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.

CROW Brace to treat severe deformity in high risk patients.

CROW - Charcot Restraint Orthotic Walker

What is a CROW Brace?

​​

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.

Limb Preservation: Total Contact Casting

Diabetics with neuropathic ulcers affect at least one quarter of all diabetics in the United States, and according to Wounds Research, approximately 1 in 5 of these individuals will eventually require an amputation of their foot. Total contact casting has recently become more popular as an option for foot protection, and to mediate the excessive wear and tear that some diabetic foot sores suffer.

What is total contact casting?

As the name suggests, this technique, which is used by many diabetic foot specialists, is a thin cast that is applied to the entire plantar surface area of the foot, as well as the lower leg. Based on its design, the cast can take up as much at 92 percent of the pressure from the ulcer site. Since ulcers often occur on parts of the foot or leg that are repeatedly impacted through daily movement, it is important that they receive as much padding as possible without affecting an individual’s normal walking patterns. Although total contact casting provides relief from certain pressures, the cast works with the natural human gait to make sure that no section of the foot or leg is required to take on excessive weight or pressure.

Does it always work?

Total contact casting has been shown to be effective in the healing of foot and lower leg ulcers, but only those that are noninfected. According to current research, the success rate is between 72 and 100 percent in most patients. A study conducted at the University Hospital Maastricht in the Netherlands examined how total contact casts would fare on infected patients, and of the 28 patients in the study group, only 36 percent showed signs of healing. The study group recommended that individuals with infected diabetic ulcers look toward alternative treatments for healing, according to the American Diabetes Association.

Surgery may become necessary in conjunction with acute infections.

Innovations in Neuropathy Pain

We are performing integrated nerve blockade treatments for our patients at Family Foot and Leg Center at our East Office exclusively. 

We are currently noticing an improvement in nerve pain in the foot and ankle area, as well as some studies are finding that some patients actually have improved balance and proprioception longterm after the treatment is completed. We will see patients 2 times a week for 4 weeks, and each treatment consists of 30 minutes which combines electrical and neuroblockade consisting of lidocaine to the peripheral nerves to the ankle and foot. This treatment is revolutionizing noninvasive management of the painful condition of neuropathy. 

New Advanced Technology

The vast majority of electromedical devices available in the United States employ LF stimulation (eg, transcutaneous electrical nerve stimulation [TENS]). Balanced MF currents have been developed that produce twice the electrical current with no electrical charge. A new type of electrical current technology has been developed to enhance the stimulating lower frequencies and nonstimulating middle frequencies for increased efficacy in clinical practice. The device also combines, and simultaneously delivers, frequency-modulated (FM) and amplitude-modulated (AM) electric cell currents in the MF range. We refer to this electromedical approach as electronic signal treatment (EST).

This new technology may reach deeper into tissue structures with simultaneous modulation of amplitude and frequency between 2,500 Hz and 33,000 Hz. It is also capable of modulating its MF electric cell-signaling current down into the LF range at available frequency rates between 0.1 and 999 Hz.

In addition, we have combined the new EST with local anesthetic injections (bupivacaine 0.25%) with clinical success. This technique provides a combined (electrical and chemical) nerve block that enhances treatment of a neuropathy or a painful condition (see Tables 1 and 2). 

According to the Gould Medical Dictionary, a nerve block is defined as “[t]he interruption of the passage of impulses through a nerve, as by chemical, mechanical, or electrical means.” Because nerve blocks occur at voltage-gated channels, all nerve blocks are essentially electrical. According to Szasz, “There is no such thing as a chemical block … only an electrical block.”6 We refer to this as combined electrochemical block (CEB).

Cancer and your feet

We see a variety of patients from all sorts of community and word of mouth referral systems. Ultimately, patients often have far more medical issues than their feet and ankles alone. I will see various patients in different stages of oncologic management, either post chemo into radiation therapy for various malignancies, and even patients post Moh's surgery and are here for skin care of the legs and feet.  Either way, various conditions may arise post chemotherapy to manage these various cancers, and often the feet and legs can have the brunt of the side effects manifesting in various ways.  We will see patients with numbness, tingling, and even swelling in the legs after these treatments. We are called to manage these secondary conditions and have a multitude of protocols in place to achieve high levels of excellent outcomes in relief of these symptoms. Here is an overall synopsis of management of swelling of the ankles and legs:

Dr Brian Timm, DPM, FACFAS

Diplomate: American Board of Podiatric Surgery 

(Soon to be named American Board of Foot and Ankle Surgery)

Swelling

---

What is swelling?

Swelling, otherwise known as edema, is a build up of fluid in the body.  Swelling most often affects the dependent extremities (like the feet, ankles and hands) but swelling can also affect other parts of the body, such as the abdomen.  Causes of swelling include:

• Fluid retention, including salt and water related to medication, heart disease, liver disease, or kidney failure.
• Blockage of veins or lymph system.
• Malnutrition.

