Charcot joints occur when the ability to sense deep pain is lost or diminished. As a result of the inability to sense pain, small fractures begin to develop in areas of stress such as the arch of the foot. The normal response to a fracture is swelling and increased blood flow (reflex vasodilatation) to the affected area of bone. The increase in blood flow tends to 'wash away' calcium from the fracture site, resulting in weakening of the bone as well as more fractures. When the normal defensive mechanism, pain, remains absent, a cycle of increasing fracture activity starts with progressive failure of the supporting bone.
The description of Charcot joints dates back to 1703 when neuropathic osteoarthropathy was first described by W. Musgrave. Charcot is credited regarding his work in 1868 for describing gait anomalies of patients with syphilis (tabes dorsalis). Jordan, in was the first to describe a relationship of diabetes to neuropathic arthropathy.
- The most common area of the foot to be effected by a Charcot joint could be the middle arch.
- Charcot joints can also develop in the rearfoot and ankle but are much less common.
- One of the most common cause of Charcot joints of the foot is peripheral neuropathy due to diabetes mellitus.
The progress of a Charcot joint could be rapid and is determined by many variables. Any ability to perceive pain may lead to a more prompt diagnosis due to a patient's concern regarding their abilities to complete an average day. Complete loss of deep pain sensation may delay earlier diagnosis. Charcot joints are easily confused with osteoarthritis, that is treated much less aggressively than a Charcot joint.
1966 Eichenholz proposed a category of Charcot joints which is broken down into three distinctive stages. Stage one, or the development stage, shows debris surrounding the joints on xray. Stage one can develop over a period of days to weeks and it is radiographic change that occurs in response to unperceived trauma. Stage two is the coalescence stage. In stage two, the bone actually starts to heal with intake of debris and healing of large fracture fragments. Stage three, often called the reconstruction or reconstitution stage, note 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.
- The classification proposed by Brodsky in 1992 includes the location of the Charcot joint and is commonly used in clinical practice nowadays.
- Brodsky's classification is as follows;
Type 1 - Lisfrank's joint - 27-60% of all Charcot joint deformities of the feet.
Type 3A - Ankle joint - 9% of all Charcot deformities.
Type 3B - the Posterior Calcaneus.
Type 4 - Multiple regions of the feet and/or ankle.
Type 5 - the Forefoot.
Charcot joints are often not diagnosed until they generate one other issue that affects a patients normal actions. These may be as simple as a great inability to fit into shoes, or as severe as an infected ulceration of the foot. By this stage, the Charcot deformity has in all likelihood progressed to a point where there is massive displacement of the bones and joints in addition to multiple displaced fractures.
- Any problem that plays a part in the loss of sensation of the foot may be considered a cause for a Charcot joint.
- Some of the people conditions include;
Diabetes mellitus Tabes dorsalis (neuropathy caused by syphilisHansen's Disease (Leprosy) Tumors with the spinal cordDegenerative change with the spinal cord or peripheral nerveAmyloid Familial-hereditary neuropathies including Charcot-MarieToothe Disease, Hereditary sensory neuropathy andDejerine-Sottas Condition Pernicious Anemia.
Injectable and systemic use of steroids PhenylbutazoneIndomethacin Vincristine
Other factors that may contribute to producing neuropathy, and subsequently, Charcot joints include;
Alcoholic neuropathy Congenital insensitivity to pain Pott'sDisease (tuberculosis of the spine)
The most common complicating factor of a Charcot joint of the foot is the prominence that evolves on the bottom of the foot, referred to as a 'rocker bottom' foot. Treatment plans occurs as the bones of the arch collapse. In an advanced rocker bottom foot, the inability to sense pain gets a complicating factor for the skin. As the bone tissue places more pressure on the skin, the skin begins to ulcerate and becomes infected.
X-rays will be the single most useful tool in diagnosing Charcot joints. Bone scans are helpful in the early phases of Charcot joints and are sensitive indicators of hyperemia (increased blood flow to the area of the fracture). Surface skin temperature is one of the most reliable indicator of the activity of the fractures. Most doctors do not keep the necessary equipment to measure skin temperature but merely measure with direct touch to be able to sense the presence or lack of warmth.
Treatment of Charcot Joints
The hallmark of treatment of Charcot joints is early diagnosis and prevention. The signs and symptoms and findings of Charcot joints vary so that each case requires careful evaluation. Therapy ofCharcot joints of the feet may include rest, throwing and also non-weight bearing to allow adequate time for fracture healing. Total contact casting or the use of a Charcot Restraint OrthoticWalker (CROW) are common in stages one and two. The goal is to limit weight bearing to enable progression to be able to stage three. This particular progression can take from many weeks as much as 6 months. Electrical stimulation, or bone arousal, is a well known adjunct in order to non-weight bearing or sending your line.
Surgical procedures for Charcot joints are often challenging not only due to the complexity of this condition but also due to the fact that these patients are usually poor surgical individuals due to other health problems (co-morbidity). Surgical procedure may include reconstruction of the arch and/or shared fusion. Usually, surgical procedures are used to return the foot to a shape that can be accommodated by regular base wear. Stage threeCharcot deformities often result in piles, bump and also unusually shaped feet because of bone fragments modifications. Reshaping the feet may be used to get rid of a boney prominence on the top or bottom of the foot.
Nomenclature: reflex vasodilitation - increased blood circulation to an area in response to inflammation
Rocker bottom foot - a dominance in which forms on the sole or perhaps bottom with the foot as a result of the collapse of the arch
The symptoms of Charcot joints vary based upon the location and severity of the condition. The first sign is localized edema swelling) of the joint or important joints. The actual edematous area may exhibit increased temperature change. Often, the first apparent sign that a patient with advanced peripheral neuropathy will notice is the fact that their shoes have become stronger or these people have difficulties fitting into a pair of shoes that have fit well for some time.
The problem in diagnosing this condition is the lack of signs that are due to peripheral neuropathy. Peripheral neuropathy makes it impossible for the patient to be able to speak in terms that would be understood by the general population such as 'my feet hurt'. As a result, the physician needs to rely more on testing and less on the history and physical examination.
The differential diagnosis for this condition should include;
- Bone tumor.
- Idiopathic edema
- Soft tissue tumor
Additional References Include;
Grady, J.F., et al: The use of electrostimulation in the treatment of diabetic neuroarthropathy J. Am. Podiatric Med. Assoc. 90(6): 287-294, 2000
- Sinha, S., Munichoodappa, C.S., Kozak, G.P: NeuroarthropathyCharcot Joints) in diabetes mellitus.
- Medicine (Baltimore)
Saltzman, CL, Johnson KA, Goldstein RH, et al: The patellar tendon-bearing brace as treatment for neuropathic arthropathy: a dynamic force checking study. Foot Ankle 13: 14, 1992
- Sticha RS, Frascone ST, Werthheimer SJ: Major arthrodesis in patients with neuropathic arthropathy.
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- Eichenholtz SN: Charcot Joints, Charles C.
- Thomas, Springfield,Il 1966
- Giurini JM: Applications as well as use of in-shoe orthoses in the conservative management of Charcot foot deformity.
- ClinPodiatric Med Surg 11: 271, 1994
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- Bassett CA, Mitchell SN, Norton L, et al: Repair of non-unions by pulsing electromagnetic fields.
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About the actual author:Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Doctor. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.