5 Facts about Charcot Neuroarthropathy you need to know

1) With an unknown definitive mechanism of incidence, this disease process has many proposed hypothetical mechanisms currently in clinical practice. Some believe that increased inflammation and microfracturing of the bone secondary to sensory loss are key components, others believe glucose levels and specific traumatic events are responsible for this process which are compounded by inability to offload and protect the injured limb leading to progressive breakdown of the bone. We all agree that these elements are part of the problem, but do not necessarily occur in all cases. Especially in non diabetics with the disease of Charcot neuroarthropathy.

2) We know that many cases start with increased warmth, redness, and swelling. Unfortunately not ALL cases give us this "textbook" presentation.

3) We also know that characteristic radiographic changes may occur.  And when they do, differing mindsets and clinical approachs are valid and are practiced routinely in my practice. If an ulceration is present, or progressive radiographic changes are found, surgery is likely required for limb salvage.

4) We generally understand that patients with low or no protective sensory threshold on their feet tend to have a higher incidence of this process.  Also patients that have poor glucose control and are obese tend to have this same increase in incidence. Edema and general leg swelling in diabetic patients with Hemoglobin A1c levels higher than 8.0 tend to have increased risk of Charcot development in their feet. Usually all of these patients have good blood flow with regards to arterial circulation, but may have venous or lymphatic flow compromise.



5) Not all patients with Charcot neuroarthropathy are diabetic. I have treated many patients whom are not diagnosed with diabetes, and did not present with red swollen foot, who developed Charcot neuroarthopathy with radiographic bone degradation and resultant foot deformity. These patients do tend to have profound sensory polyneuropathy of unknown etiology (idiopathic) and are still at risk given the above listed requirements. I have had to reconstruct several patient's feet without diabetes as an underlying diagnosis, and it seems that they tend to have less overall complications but are still prone to the neuroarthropathy nonetheless.



The take away from this blog is that many of the "facts" about this disease process have some "grey area" information. You should seek the expert opinion with good experience in this disease process prior to any surgical intervention or decision for lower leg or foot amputation. The doctors at FFLC are well equipped to accommodate and treat this condition and are well versed in all avenues regarding limb salvage.

National Diabetes Awareness Month

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For most people, November is the time of year to begin preparing for the holiday season, but November is also National Diabetes Month.  In the United States alone, 25.8 million children and adults have diabetes.  This makes up about 8.3% of the population, and is projected to reach 21% by the year 2050.  There are millions of Americans with undiagnosed diabetes.

Many more who will eat candied apples, canned cranberries, apple and pumpkin pie, and all the turkey and stuffing they can handle; and may likely be precipitating their diabetes and obesity even further without even being aware that they have the signs/symptoms of diabetes in the first place. 

Early warning signs of the disease:

• Increased thirst
• Increased hunger (especially after eating)
• Dry mouth
• Frequent urination or urine infections
• Unexplained weight loss (even though you are eating and feel hungry)
• Fatigue (weak, tired feeling)
• Blurred vision
• Headaches

Diabetes can affect the entire body, including the foot and ankle.  Neuropathy is one of the most common complaints of diabetic patients.  Neuropathy results in damage to nerves, specifically the peripheral nerves, or nerves outside of the brain and spinal cord. Peripheral Neuropathy causes a burning or tingling sensation usually on the feet and legs, or on the arms.  This damage to the nerves is caused by excess blood glucose, or high blood sugar.  Over time excess glucose injures the walls of blood vessels that supply the nerves.  As neuropathy worsens, the ability to feel the lower extremity becomes diminished, which makes diabetics more prone to injuries that go unnoticed.  Neuropathy is the leading cause of diabetic foot ulcers.  Diabetic foot ulcers are caused from a combination of neuropathy, trauma, and deformity.  Deformities such as hammertoes, equinus (limited upward bending of the ankle), or bunions in diabetic patients are more problematic than in non-diabetic patients because of the other complications that come with diabetes.  If diabetic foot ulcers are left untreated they may end up getting infected, and even result in amputation.  Diabetic patients often have decreased circulation in the extremities due to hardening of the arteries or vessels, and this may slow healing time, which is why it’s vital for diabetic patients to take extra precautions when it comes to caring for their feet. 

Although diabetes is a life altering disease keeping a tight control on blood glucose levels can minimize complications.  Other ways to protect the feet in individuals with diabetes are by wearing special shoes made for diabetics, examining the feet daily, washing the feet and making sure to dry them completely, avoiding smoking, wearing clean, dry socks that are changed daily, and never walking barefoot.  Management of diabetes is the key to preventing complications, and for those that do not have diabetes the key to prevention is exercise, maintaining a healthy weight, and eating a well balanced diet.

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

External fixation here in Naples Florida

External fixation may look very high-tech, and maybe even scary.  However, external fixation has been used in one way or another since almost 2400 years ago.  External fixation techniques were described by Hippocrates, and were used in treating tibia fractures.  External fixation is a minimally invasive technique to reduce displaced fractures and has become a very important part of deformity correction and nonunion and pseudo arthrosis repair as well.