Chemotherapy-related, or cancer swelling:

• Some chemotherapy drugs can cause fluid retention in the body.  This form of cancer swelling is most noticable in the feet, ankles, hands, and face.
• Swelling or angioedema may also occur with hives as part of an allergic reaction.  It is a vascular reaction that causes an increased ability for fluid in the cells to "leak" into the layers of the skin, resulting in swelling.  This happens much less often than hives alone.  The fluid retention causes swelling generally in the tongue, lips, or eyelids. Swelling of the airways can result in difficulty breathing, closing off of the airway and death.  If swelling is happening along with signs of breathing difficulty seek help immediately.

What are some symptoms of swelling to look for?

• Feet and lower legs get larger when you sit or walk.
• Take a look at your feet, ankles and hands.  Are they swollen?  When you press on the skin with your finger, is there an indentation that stays for a few seconds?  If so, you may have "pitting edema."
• Hands feel tight when you make a fist
• Rings are too tight
• Abdomen appears to be swelling or distended
• Shortness of breath (especially when lying down)

Things you can do to manage swelling:

• Elevate your feet as often as possible. (Either sitting in a chair with your feet on a stool with a pillow or in the bed or couch with feet up on two pillows)
• Do not stand for long periods of time.
• Avoid tight clothing (shoes, girdles, etc).
• Do not cross your legs.
• Reduce your salt intake if swelling is present. Avoid foods such as bouillon, potato chips, tomato juice, bacon, ham, canned soups, soy sauce, and table salt, for example.
• Try to eat a balanced diet (see eating well section).
• If your swelling is severe, consider wearing Jobst stockings or TED hose.
• Weigh yourself daily. Notify your doctor or health care provider if you have gained 5 pounds or more in a week.
• Take your medications exactly as prescribed.

Drugs or recommendations that may be prescribed by your doctor or health care provider for symptoms of swelling:

• Depending upon the causes of your swelling, your doctor or health care provider may prescribe a diuretic.  Diuretics - may be known as "water pills" as they work by making you urinate out extra fluid. Some examples of this medication may include furosemide (Lasix), and Hydrochlorthiazide. You may receive this medication alone or in combination with other medications.
• Your doctor or health care provider may recommend that you see a registered dietitian to help plan a diet tailored to your condition.

When to call your doctor or health care provider about swelling:

Call your doctor or health care provider immediately: 

• If you are short of breath.

Call your doctor or health care provider within 24 hours:

• If you have gained 5 pounds or more in one week.
• If you develop sudden and severe fluid retention.
• Your feet or hands feel cold to the touch.
• If you are unable to eat for more than a day.
• If you have urinated only a little bit or not at all.
• If the swelling appears to move up your arms or legs.

PRP Literature Review

As the use of PRP increases, additional studies may establish PRP as an efficacious treatment modality and guide future treatment of chronic diabetic foot ulceration.

- Yale Journal of Biology and Medicine March 2010



We have been using PRP injections in this manner since 2010 as well, and this study was published promptly (and independently) from our center, but it shows the progressive mindset and improved outcomes from our center.

We are always striving to obtain the latest in technology to help treat our patients both effectively and not only by use of standard of care methods we will often go ABOVE the standard of care to ensure the most optimal in outcomes for our patients with diabetic wounds and neuropathic ulcerations.


McAleer et al. (2006) found that the use of autologous PRP was successful in healing a chronic lower extremity wound in a case study of a 57-year-old man with type 2 diabetes and a wound of six months duration. 


Salemi et al. (2008) was a more recent case study evaluating the effectiveness of a combination of autologous adipose tissue and PRP in a lower extremity ulcer of three years duration in a non-diabetic 65-year-old male patient.

Margolis et al. (2001) was a retrospective cohort study devised to estimate the effectiveness of platelet releasate (PR) in the treatment of diabetic neuropathic foot ulcers. Of the 26,599 patients included in the study, 21 percent were treated with PR by the end of the 12-week run-in period before the 20-week study period began.  The investigators concluded that PR was more likely to be used in more severe wounds and was also more effective in treating these wounds than the standard of care. 

Driver et al. (2006) carried out the first reported prospective, randomized, controlled multicenter trial in the United States regarding the use of autologous PRP for the treatment of diabetic foot ulcers. Participants included 72 patients with type 1 and type 2 diabetes between the ages of 18 and 95 from 14 investigation sites suffering from an ulcer of at least four weeks duration. In this study, investigators compared the effectiveness of autologous PRP gel to that of normal saline gel for 12 weeks. The primary objective of this study was to evaluate the safety of PRP and the incidence of complete wound closure, defined as 100 percent re-epithelialization, when compared to the control treatment, and a secondary objective was rate of wound closure. Patients were randomized into two groups — standard of care with PRP gel or control (saline gel) — and were evaluated biweekly for 12 weeks. After excluding 32 patients from the final per-protocol analysis because of failure to complete treatment and protocol violations, the authors found that 68.4 percent (13/19) of patients in the PRP group and 42.9 percent (9/21) in the control group had wounds that healed. Wounds in the PRP group healed after a mean of 42.9 days (SD 18.3) vs. 47.4 days (SD 22.0) in the control group. 

This is significant, because the longer the duration of time that there is an ulceration on the plantar skin the more directly proportional to likelihood of osteomyelitis formation occurs. 


Metalink: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2844688/