Charcot joint arthropathy and rehabilitation management

this ppt describes Charcot joint arthropathy and rehabilitation management

1. CHARCOT JOINT ARTHROPATHY and rehab management Dr. Harshaand Popalwar MBBS, MD,DNB, MNAMS, PGDHM, FDFM Specialist Grade Two Department of Physical Medicine and Rehabilitation Safdarjung Hospital, New Delhi

2. DEFINITION Charcot foot ( i.e.neuropathic osteoarthropathy ) can be defined as a noninfectious and progressive condition of single or multiple joints characterized by joint dislocation, pathologic fractures, and severe destruction of the pedal architecture that is closely associated with peripheral neuropathy.

3. INTRODUCTION The description of Charcot joints dates back to 1703 when neuropathic osteoarthropathy was first described by W. Musgrave. Jean-Martin Charcot  a French neurologist is credited for his work in 1868 for describing gait anomalies of patients with syphilis ( tabes dorsalis ). Jordan , in 1936, was the first to describe a relationship of diabetes to neuropathic arthropathy

4. etiology Any condition resulting in decreased peripheral sensation,  proprioception , and fine  motor control : Diabetes mellitus   neuropathy with Charcot joints in 1/600-700 diabetics. Related to long-term poor glucose control. Alcoholic neuropathy Cerebral palsy Leprosy Syphilis  ( tabes dorsalis ), caused by the organism  Treponema pallidum Spinal cord injury Myelomeningocele Syringomyelia Intra- articular   steroid  injections Congenital insensitivity to pain Spina bifida Peripheral nerve injury Multiple sclerosis Poliomyelitis

5. Underlying Mechanisms Two primary theories have been advanced: Neurotrauma throry : Loss of peripheral sensation and proprioception leads to repetitive  microtrauma  to the joint in question; this damage goes unnoticed by the neuropathic patient, and the resultant inflammatory resorption of traumatized bone renders that region weak and susceptible to further trauma. Indeed, it is a  vicious cycle . In addition, poor fine motor control generates unnatural pressure on certain joints, leading to additional microtrauma . .

6. This micrtrauma produces intracapsular effusions,ligamentous laxity,and joint instability. With continued use of injured extrimity,further degeneration ensues, which results in a charcot joint

7. Neurovascular theory : Neuropathic patients have dysregulated   autonomic nervous system  reflexes, and de-sensitized joints receive significantly greater blood flow. The resulting  hyperemia  leads to increased osteoclastic resorption of bone, and this, in concert with mechanical stress, leads to bony destruction.

8. In reality, both of these mechanisms probably play a role in the development of a Charcot joint.

9. The presence of sensory neuropathy renders the patient unaware of the initial precipitating trauma and often profound osseus destruction taking place during ambulation. The concomitent autonomic neuropathy with its associated osteopenia and relative weakness of bone predisposes it to fracture. Capsular and ligamentous distension or rupture is also a part of this process,leading to the typical joint subluxations and loss of normal pedal architecture in the classic rocker bottom charcot foot.

10. Classification of charcot arthropathy . In 1966 Eichenhol z proposed a classification of Charcot joints which is broken down into three distinctive stages. Stage one , or the development stage, shows debris surrounding the joints on x-ray. Stage one can develop over a period of days to weeks and is merely radiographic change that occurs in response to unperceived trauma. Stage two is the coalescence stage. In stage two, the bone begins to heal with absorption of debris and healing of large fracture fragments. .

11. Stage three , often called the reconstruction or reconstitution stage, notes a reduction in bone turn over and  reformation of stable bone structure. Stage 0 was added in 1999 by Sella and Barrette to include patients who exhibit clinical symptoms of Charcot arthropathy but have yet to show radiographic changes In clinical practice,the initial developmental stage is considered active or acute, whereas the coalescent and reconstructive stages are considered to be the quiescent or reparative.

12. Radiographic findings Radiologically , osteoarthropathy takes on the appearance of severely destructive form of degenerative arthritis. Sanders and frykberg describe typical neuropathic osteoarthropathy patterns of joint involvement based on joint location in diabetic patients. these patterns may exist independently or in combination with each other as determined through clinical and radiographic findings.

13. Pattern 1:forefoot

14. Pattern 1 encompasses atrophic changes or osteolysis of the MTP and interphalangeal joints with the characteristic sucked candy appearance of the distal metatarsals. Ten to thirty percent of the neuropathic osteoarthropathies have been categorised in various reports as pattern 1.

15. Pattern 2:tarsometatarsal( lisfranc’S ) JOINT

16. Pattern 2 involves lisfranc’s joint,typically with the earliest clue being a very subtle lateral deviation of the base of the second metatarsal at the cunieform joint. Once the stability of this ‘keystone’ is lost, the loisfranc joint complex will often subluxate dorsolaterally . Fracture of the second metatarsal base allows for greater mobility in which subluxation of other metatarsals occur.

17. The rupture of the intermetatarsal and tarsometatarsal ligaments plantarly will also allows a collapse of the arch during normal weight bearing,leading to the classic rocker bottom deformity. pattern 2 is the most common presentation in clinical practice.

