Charcot Arthropathy

Western Health Orthopaedic Registrar presentation
Dr Daniel Sydenham

Epidemiology

• Usually develops in weight bearing joints
• Usually secondary to DM in lower extremity & syringomyelia in shoulder
• Associated with peripheral neuropathy

Pathology

Pathogenesis

• Usually develops in weight bearing joints
• Usually secondary to
  • diabetes mellitus in lower extremity
  • syringomyelia in shoulder
• Associated with peripheral neuropathy

Histology

• osteochondral fragments embedded within synovium
• Related to destruction of afferent proprioceptive fibers & subsequent unrecognized trauma to joint

Classification

Staging (Eichenholtz)

Stage		Description
0		diabetic patient with peripheral neuropathy & acute ankle sprain or Fracture
1	Fragmentation	acute inflammatory process characterized by edema, hyperemia & erythema & bony fragmentation on xrays
2	Coalescence	swelling, redness & warmth with coalescing new bone at site of fracture or dislocation on xrays
3	Resolution	resolution of clinical inflammation & bony consolidation on xray (usu 9-12 mos after onset)

Treatment

Stage		Treatment
0		always treat acute ankle fractures immediately ORIF has ↑ complications including wound necrosis & amputation if casting, must remain NWB > 6 weeks treat ankle sprains aggressively with NWB & foam walker boot
1	Fragmentation	high rate of complications following surgery NWB in total contact casts or foam walker boot for prolonged periods of time (up to 9-12 mos) until reparative stage reached
2	Coalescence	as aboce
3	Resolution	can intervene surgically at this stage but still has ↑ risk of complications usually performing reconstructive fusions to prevent pressure points & recurrent ulceration

Preoperative evaluation

• internal medicine consult
  • control of diabetes
  • assessment of end organ dysfunction
• vascular consult
  • assess vascular supply to foot
• document neuropathy
  • vibration sense & filament tests

Indications for Surgery

• R ecurrent ulceration
• I nfection
• P ain