1. Charcot ArthropathyMansoura 2 nd International DF Training Course Charcot Arthropathy. Hanan El-Soutouhy Gawish. Prof Int Med, Diabetes Unit,Mansoura University International Working Group of Diabetic Foot Egypt Representative

2. Charcot ArthropathyMansoura 2 nd International DF Training Course History Mitchell,1831: The first association between joints and neurological diseases. Charcot 1868: Arthropathy and tabes dorsalis. Jordan 1936: Neuritic manifestation of DM

3. Charcot ArthropathyMansoura 2 nd International DF Training Course Charcot’s Foot A Neuropathic Arthropathy Caused by repetitive trauma in the setting of: Diminished sensation & proprioception Motor neuropathy results in muscle imbalance & abnormal weight bearing. “Rocker Bottom Deformity” a convex deformity of the foot’s plantar aspect caused by the collapse of metatarsal bones

4. Charcot ArthropathyMansoura 2 nd International DF Training Course

5. Charcot ArthropathyMansoura 2 nd International DF Training Course

6. Charcot ArthropathyMansoura 2 nd International DF Training Course Aetiopathogenesis  Peripheral sensory neuropathy is always present +/- motor.  Autonomic neuropathy leads to increased blood flow.( plethysmography & uptake of isotopes).  Trauma may be an important precipitating factor, although 2/3 rd of patients don’t remember any injury.  Bone metabolism both osteoblastic and osteoclastic activities are increased.

7. Charcot ArthropathyMansoura 2 nd International DF Training Course

8. Charcot ArthropathyMansoura 2 nd International DF Training Course

9. Charcot ArthropathyMansoura 2 nd International DF Training Course Epidemiology  Incidence : 0.1 – 0.5 %. Increased in patients with neuropathy.  Common in the 4 th or 5 th decades of life.  Bilateral in 30 % of patients.  Sex difference : No  Type 1 or type 2: Both are at risk.  Majority: in the mid foot but any bone or joint in the foot or ankle can be affected.

10. Charcot ArthropathyMansoura 2 nd International DF Training Course Clinical Features and Diagnosis Acute Charcot  Warm, inflamed and swollen.  Misdiagnosed as cellulitis, osteomyelitis or inflammatory arthropathy as gouty or septic.  Although sensory neuropathy, pain is common feature followed by discomfort.  Diagnosis by exclusion as investigations in early stages are negative.

11. Charcot ArthropathyMansoura 2 nd International DF Training Course Clinical Features and Diagnosis High index of suspicion is necessary so that appropriate treatment is immediately instituted to prevent severe deformity!

12. Charcot ArthropathyMansoura 2 nd International DF Training Course Clinical Features and Diagnosis Chronic Charcot, may be months, painless, without temperature difference and deformed.  Reactivation by further trauma is frequent.  Patients are at high risk of ulceration and amputation, so long term follow up is recommended.

13. Charcot ArthropathyMansoura 2 nd International DF Training Course Investigations  X-ray : Early; absent or subtle finding. Late; bone and joint destruction, fragmentation.  Tc bisphosphonate bone scan: Increased bone uptake.  In labeled leucocytes scan to differentiate from osteomyelitis.  MRI: Bone marrow oedema is the earliest sign.

14. Charcot ArthropathyMansoura 2 nd International DF Training Course Treatment 1.Immobilization 2.Radiotherapy and Ultrasound. 3.Pharmacological Treatment. 4.Surgical Treatment.

15. Charcot ArthropathyMansoura 2 nd International DF Training Course Treatment 1.Immobilization: Total Contact Cast (TCC), Removable Cast Walker (RCW).

16. Charcot ArthropathyMansoura 2 nd International DF Training Course Removable Cast Walker

17. Charcot ArthropathyMansoura 2 nd International DF Training Course Treatment 1.Immobilization: Almost 16 weeks (3-6 months) but may be more. (temp gradient less than 1 on 2 occasions or radiology).

18. Charcot ArthropathyMansoura 2 nd International DF Training Course Treatment 2.Radiotherapy and Ultrasound: May be useful in conjunction to offloading but only few small studies.

19. Charcot ArthropathyMansoura 2 nd International DF Training Course Treatment 3. Pharmacological Treatment. Pilot study first using pamidronate,1994. Other Bisphosphonates were used to decrease disease activity and bone turnover markers. Calcitonin were also used. Given for 12 weeks or till temp gradient is less than 2 on 2 consecutive visits.

20. Charcot ArthropathyMansoura 2 nd International DF Training Course Treatment 4.Surgical treatment: No role in acute. Later may be to remove bony deformities or constructive surgeries to achieve a stable shape. Techniques include; Arthrodesis, exostectomies, reconstruction and Achilles tendon lengthening.

21. Charcot ArthropathyMansoura 2 nd International DF Training Course

22. Charcot ArthropathyMansoura 2 nd International DF Training Course

23. Charcot ArthropathyMansoura 2 nd International DF Training Course

24. Charcot ArthropathyMansoura 2 nd International DF Training Course

25. Charcot ArthropathyMansoura 2 nd International DF Training Course Conclusion  High degree of suspicion to diagnose acute Charcot arthropathy.  High risk categorization.  Immobilization and Bisphosphonate.

26. Charcot ArthropathyMansoura 2 nd International DF Training Course Thank You