Jean François Malgaigne was one of the many pioneers that made advancements with external fixation devices.  In 1846, Malgaigne used a device that consisted of a clamp and four metal prongs to reduce and stabilize a fracture of the patella, or kneecap.  Following this external fixation device many other similar inventions were used to treat fractures in various locations.  In 1938, Raoul Hoffman made advancements that made external fixation even more useful, and allowed surgeons to place pins into a fracture for stabilization with guidance, while being minimally invasive.  In 1951, Dr. Gavriil A. Ilizarov developed the external fixation device that is still in use today.  Ilizarov’s fixation device consists of a metal frame that encircles the limb, and is attached to underlying bone by pins.  Threaded rods and hinges allow movement of the bone to the correct alignment.  Ilizarov’s external fixator is great because adjustments can be made without opening the fracture site, and the device provides stability. Also it can be converted to internal fixation once the soft tissues have become less swollen. 

Modern day external fixation not only provides stability to a fracture, but can also be used for soft tissue deformities, as well as other bony deformities.  External fixation is preferred when slow correction is required, and even more useful in high risk patients with vascular disease and even open fractures with high risk of infection.  The chance of getting a blood clot is lessened because with external fixation patients can be partial weight bearing, or weight bearing as tolerated following the procedure due to the stability that the fixation provides.  External fixators have been used for other bony deformities, such as Charcot, ankle arthritis, and clubfoot.  External fixation can also be used to lengthen amputated foot and toe stumps.  External fixation has definitely helped many people, but there are still some cons.  Pain and infections are two issues associated with external fixation, and rates vary depending on the extent of the procedure, and the location of the device.  External fixation devices are used by specially trained physicians and all three of the doctors at FFLC are capable of utilizing these various techniques for patients that require such interventions.  

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

CROW Brace to treat severe deformity in high risk patients.

CROW - Charcot Restraint Orthotic Walker

What is a CROW Brace?

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The Charcot Restraint Orthotic Walker, or CROW, is a stable boot designed to accommodate and support a foot with Charcot neuroarthropathy. The CROW consists of a fully enclosed ankle/foot orthotic with a rocker-bottom sole.  It is a common treatment used after the acute charcot foot has calmed down.

 

What is Charcot deformity?

This occurs when bones and joints in the foot fracture, break up or pop out of place with minimal or no known direct injury. In the United States, this deformity is most commonly seen in people with diabetes. The foot first enters an acute stage of swelling, warmth and redness, which eventually diminish. Broken bones and dislocations can occur, causing severe deformities of the foot and ankle. Some patients develop pain or ulcers when the affected foot becomes deformed. CN can affect the other foot or happen again in the same foot. The foot does not regain its normal shape. 

What is a CROW made of?

The boot is custom made for each patient’s foot. The outer shell consists of two plastic or fiberglass clamshell pieces that fit and are strapped together with Velcro. It is sturdy and can prevent other bones from cracking or breaking and can be walked on. The bottom of the boot has a rounded rocker-bottom shape. The boot contains a custom, removable foam insole. Each insole is adjusted to distribute weight equally and also to support the ankle joint.

 

What does the boot do?

The CROW functions by providing even support to the entire foot, especially to areas that are overstressed due to the neuroarthropathy. These deformities often cause the foot to bend out of shape. The resulting stress on the foot can cause ulcers, which can develop into severe infections if left untreated. By distributing pressure equally throughout the leg and foot, the CROW removes excessive forces and gives the foot time to heal. It is easier to use than a cast, can be removed for wound care and washing, and is more durable.

 

Which patients can use the CROW?

Patients with acute Charcot can begin using the CROW after the swelling has receded. This can take months.  Patients with mild to moderate deformities will benefit most from the CROW. Patients with severe  deformities or extreme foot/ankle instability may need surgery instead of using the CROW.

 

How does it affect daily life?

Fortunately, the CROW is adaptable to daily life. Because of the clamshell design, the patient can easily remove the boot in order to keep the foot clean and sleep better. In addition, its fitted shape and good support allow people to return to walking, standing and driving more normally.

 

What are typical outcomes?

The most important outcome is that patients are able to continue to bear weight while minimizing pressure and giving the foot a chance to heal. Healing may require many months. However, the disease process may return and/or affect the other foot, so regular and lifelong monitoring of the condition is necessary.

 

What are the possible complications?

Despite the sturdiness of the boot and the distribution of forces, the bones of the foot could still break. The foot could develop open sores, though the boot is designed to prevent it. As always with Charcot deformity, some joints may heal incorrectly or not at all. Unfortunately, other factors such as poor glucose control and bad nutrition can prevent healing despite use of a CROW.

 

Frequently Asked Questions

What options do I have when my foot is still swollen?Patients often wear special casts until their feet stop swelling enough for them to use a CROW. The cast serves to stabilize the foot and prevent unstable motion, similar to the CROW. However, unlike the CROW, these casts cannot be removed.

Overview of the Charcot disease

What is it?

