8 Case History : 2 45yrs old married female DM2 15yrs (Retinopathy: PRP, Nephropathy: crt clr 103 )HTN 5yrsPost amputation RT big toe 3yrsSwelling LT foot 2 months, treated as cellulitis with antibiotics
14 Tragic “Rule of 15” 15% of diabetes Foot ulcer in lifetime of patients 15% of foot ulcers Osteomyelitis15% of foot ulcers AmputationClinical Care of the Diabetic Foot, 2005Foot ulcers precipitate about 85% of diabetic amputations. Key epidemiologicpoints about diabetic foot ulcer can be summarized by the “Rule of 15”:15% of diabetes patients will experience a foot ulcer during their lifetime.15% of these foot ulcers will progress to osteomyelitis.Even with optimal multidisciplinary care, 15% of diabetic foot ulcers will result in a lower extremity amputation at some level.
15 Tragic “Rule of 50” 50% of amputations 50% of patients Transfemoral/ transtibial level2nd amputation in 5 yearsDie in 5 yearsHowever, more important than expense, amputations have tragic consequencesfor the individual that can be summarized by the “Rule of 50”:50% of diabetic amputations occur at the very disabling transfemoral or transtibial levels.50% of these patients will require a second amputation within just 5 years.50% of these patients will die within 5 years, most from concurrent coronary artery disease or cerebrovascular disease.Clinical Care of the Diabetic Foot, 2005
16 History of charcot foot Mitchell,1831: The first association between joints and neurological diseases.Charcot 1868: Arthropathy and tabes dorsalis.Jordan 1936: Neuritic manifestation of DM
17 Charcot’s Foot A Neuropathic Arthropathy Caused by repetitive trauma in the setting of:Diminished sensation & proprioceptionMotor neuropathy results in muscle imbalance & abnormal weight bearing.“Rocker Bottom Deformity”a convex deformity of the foot’s plantar aspect caused by the collapse of metatarsal bonesWHEN YOUR FEET THEY START TO CRUMBLE TO YOUR DOCTOR YOU SHOULD FUMBLE
20 Etiology Peripheral sensory neuropathy is always present +/- motor. Autonomic neuropathy leads to increased blood flow.Trauma may be an important precipitating factor, although 2/3rd of patients don’t remember any injury.Bone metabolism both osteoblastic and osteoclastic activities are increased.
22 Epidemiology Incidence : 0.1 – 0.5 % . General: Increased in patients with neuropathy.Diabetics: 3-5%Common in the 4th or 5th decades of life.Bilateral in 30 % of patients.Sex difference : NoType 1 or type 2: Both are at risk.Majority: in the mid foot but any bone or joint in the foot or ankle can be affected.
23 Clinical Features and Diagnosis Acute CharcotWarm, inflamed and swollen.Misdiagnosed as cellulitis, osteomyelitis or inflammatory arthropathy as gouty or septic.Although sensory neuropathy, pain is common feature followed by discomfort.Diagnosis by exclusion as investigations in early stages are negative.
24 Clinical Features and Diagnosis High index of suspicion is necessary so that appropriate treatment is immediately instituted to prevent severe deformity!
25 Clinical Features and Diagnosis Chronic Charcot, may be months, painless, without temperature difference and deformed.Reactivation by further trauma is frequent.Patients are at high risk of ulceration and amputation, so long term follow up is recommended.
26 Investigations X-ray : Early; absent or subtle finding. Late; bone and joint destruction, fragmentation.bone scan: Increased bone uptake.In labeled leucocytes scan to differentiate from osteomyelitis.MRI: Bone marrow edema is the earliest sign.
34 Treatment 3. Pharmacological Treatment. Pilot study first using pamidronate,1994.Other Bisphosphonates were used to decrease disease activity and bone turnover markers.Calcitonin were also used.Given for 12 weeks or till temp gradient is less than 2 on 2 consecutive visits.
35 Treatment Surgical treatment: No role in acute. Later may be to remove bony deformities or constructive surgeries to achieve a stable shape.Techniques include; Arthrodesis, exostectomies, reconstruction and Achilles tendon lengthening.