Elsevier

Journal of Diabetes and its Complications

Volume 23, Issue 6, November–December 2009, Pages 409-426
Journal of Diabetes and its Complications

Charcot arthropathy of the foot and ankle: modern concepts and management review

https://doi.org/10.1016/j.jdiacomp.2008.09.004Get rights and content

Abstract

Charcot arthropathy (Charcot neuroarthropathy, diabetic neuropathic osteoarthropathy, or neuropathic arthropathy) remains a poorly understood disease, although recent research has improved our level of knowledge regarding its etiology and treatment. The effects of Charcot arthropathy are almost exclusively seen in the foot and ankle, and the diagnosis is commonly missed upon initial presentation. It has been well established that this complication of diabetes mellitus severely reduces the overall quality of life and dramatically increases the morbidity and mortality of patients. However, there are few high-level evidence studies to support management and treatment options at this point in time. The goal of this study is to evaluate the modern concepts of Charcot arthropathy through a review of the available literature and to integrate a perspective of management from the authors' extensive experience.

Introduction

Charcot arthropathy of the foot and ankle is a deforming and destructive process that can lead to increased patient morbidity due to gross instability, recurrent ulcerations, and/or amputation (Armstrong & Peters, 2002, Frykberg et al., 2006, Saltzman et al., 2005). Charcot arthropathy has been associated with leprosy, toxic exposure, syringomyelia, poliomyelitis, rheumatoid arthritis, multiple sclerosis, congenital neuropathy, and traumatic injury (Gupta, 1993, Johnson, 1967, Sanders & Frykberg, 2007). However, diabetes mellitus has become the most common etiology in the modern era (Miller & Lichtman, 1955). The diagnosed cases of Charcot arthropathy associated with diabetic patients range from 0.08% to 7.5% (Sanders & Frykberg, 2007); however, true prevalence is likely unknown due to cases undiagnosed by untrained clinicians (Rajbhandari, Jenkins, Davies, & Tesfaye, 2002). The effects of Charcot arthropathy are almost exclusively seen in the foot and ankle (Frykberg & Belczyk, 2008); however, the supply of scientific data and evidence-based treatments is largely based on retrospective studies. Known as Charcot neuroarthropathy and diabetic neuropathic osteoarthropathy (Sanders & Frykberg, 2007), this complication of diabetes mellitus severely reduces the overall quality of life and dramatically increases the morbidity and mortality of patients (Gazis et al., 2004, Lee et al., 2003).

Section snippets

Historical review and epidemiology

Sir William Musgrave is believed to have first recorded descriptions of “neuropathic arthritis” as a complication of venereal disease in 1703 (Armstrong & Peters, 2002, Gupta, 1993, Kelly, 1963), but most of the world's medical communities remained unaware of this disease. In 1831, an American physician, John Kearsley Mitchell, reported a case of “caries [tuberculosis] of the spine” that correlated spinal disease with hot, swollen, and asymmetrical joints (Mitchell, 1831). Silas Weir Mitchell

Etiology and pathogenesis

Diabetic Charcot arthropathy typically presents as a warm, swollen, and erythematous foot and ankle. The appearance of the extremity may be indistinguishable from infection, and almost all afflicted patients have severe peripheral neuropathy. It is this lack of protective sensation that delays identification of bony stress injuries that may overload the insensate limb, leading to an active Charcot process (Chantelau, 2005, Schon & Marks, 1995, Sella & Barrette, 1999).

Charcot, 1868, Charcot &

The course of Charcot arthropathy: modified Eichenholtz stages

Early literature contributions concerning Charcot arthropathy lacked clinical findings that correlated with radiographic descriptions of the disease. Eichenholtz (1966) published a landmark article on Charcot arthropathy based on radiographic appearance and its physiologic course. Dividing the condition throughout its process, he described three separate but linear stages: developmental, coalescent, and reconstructive stages. Shibata, Tada, and Hashizume (1990) modified the Eichenholtz system

Anatomical classifications

Several authors have anatomically classified the characteristics of Charcot arthropathy by observing the patterns of destruction to the foot and ankle (Brodsky & Rouse, 1993, Sanders & Frykberg, 2007, Sanders & Mrdjenovich, 1991, Schon et al., 1998, Sella & Barrette, 1999). Although this disease has been associated with other bodily sites in the diabetic patient (Bayne & Lu, 1998, Lambert & Close, 2002), it almost exclusively affects the foot and the ankle.

