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