Charcot neuroarthropathy: Charcot neuroarthropathy:

22

HistoryHistory

A 53-year-old man presented to an A 53-year-old man presented to an emergency department because of pain, emergency department because of pain, swelling, and redness in his right foot, which swelling, and redness in his right foot, which began 3 days before. He recalled no overt began 3 days before. He recalled no overt trauma, but he was jogging when he first trauma, but he was jogging when he first noticed the pain, which he described as a noticed the pain, which he described as a constant aching and rated as high as 8 on a constant aching and rated as high as 8 on a scale of 10. scale of 10.

33

Other history:Other history:10 years ago he was diagnosed with 10 years ago he was diagnosed with diabetes mellitus, for which he currently diabetes mellitus, for which he currently takes rosiglitazone (Avandia) 2 mg/day and takes rosiglitazone (Avandia) 2 mg/day and metformin (Glucophage XR) 500 mg four metformin (Glucophage XR) 500 mg four tablets daily. tablets daily. He also takes ramipril (Altace) 10 mg/day He also takes ramipril (Altace) 10 mg/day for hypertension, as well as a daily for hypertension, as well as a daily multivitamin. multivitamin. He has a history of hyperlipidemia and a He has a history of hyperlipidemia and a family history of diabetes mellitus and family history of diabetes mellitus and Parkinson disease. Parkinson disease. He has never been hospitalized and has He has never been hospitalized and has never undergone surgery. never undergone surgery.

44

Findings:Findings:

On examination: On examination: Weight 104 kg (229 lb), and height 6 feet 1 Weight 104 kg (229 lb), and height 6 feet 1 inch.inch.BP-160/90 mm Hg, Pulse 104, Temperature BP-160/90 mm Hg, Pulse 104, Temperature 100.4°F (38°C), 100.4°F (38°C), CVS: rate and rhythm were normal, with CVS: rate and rhythm were normal, with normal S1 and S2 and no murmurs. normal S1 and S2 and no murmurs. Lungs: clear to auscultation Lungs: clear to auscultation

55

Foot examination:Foot examination:

Left foot appeared normal, Left foot appeared normal, but his right foot was but his right foot was swollen, hot, and red as far swollen, hot, and red as far up as the lower leg, and it up as the lower leg, and it was hard, especially on the was hard, especially on the dorsal side; there were small dorsal side; there were small patches of ecchymosis patches of ecchymosis around the second and third around the second and third toes toes his capillary refill was good his capillary refill was good bilaterally, and no skin bilaterally, and no skin lesions or abrasions were lesions or abrasions were noted. noted.

66

Lab reports:Lab reports:

blood glucose level 239 mg/dL (normal 70–blood glucose level 239 mg/dL (normal 70–110), 110), hemoglobin A1c 9.7% (normal 4%–6%), and hemoglobin A1c 9.7% (normal 4%–6%), and white blood cell count 13.41 × 109/L white blood cell count 13.41 × 109/L (normal 4.5–11.0) (normal 4.5–11.0) diagnosis of cellulitis diagnosis of cellulitis intravenous antibiotics for 3 days and then a intravenous antibiotics for 3 days and then a prescription for oral antibiotics prescription for oral antibiotics

77

Few weeks later:Few weeks later:

neurologic evaluation: neurologic evaluation: a loss of protective sensation, a loss of protective sensation, contraction of the toes, and dryness, contraction of the toes, and dryness, consistent with peripheral neuropathy. consistent with peripheral neuropathy.

88

swollen, hot, and red foot-swollen, hot, and red foot-Differential Diagnosis:Differential Diagnosis:

cellulitis cellulitis osteomyelitis, osteomyelitis, acute gout, acute gout, abscess, abscess, neuropathic fracture, neuropathic fracture, deep venous thrombosis deep venous thrombosis Charcot Charcot neuroarthropathy neuroarthropathy

No open ulceration or No open ulceration or history of an open wound, history of an open wound, infection is probably not the infection is probably not the culprit culprit (diabetic foot infections begin with a direct (diabetic foot infections begin with a direct inoculation through an opening in the skin, inoculation through an opening in the skin, such as a diabetic neuropathic foot ulcer) such as a diabetic neuropathic foot ulcer)

DVT- asymmetric edema of DVT- asymmetric edema of the leg the leg Fracture-location of the Fracture-location of the edema and ecchymosis in our edema and ecchymosis in our the midfoot the midfoot Gout pain is severe, with Gout pain is severe, with rapid onset, and slowly rapid onset, and slowly improves even without improves even without treatment treatment

99

A plain anteroposterior radiograph shows no osseous abnormalities Stage 0

Taken 3 to 4 months after the initial presentation, Charcot neuroarthropathy has progressed to stage 2 after delayed immobilization. Stage 2

