hindfoot osteotomy
2 Fusion of selected jts
- Aim is shoeable plantigrade foot
Stage XR Clinical Features
I– demineralisation of Acute inflammation, swelling, erythema,
Dissolution regional bone warmth (easily confused with infection)
(also called periarticular (key distinguisher from infection is that
Fragmentatio fragmentation, joint erythema of charcot’s reduces with
n or dislocation elevation for 10min) bone scan & Indium
Development big feature is labelled WBC scan may help but clinical
stage) hyperaemic response best
which Rx is NWB TCC
precedes XR changes of
fragmentation by hours
to weeks
II – Absorption of osseous Identified by changes of less
Coalescence debris in soft tissues, inflammation, less swelling, ↑ stability at
organisation & early # site
healing of # fragments, Rx is PWB in TCC, bivalved AFO,
periosteal new bone CROW
formation
III – Smoothing of edges, Identified by absence of oedema &
Resolution sclerosis, osseous or warmth
(Consolidatio fibrous ankylosis, Permanent enlargement of foot & ankle,
n) complete bone healing fixed deformity, minimum activity
& resolution of related swelling, normal skin Temp
osteopenia Rx double upright calf lacer c extra
depth shoe & custom moulded inlay,
rocker sole & extended steel shank
May go into shoe alone or AFO