Charcot arthropathy, also known as Charcot foot and ankle, is a syndrome in patients who have neuropathy or loss of sensation. It includes fractures and dislocations of bones and joints that occur with minimal or no known trauma.​

Symptoms and Clinical Presentation

​Initially, there may be swelling, redness and increased warmth of the foot and ankle. Later, when fractures and dislocations occur, there may be severe deformities of the foot and ankle, including collapse of the midfoot arch (often called rocker bottom foot) or instability of the ankle and hindfoot. The syndrome progresses through three general stages:

•Stage 1 (acute, development-fragmentation): marked redness, swelling, warmth; early radiographs show soft tissue swelling, and bony fragmentation and joint dislocation may be noted several weeks after onset
•Stage 2 (subacute, coalescence): decreased redness, swelling and warmth; radiographs show early bony healing
•Stage 3 (chronic, reconstruction-consolidation): redness, swelling, warmth resolved; bony healing or nonunion and residual deformity are frequently present.

Cause (including risk factors) 

Charcot foot occurs in patients with peripheral neuropathy resulting from diverse conditions including diabetes mellitus, leprosy, syphilis, poliomyelitis, chronic alcoholism or syringomyelia. Repetitive microtrauma that exceeds the rate of healing may cause fractures and dislocations. Changes in circulation may cause resorption of bone, weakening the bone and increasing susceptibility to fracture and dislocation. 

Anatomy 

Charcot arthropathy may affect any part of the foot and ankle, including (in decreasing order of frequency) the midfoot, hindfoot, ankle, heel and forefoot.  Multiple regions may be involved concurrently.  Fractures and dislocations frequently involve several bones and joints, with extensive fragmentation and deformity. 

Diagnosis 

Time between onset of symptoms and diagnosis may be several weeks or months. Delay in diagnosis may or may not affect the end result because gross instability may occur even if prompt diagnosis is made. Diagnosis is based on a high index of suspicion for this problem in patients with neuropathy. Increased redness, swelling and warmth may be the only early signs. Some patients have pain. Early radiographs may show soft tissue swelling with no bony changes, but repeat radiographs several weeks later may show bone and joint changes.

Treatment Options 

Non-Surgical: Non-operative treatment includes a protective splint, walking brace, orthosis or cast. Early weightbearing is allowed in stage 1 by 41 percent of specialists and in stage 2 by 49 percent of specialists, and other specialists recommend non-weightbearing. After stable healing is noted in stage 3, treatment includes accommodative footwear with protective orthoses.Surgical: Selected patients with instability in the early stages may be treated with open reduction and internal fixation and fusion. In the later stages, surgical options may include realignment osteotomy and fusion (correction of deformity) or ostectomy (removal of bony prominence that could cause an ulcer ). 

* Sometimes the surgery can fail, and this is commonly because of improper or inadequate fixation, poor glucose management, obesity, noncompliance, and even infection. 

Charcot and you.

Many diabetic patients may have heard warnings to look out for “charcot foot” but they may not know exactly what this means.  Different from diabetic charcot foot is an inherited disease with another characteristic foot type called Charcot-Marie-Tooth disease.  As a part of September’s Charcot-Marie-Tooth (CMT) disease awareness month, it is critical for patients to understand the differences between these two neurological disorders. 

CMT

Charcot-Marie-Tooth disease is caused by a gene defect that is often inherited.  If CMT is seen in other family members, parents should be on the lookout for the development of slowly progressing muscle weakness in the lower extremities before age 20.  Individuals with CMT have nerves that lose their myelin covering, which normally allows signals to be sent to and from skin and muscles at a normal speed allowing sensation and muscle contraction.  Patients will not usually complain of any numbness because their sensation was likely never completely normal.  As a result of the weakness and loss of sensation, first in the legs then typically seen in the upper extremities, kids with CMT may seem clumsy and have difficulty walking without tripping or rolling their ankles. The feet will often have a high arch appearance and may be prone to ulcers from damage caused by lack of ability to sense pain. 

Diabetic Charcot Foot

Patients with diabetes need to be concerned about charcot arthropathy when they develop areas of the foot where they can no longer feel anything.  The combination of lack of sensation allowing damage to the foot that patient cannot feel and an increased blood flow supplying mediators of the inflammatory process allows a “charcot joint” to develop.  In the charcot joint, the repeated small injuries occurring cause bones to gradually fracture and dislocate.   This causes deformity (often an extreme flat foot) which typically places the diabetic patient’s foot at a greatly increased risk of developing ulcers and subsequent infection with severe consequences.  The most common signs of the development of charcot arthropathy are swelling and increased temperature of the affected area of the foot, redness, pain and the feeling of a “loose bag of bones” when the joint is moved. 

In both diabetes with loss of sensation, and Charcot-Marie-Tooth, foot self-exams are immeasurably important in preventing ulceration and further complications.  Protective shoe gear and custom made orthotics can provide additional protective measures for the foot.  As shown by these two disease processes, loss of sensation in the foot is a major problem that should always be evaluated by your foot and ankle specialists here in Naples Florida.