Sanders and Frykberg (1991) divided

Clinical presentation and standard diagnostics

The American Diabetes Association (2008) recently released its position statement for standards of medical care and foot care recommendations for patients. The American Diabetes Association (2004) has long recognized the need for the screening and evaluation of the foot and ankle of patients with long-standing diabetes, especially those who have developed neuropathy. These recommendations rely on a keen understanding of the diabetic foot and ankle, with all their possible complications. If the

Nonoperative therapies and medical management

The treatment of Charcot arthropathy depends on many factors, including the course or stage of Charcot arthropathy (Eichenholtz, 1966), location(s) of involvement (Sanders & Frykberg, 2007, Sinacore, 1998), presence of ulcers (Saltzman et al., 2005), and ability to achieve a stable and plantigrade foot (Harrelson, 1993). Other factors that could affect treatment options are comorbidities (American Diabetes Association, 2008) such as cardiovascular disease, morbid obesity, nephropathy, or

Integrated strategy for operative treatment and management

As the discipline of evidence-based medicine continues to improve patient care and clinical practice, operative treatment for Charcot arthropathy must also integrate individual clinical expertise with the best available external evidence (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Individual clinical expertise relies on the proficiency and judgment acquired through clinical experience and practice with Charcot arthropathy patients. The best available external evidence relies on

Conclusion

In the era of evidence-based medicine, Charcot arthropathy of the foot and ankle remains a poorly understood disease, although recent clinical and basic science research has improved our level of knowledge regarding its etiology and treatment. However, there are few high-level evidence studies to support management and treatment options at this point in time.

The current goals for clinicians treating Charcot arthropathy include the following:

  • 1.

    Maintaining a high index of suspicion in diabetic

References (148)

  • American Diabetes Association

    Preventive foot care in diabetes

    Diabetes Care

    (2004)
  • American Diabetes Association

    Standards of medical care in diabetes—2008

    Diabetes Care

    (2008)
  • Anonymous

    Sitzung vom 17. November 1886

    Berliner Klinische Wochenschrift

    (1886)
  • ArmstrongD.G. et al.

    Elevated peak plantar pressures in patients who have Charcot arthropathy

    Journal of Bone and Joint Surgery, American Volume

    (1998)
  • ArmstrongD.G. et al.

    Charcot's arthropathy of the foot

    Journal of the American Podiatric Medical Association

    (2002)
  • ArmstrongD.G. et al.

    Technique for fabrication of an “instant” total contact cast for treatment of neuropathic diabetic foot ulcers

    Journal of the American Podiatric Medical Association

    (2002)
  • ArmstrongD.G. et al.

    The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic

    Journal of the American Podiatric Medical Association

    (1997)
  • BanksA.S. et al.

    Charcot foot

    Journal of the American Podiatric Medical Association

    (1989)
  • BaumhauerJ.F. et al.

    Cytokine-induced osteoclastic bone resorption in Charcot arthropathy: An immunohistochemical study

    Foot & Ankle International

    (2006)
  • BayneO. et al.

    Diabetic Charcot's arthropathy of the wrist. Case report and literature review

    Clinical Orthopaedics and Related Research

    (1998)
  • BemR. et al.

    Intranasal calcitonin in the treatment of acute Charcot neuroosteoarthropathy: A randomized controlled trial

    Diabetes Care

    (2006)
  • BlackD.M. et al.

    Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis

    New England Journal of Medicine

    (2007)
  • BloomgardenZ.T.

    Clinical diabetic neuropathy

    Diabetes Care

    (2005)
  • BonoJ.V. et al.

    Surgical arthrodesis of the neuropathic foot. A salvage procedure

    Clinical Orthopaedics and Related Research

    (1993)
  • BoultonA.J. et al.

    Venous oxygenation in the diabetic neuropathic foot: Evidence of arteriovenous shunting?

    Diabetologia

    (1982)
  • BrightonC.T. et al.

    Oxygen tension in zones of the epiphyseal plate, the metaphysis and diaphysis. An in vitro and in vivo study in rats and rabbits

    Journal of Bone and Joint Surgery, American Volume

    (1971)
  • BrinkD.S. et al.

    Subtalar and talonavicular joint dislocation as a presentation of diabetic neuropathic arthropathy with salvage by triple arthrodesis

    Journal of Foot and Ankle Surgery

    (1994)
  • BrodskyJ.W.

