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.

Milan Defender Zapata Sidelined Due to Foot Injury

Serie A club Milan defender Cristian Zapata suffers from a fractured foot during the final minutes against Sassuolo.

“AC Milan communicates that in the final minutes of Milan-Sassuolo, Cristian Zapata, following a challenge with another player, suffered a bone fracture at the base of the second metatarsal in his right foot.”

Metatarsal fractures are common injuries of the foot, typical caused by direct crushing injury or by twisting injury where the forefoot is fixed and hindfoot or leg rotating (more common, associated with sports injury). The 5^rd metatarsal bone is most commonly fractured metatarsal bone, while the 3^rd rarely gets fractured in isolation. A British journalist named the 2^nd metatarsal bone the “Beckham bone” due to a fracture David Beckham got after he was tackled by Aldo Duscher, this received a lot of publicity during that time.

Generally these injuries may be treated nonsurgically with a walking boot, or cast. Irregardless of treatment, it is likely this injury will sideline this footballer for a minimum of 8 weeks.  

The Lover's Fracture

The calcaneus bone, or heel bone, is among the most commonly fractured tarsal bone in the foot.  Calcaneus fractures account for 1-2% of fractures in the body.  

Calcaneus fractures are also known as the Lover’s fracture.  

Calcaneal fractures often occur due to a jump from a height, which is how the term “Lover’s fracture” was coined because a lover may jump from great heights to escape from a lover’s spouse or boyfriend.

Calcaneal fractures are generally traumatic fractures occurring from motor vehicle accidents, muscular stress, or falls from a height.  We usually see these injuries in worker's injury claim cases, whereby someone has fallen off of a ladder or rooftop. 

Calcaneal fractures are categorized based on whether the fracture is displaced (greater than 2mm displacement), open (with soft tissue or bony structure exposed), closed (with skin and soft tissue intact), or comminuted (3 or more pieces).  Treatment for calcaneal fractures varies based on the type of fracture.  Standard radiographs and CT scan are used to diagnose calcaneal fractures, and determine the severity of the injury.  Pain over the heel, inability to walk, or a hematoma that extends to the sole of the foot are all signs of a calcaneal fracture.  

Presence of a hematoma on the sole is known as the “Mondor Sign”.  In a non-displaced fracture nonsurgical treatment may be sufficient.  Displaced or comminuted fractures typically require surgical treatment consisting of some type of fixation with metal plates or screws or more recently we have used multiplanar external fixation for restoration of height, the angle, and joint space of the posterior facet in the subtalar joint. 

In closed fractures surgical treatment is often postponed until swelling has subsided.  In open (exposed soft tissue or bone) or avulsion fractures (when a tendon pulls off a piece of bone), more urgent treatment is required.  Open fractures are exposed to the environment and need to be cleaned and then surgically corrected within a short time period to prevent infection which is another advantage of external fixation. 

 

Minor calcaneal fractures usually heal within a few months, and cause minimal long-term limitations.  More severe fractures may take years to heal, and never return to the previous condition.  

Long-term complications may include pain, limb length discrepancies, and changes in gait with chronic swelling, and reduced endurance and strength.  

Early treatment by the foot and ankle surgeon (ie Family Foot and Leg Center)  is the key to minimizing long-term complications. 

-Dr Timm