NEUROPATHIC (CHARCOT )FOOT

Blood supplyBlood supply

t

Arterial: ◦Posterior tibial and dorsalis

pedis supply the footVenous:

◦Deep veins follow the arteries◦Superficial veins arise from

dorsal venous arch

Nerve supplyNerve supply

The foot is supplied by the (1) tibial,

(2) deep peroneal, (3) superficial

peroneal, (4)sural, and (5)saphenous

CHARCOT FOOTNamed after Jean-Martin Charcot (1868)

Charcot noted this disease process as a complication of syphillis

In 1936, Charcot foot was found to be related to diabetic patients

Pathophysiology:

Neurotraumatic theory

Neurovascular theoryNeurotraumatic theory:Unperceive trauma to insensate foot.Pt unaware of osseous destruction occur during ambulationMicro trauma leads to progressive destruction to bones and joints

Neurovascular theory:Autonomic neuropathy causing extremities to receive increased bloodflowResults in mismatch in bone destruction and synthesis, leading to osteopenia

THE FOLLOWING ARE THE PRINCIPLE

PREDISPOSING DISEASES:

DIABETES

SYRINGOMYELIA

LEPROSY

TABES DORSALIS

Physical

9

Physical Findings & Investigations

Physical

10

Physical Findings & Investigations

Presentation:

Vary from mild swelling and no deformity to moderate deformity with significant swelling

Always presents with signs of inflammation: warmth, joint effusion, erythema, bone resorption

Pain occurs in > 75% of patients

Instability and loss of joint function; “bags of loose bones”

Amputation Risk (Usually BKA)

Type 100 person-year

Charcot alone 4.1

Ulcer alone 4.7

Charcot + Ulcer Up to 12 times

Classification

Many types

Based on anatomic involvement

Brodsky and Rouse system

Schön Classification

Type Pattern

1 Lisfranc (60%)

2 Cuneonavicular

3 Perinavicular (3a ankle joint, 3b posterior calcaneous)

4 Transverse tarsal (multiple joint)

5 Forefoot

MANAGEMENT

Conservative Surgery

ACUTE PHASE

POST-ACUTE PHASE

Acute phase:

Immobilization: e.g. Total contact cast (3-6 months)

Reduction of stress

Ideally non-weight bear

PWB with crutches

Post-acute phase: Patient education and foot care

Consider brace e.g. Charcot restraint orthotic walker

Total healing typically takes 1-2 years

Surgical therapy:

Based on location of disease, surgeon preferences and experience with Charcot arthropathy

Surgical procedure include exostosectomy of bony prominence, osteotomy, arthrodesis, screw and plate fixation, ORIF, reconstructive surgery, fusion with Achilles tendon lengthening, autologous bone grafting and amputation.

Location Surgery

Ankle with displaced # ORIF

Tibiotalar destruction Arthrodesis

Avascular necrosis of talus Talectomy with tibiocalcaneal fusion

Hindfoot Arthrodesis

Midfoot Correction of rocker-bottom deformity and osteotomies for bony prominence

Hindfoot/ankle equinus contracture

Posterior release/Achilles tendon leengthening

Forefoot Resection arthroplasty or cheilectomy

DIABETIC FOOT

The Diabetic Foot may be defined as a group of syndromes in which neuropathy, ischaemia, and infection lead to tissue breakdown resulting in morbidity and possible amputation

( WHO 1995 )

Peripheral Neuropathy

Sensory

Motor

Autonomic

Precipitating

Factors

Trauma

puncture/thermal/stress/footwear

MANAGEMENT

Thank you