    The diabetic foot

  • BrodskyJ.W. et al.

    Exostectomy for symptomatic bony prominences in diabetic Charcot feet

    Clinical Orthopaedics and Related Research

    (1993)
  • BrowerA.C. et al.

    Pathogenesis of the neurotrophic joint: Neurotraumatic vs. neurovascular

    Radiology

    (1981)
  • ChantelauE.

    The perils of procrastination: Effects of early vs. delayed detection and treatment of incipient Charcot fracture

    Diabetic Medicine

    (2005)
  • ChantelauE. et al.

    Charcot foot in diabetes: Farewell to the neurotrophic theory

    Hormone and Metabolic Research

    (2006)
  • ChantelauE. et al.

    Evaluation of the diabetic Charcot foot by MR imaging or plain radiography—An observational study

    Experimental and Clinical Endocrinology & Diabetes

    (2006)
  • ChantelauE. et al.

    “Silent” bone stress injuries in the feet of diabetic patients with polyneuropathy: A report on 12 cases

    Archives of Orthopaedic and Trauma Surgery

    (2007)
  • ChantelauE. et al.

    The diabetic Charcot foot: MRI discloses bone stress injury as trigger mechanism of neuroarthropathy

    Experimental and Clinical Endocrinol & Diabetes

    (2006)
  • CharcotJ.M.

    Sur quelques arthropathies qui paraissent dépendre d'une lésion du cerveau ou de la moelle épinière

    Archive de Physiologie Normale Pathologique

    (1868)
  • CharcotJ.M. et al.

    Affections osseuses et articulaires du pied chez les tabétiques (Pied tabétique)

    Archives de Neurologie

    (1883)
  • ClassenJ.N. et al.

    Management of foot conditions of the diabetic patient

    American Surgeon

    (1976)
  • ClohisyD.R. et al.

    Fractures associated with neuropathic arthropathy in adults who have juvenile-onset diabetes

    Journal of Bone and Joint Surgery, American Volume

    (1988)
  • CundyT.F. et al.

    Osteopenia and metatarsal fractures in diabetic neuropathy

    Diabetic Medicine

    (1985)
  • EdisonJ. et al.

    Neuropathic osteoarthropathy of the shoulder

    Journal of Clinical Rheumatology

    (2005)
  • EdmondsM.E. et al.

    Increased uptake of bone radiopharmaceutical in diabetic neuropathy

    Quarterly Journal of Medicine

    (1985)
  • EdmondsM.E. et al.

    Medial arterial calcification and diabetic neuropathy

    British Medical Journal (Clinical Research Edition)

    (1982)
  • EloesserL.

    On the nature of neuropathic affections of the joints

    Annals of Surgery

    (1917)
  • FabrinJ. et al.

    Long-term follow-up in diabetic Charcot feet with spontaneous onset

    Diabetes Care

    (2000)
  • FujikawaY. et al.

    The human osteoclast precursor circulates in the monocyte fraction

    Endocrinology

    (1996)
  • GazisA. et al.

    Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot)

    Diabetic Medicine

    (2004)
  • GoebelF.D. et al.

    Monckeberg's sclerosis after sympathetic denervation in diabetic and non-diabetic subjects

    Diabetologia

    (1983)
  • GradyJ.F. et al.

    Use of electrostimulation in the treatment of diabetic neuroarthropathy

    Journal of the American Podiatric Medical Association

    (2000)
  • Cited by (159)

    • Mimickers of Inflammatory Arthritis Induced by Checkpoint Inhibitors

      2024, Rheumatic Disease Clinics of North America
    • Charcot Foot: The Zebra You Need to Know

      2023, Journal for Nurse Practitioners
    • Surgical Outcomes in Charcot Arthropathy

      2023, Orthopedic Clinics of North America
    • Nondiabetic Charcot Neuroarthropathy: Evaluation and Treatment

      2022, Clinics in Podiatric Medicine and Surgery
    • Diagnostic Imaging of Diabetic Foot Disorders

      2022, Foot and Ankle Clinics
      Citation Excerpt :

      In stage 0, clinical signs such as erythema and changes in MRI are present but there are no changes in standard radiography evident yet. Correct diagnosis and treatment in this stage are critical to prevent further progression and final foot deformity.19 Stage 0 on MRI is seen as subchondral edema with or without microfracture, leading to intraarticular debris and subchondral cysts.

    View all citing articles on Scopus
    View full text