1010

Four stages of Charcot Four stages of Charcot neuroarthropathy are recognized neuroarthropathy are recognized

Stage 0 (inflammation): characterized by erythema, Stage 0 (inflammation): characterized by erythema, edema, and heat but no structural changes edema, and heat but no structural changes Stage 1 (development) :bone resorption, bone Stage 1 (development) :bone resorption, bone fragmentation, and joint dislocation. fragmentation, and joint dislocation. Stage 2 (coalescence): involves bony consolidation, Stage 2 (coalescence): involves bony consolidation, osteosclerosis, and fusion after bony destruction. osteosclerosis, and fusion after bony destruction. Absorption of small bone fragments, fusion of joints, Absorption of small bone fragments, fusion of joints, and sclerosis of the bone and sclerosis of the bone Stage 3 (reconstruction): osteogenesis, decreased Stage 3 (reconstruction): osteogenesis, decreased osteosclerosis, and progressive fusion. Healing and osteosclerosis, and progressive fusion. Healing and new bone formation occur. Decreased sclerosis and new bone formation occur. Decreased sclerosis and bony remodeling signify that the deformity (for bony remodeling signify that the deformity (for example, subluxation, incongruity, and dislocation) is example, subluxation, incongruity, and dislocation) is permanent permanent

1111

1212

Charcot neuroarthropathy Charcot neuroarthropathy and Diabetesand Diabetes

25% of diabetics with this pathology had 25% of diabetics with this pathology had wrong initial diagnosis as-infection, gout, wrong initial diagnosis as-infection, gout, arthritis, fracture, venous insufficiency, and arthritis, fracture, venous insufficiency, and tumor tumor

1313

MRI scan: can show changes in MRI scan: can show changes in stage 0, thus enabling treatment stage 0, thus enabling treatment to be started sooner to be started sooner

4 to 6 weeks after 4 to 6 weeks after presentation shows presentation shows areas of significant areas of significant bone marrow bone marrow edema of the edema of the navicular, medial, navicular, medial, middle, and lateral middle, and lateral cuneiform bones, cuneiform bones, and at the bases of and at the bases of several metatarsal several metatarsal bones. bones.

Offers the highest diagnostic accuracy - ligamentous disruption, concomitant joint deformity, and the center of signal enhancement within joints and subchondral bone (In complex regional pain syndrome no changes occur)

1414

TREATMENT:TREATMENT:

IMMOBILIZATION- cast (8 to 12 weeks) IMMOBILIZATION- cast (8 to 12 weeks) later removable braces or a Charcot restraint later removable braces or a Charcot restraint orthotic walker (4-6 months)orthotic walker (4-6 months)BISPHOSPHONATES may help prevent bone BISPHOSPHONATES may help prevent bone resorptionresorptionSURGERY SURGERY

1515

TREATMENT OUTCOMETREATMENT OUTCOME

The patient’s condition resolved, with eventual The patient’s condition resolved, with eventual multiplanar deformity and with widening of the multiplanar deformity and with widening of the midfoot and increased pressure points.midfoot and increased pressure points.He is able to wear an extra-depth shoe, with a He is able to wear an extra-depth shoe, with a custom total contact inlay. custom total contact inlay. He continues his profession as an attorney and He continues his profession as an attorney and goes about his normal daily activities; however, goes about his normal daily activities; however, he is no longer able to golf and must limit his he is no longer able to golf and must limit his walking. walking. He subsequently developed ulcerations to both He subsequently developed ulcerations to both feet, but they resolved with conservative wound feet, but they resolved with conservative wound care and surgical care. care and surgical care. He is seen in the diabetic foot clinic every 6 to 8 He is seen in the diabetic foot clinic every 6 to 8 weeks.weeks.

1616

? Tests? Tests

No specific lab test for Charcot exsistsNo specific lab test for Charcot exsistsLeukocytosis, an elevated C-reactive protein Leukocytosis, an elevated C-reactive protein and erythrocyte sedimentation rate, and and erythrocyte sedimentation rate, and recent unexplained hyperglycemia suggest recent unexplained hyperglycemia suggest infection infection In this patient antibiotics did not improve In this patient antibiotics did not improve his conditionhis condition

1717

weight-bearing images requiredweight-bearing images required

the reconstruction the reconstruction stage with resolved stage with resolved edema, absence of edema, absence of osteosclerosis, and osteosclerosis, and relative osteopenia. relative osteopenia. Also seen is healing of Also seen is healing of the fractures of the the fractures of the second and third second and third proximal phalanges, proximal phalanges, the site of the the site of the ecchymosis ecchymosis