18. Pattern 3:midtarsal and naviculocunieform joints Pattern 3 incorporates changes within the midtarsal joint with the frequent addition of naviculocunieform joint. Spontaneous dislocation of the talonavicular joint with or without fragmentation characterize this pattern.

19. Pattern 4:ankle and subtalar joint. It involves the ankle joint, including the subtalar joint and body of the talus. Massive osteolysis is frequently observed in this pattern with attendent ankle or subtalar subluxation and angular deformity. Tibial or fibular malleolar fracture are frequently seen in association with osteoarthropathy in this location and most likely precipitate the development of the joint dissolution. It is found in approximately 10 % of reported cases.

20. Pattern 5: calcaneus ( calcaneal insuficiency avulsion fracture) It is least common presentation and is characterised by extraarticular fracture of the calcaneus . This is more appropriately considered a neuropathic fracture of body or,more commonly,the posterior tuberosity of calcaneus .

21. Clinical presentation Clinical features of acute charcot joint- 1 . vascular - a) bounding pulse b) erythema c) swelling d) warmth 2.neuropathic - a) absent or diminished: pain, proprioception , deep tendon reflexes.

22. 3) skeletal - a) rocker bottom deformity b) medial tarsal subluxation c) digital subluxation d) rearfoot equinovarus e) rearfoot subluxation f) hypermobility 4) cutaneous - a) neuropathic ulcer b) hyperkeratosis c) infection

23. Rocker bottom feet

24. Clinical diagnosis of acute charcot arthropathy Plain radiographs are invaluable for ascertaining the presence of osteoarthropathy in a warm, swollen, insensate foot. With a concomitant wound, it may initially be difficult to differentiate between acute charcot arthropathy and osteomyelitis solely based on plain radiographs.

25. When ulcer probes to bone, a bone biopsy is indicated and should be considered most specific method of distinguishing between osteomyelitis and charcot arthropathy . A biopsy consisting of multiple shards of bone and soft tissue embeded in the deep layers of synovium is pathognomic for neuropathic osteoarthropathy .

26. Tecnetium bone scan- expensive and nonspecific to differentiate between osteomyelitis and charcot arthropathy . Indium scanning still expensive,but has been shown to be more specific.

27. Conservative management. Immobilization and reduction of stress are considered the mainstay of treatment for acute charcot arthropathy . Non weight bearing on the affected limb for 8-12 weeks removes the continual trauma and should promote conversion of the active charcot joint to the quiescent phase.

28. Off-loading or immobilization devices used in the management of charcot feet. - wheelchai -crutches -walker -Elastic bandage or jones dressing - unna’s boot -total contact cast -fixed ankle walking brace -Posterior splint -patellar tendon-bearing brace - charcot restraint orthotic walker (CROW) -surgical shoe with custom inlay

29. Off loading with or without immobilization should be anticipated for approximately 3-6 months, depending on the severity of joint destruction. When the patient enters quiescence phase, management is directed at a gradual resumption of weight bearing with prolonged or permenent bracing.

30. Care must be taken to wean the patient gradually from non-weight bearing to partial to full weight bearing with the use of assistive devices. Charcot restraint orthotic walker(CROW) or other similar total contact prosthetic walkers have gained acceptance as useful protective modalities for the initial period of weight bearing.

31. Feet must be closely monitored during the time of transition to permanent footware to ensure that the acute inflammatory process does not recure . Forefoot and midfoot deformities (patterns 1-3) often do well with custom full length inserts and comfort or extra depth shoes once bracing is no longer required.

32. Severe midfoot deformities will often require the fabrication of custom shoes to accommodate the misshapen foot. Rearefoot osteoarthropathy with minimal deformity may require only a deep, well cushioned shoe with a full-length orthotic device. For mildly unstable ankles without severe deformity or joint dissolution,high -top custom shoes can sometime provides adequate stability against transverse plane rotational forces.

33. The moderately unstable ankle will benefit from an ankle foot orthosis (AFO) and a high-top therapeutic shoe. The severely unstable or maligned rearfoot will require a patrllar tendon-bearing (PTB) brace incorporated into a custom shoe.

34. total contact custom orthosis with rocker sole

35. charcot restraint orthotic walker (CROW)

36. charcot restraint orthotic walker

37. Medical management Control of sugar in diabetic patient Management of infection with antibiotics In the setting of altered bone mineral density (BMD) in patients with diabetes, bisphosphonates can be use to prevent further osteoporosis in charcot arthropathy .

38. Surgical therapy Neuropathic arthropathy should not be considered primarily a surgical disorder. Surgery should be contemplated only when attempts at conservative care have failed to provide a stable, plantigrade foot. instability, gross deformity,and progressive destruction despite immobilization are the primary indications for surgical intervention. Procedures such as simple bone resections, osteotomies , midfoot or major tarsal reconstraction , and ankle arthrodesis might become necessary.

39. Amputations should usually be regarded as a procedure of last resort in neuropathic patients and not as a normal consequence of osteoarthropathy .

40. Thank you