Charcot Arthropathy .
40
Charcot Arthropathy. Dr. Saima Hashim Khan Dept. of Diabetes & Endocrinology HMC. PGMI
description
Charcot Arthropathy. Dr. Saima Hashim Khan Dept. of Diabetes & Endocrinology HMC. PGMI. Case History : 1. 55yrs old married female Type2 diabetic 25yrs HTN 7yrs Swelling right foot >1month, treated as cellulitus with antibiotics. INVESTIGATION. Hb 10.8g/dl, TLC 9900/cmm - PowerPoint PPT Presentation
Transcript of Charcot Arthropathy .
Charcot Arthropathy.
Dr. Saima Hashim KhanDept. of Diabetes & Endocrinology
HMC. PGMI
Case History : 1
• 55yrs old married female
• Type2 diabetic 25yrs
• HTN 7yrs
• Swelling right foot >1month, treated as cellulitus with antibiotics
INVESTIGATION• Hb 10.8g/dl, TLC 9900/cmm
• S.creatinine 0.7mg/dl
• S.uric acid 4.0mg/dl
• X ray foot.
4
5
MRI Foot
7
Case History : 2
• 45yrs old married female
• DM2 15yrs (Retinopathy: PRP, Nephropathy: crt clr 103 )
• HTN 5yrs
• Post amputation RT big toe 3yrs
• Swelling LT foot 2 months, treated as cellulitis with antibiotics
Investigations
• Hb:9.5 gm/dl, TLC 9600/cmm
• URIC ACID 4.2mg/dl
• CREATININE 1.02mg/dl
• DOPPLER U/S LT FOOT : no DVT normal arterial flow and subcutaneous edema.
• Xray Foot:
10
X Ray Foot
11
12
13
Tragic “Rule of 15”
• 15% of diabetes Foot ulcer in lifetime of patients
• 15% of foot ulcers Osteomyelitis
• 15% of foot ulcers Amputation
Clinical Care of the Diabetic Foot, 2005
• 50% ofamputations
• 50% of patients
• 50% of patients
Tragic “Rule of 50”
Transfemoral/Transfemoral/transtibial leveltranstibial level
22ndnd amputation in amputation in 5 years 5 years
Die in Die in 5 years 5 years
ClinicalClinical CareCare ofof thethe DiabeticDiabetic FootFoot, 2005, 2005
History of charcot foot
Mitchell,1831: The first association between joints and neurological diseases.
Charcot 1868: Arthropathy and tabes dorsalis.
Jordan 1936: Neuritic manifestation of DM
Charcot’s Foot A Neuropathic Arthropathy
Caused by repetitive trauma in the setting of:
• Diminished sensation & proprioception• Motor neuropathy results in muscle
imbalance & abnormal weight bearing.• “Rocker Bottom Deformity” a convex deformity of the foot’s plantar
aspect caused by the collapse of metatarsal bones
Etiology
Peripheral sensory neuropathy is always present +/- motor.
Autonomic neuropathy leads to increased blood flow.
Trauma may be an important precipitating factor, although 2/3rd of patients don’t remember any injury.
Bone metabolism both osteoblastic and osteoclastic activities are increased.
Epidemiology
Incidence : 0.1 – 0.5 % . General: Increased in patients with neuropathy.Diabetics: 3-5%Common in the 4th or 5th decades of life.Bilateral in 30 % of patients. Sex difference : NoType 1 or type 2: Both are at risk.Majority: in the mid foot but any bone or
joint in the foot or ankle can be affected.
Clinical Features and Diagnosis
Acute Charcot Warm, inflamed and swollen. Misdiagnosed as cellulitis, osteomyelitis or
inflammatory arthropathy as gouty or septic.Although sensory neuropathy, pain is
common feature followed by discomfort.Diagnosis by exclusion as investigations in
early stages are negative.
Clinical Features and Diagnosis
High index of suspicion is necessary so that appropriate treatment is immediately instituted to prevent severe deformity!
Clinical Features and Diagnosis
Chronic Charcot, may be months, painless, without temperature difference and deformed.
Reactivation by further trauma is frequent.Patients are at high risk of ulceration and
amputation, so long term follow up is recommended.
InvestigationsX-ray : Early; absent or subtle finding. Late; bone and joint destruction,
fragmentation. bone scan: Increased bone uptake.In labeled leucocytes scan to differentiate
from osteomyelitis.MRI: Bone marrow edema is the earliest
sign.
Treatment
1. Immobilization
2. Pharmacological Treatment.
3. Surgical Treatment.
Treatment
1. Immobilization:
Almost 16 weeks (3-6 months) but may be more.
(temp gradient less than 1 on 2 occasions or serial radiology).
Treatment
1. Immobilization:
• Bed rest
• Half-shoes
• Crutches, Walkers and Wheelchairs
• Total contact cast (TCC) -gold standard
• Prefabricated pneumatic walking brace ( Air cast )
Total contact cast
Air cast
Half shoe
Modified/custom shoes/orthoses
Treatment
3. Pharmacological Treatment.
Pilot study first using pamidronate,1994. Other Bisphosphonates were used to decrease
disease activity and bone turnover markers. Calcitonin were also used. Given for 12 weeks or till temp gradient is less than 2
on 2 consecutive visits.
Treatment
4. Surgical treatment: No role in acute. Later may be to remove bony deformities or
constructive surgeries to achieve a stable shape.
Techniques include; Arthrodesis, exostectomies, reconstruction and Achilles tendon lengthening.
Take Home Message
High degree of suspicion to diagnose acute Charcot arthropathy.
High risk categorization.ImmobilizationBisphosphonate.Customized Foot Wear
Thank You
