1. Newcastle Upon Tyne Hospitals NHS Foundation Trust
Charcot Foot Disease
Dr Ahmad Abou-Saleh
Nicola Coates
Newcastle Upon Tyne Hospitals NHS Foundation Trust

2. Aims and Outcomes Aims:
Become familiar with the condition – risk factors, pathogenesis, investigation and management
Inform your clinical practice on management of the condition
Outcomes
List risk factors and causes
Create a care pathway for these patients incorporating investigations and management

3. Outline History and Definition of the condition
Pathogenesis, associated conditions, risk factors
Clinical presentation
Investigations - Imaging
Management – offloading, surgery, footwear
Complex cases in context of diabetes

4. History
1703 – William Musgrave described arthralgia in association with venereal disease
1831 – John Mitchell described effects of peripheral neuropathy in lower limbs secondary to Tuberculous spinal disease
1868 – Jean-Martin Charcot described neuropathic osteoarthropathy affecting long bones and joints in Tertiary Syphilis  “Charcot Disease”
1936 – William Jordan linked Charcot Disease to Diabetes Mellitus

5. Charcot Foot Disease
Neuropathic Osteoarthopathy affecting bones, joints and soft tissue of the ankle and foot through a localised inflammatory process
Most common cause is Diabetes Mellitus
Other causes – Spina Bifida, Syringomyelia, Infection (Syphilis, Leprosy), Alcohol excess, Meningomyelocoele, Spinal cord injury

6. Charcot Foot in Diabetes - Pathophysiology
Peripheral neuropathy – Loss of sensation, pain and temperature modalities
Loss of protective function of sensation leading to repetitive foot trauma
Preserved or exaggerated peripheral neurovascular reflexes and arterio-venous shunting  Leads to increased bone resorption and osteopenia

7. Normal peripheral blood flow in Charcot
Shapiro et al, 1998

8. Uncontrolled Inflammatory processes
Molines et al, 2010

9. Charcot Foot in Diabetes - Pathophysiology
Osteopenia as risk factor? Association between reduced BMD and foot fracture and dislocation in Diabetics
Reduced Bone Mineral Density (BMD) in both Type 1 and Type 2 Diabetes Mellitus
High prevalence of Charcot disease in diabetic patients with kidney and/or pancreas transplant (glucocorticoid therapy)
Thiazolidinedione (Pioglitazone) use? Vitamin D deficiency?

10. Diagnosis – Acute presentation

11. Diagnosis – Acute presentation
Swollen, warm erythematous foot
Palpable peripheral pulses – Arterial blood flow preserved
Presence of peripheral neuropathy on examination
Absence of pain or mild-modest discomfort out of proportion to degree of injury

12. Diagnosis – Acute presentation
Significant temperature difference between the feet
History of trauma may be present – Disease can be precipitated by mild events
Precipitated by surgery (even in the other foot!) and soft tissue infection
Differential diagnosis – Gout, Cellulitis, Deep Venous Thrombosis (DVT)

13. Radiology - Radiograph
Can be normal!
Early stages – Subtle fractures or dislocations
More advanced disease may show overt fractures and deformities
6Ds – Degeneration, Destruction, Dislocation, Deformity, Debris, Dense

15. Magnetic Resonance Imaging (MRI)
Able to detect subtle changes in bone and soft tissue not necessarily evident on plain radiography
Note may be difficult to differentiate between active Charcot process and osteomyelitis
Other imaging modalities: SPECT-CT, Technetium-99m bone scan, White blood cell scan

16. Treatment - Offloading
Reducing pressure on foot to prevent further trauma and perpetuation of underlying inflammatory processes
Use of specific devices – Total Contact Casting, Aircast boot, Surgical sandal, wheelchair, crutches
Duration and degree of offloading dependent on clinical and radiological assessment

17. Total Contact Casting
Gold standard – allows for complete removal of all
pressure on the foot
Frequent removal and replacement to allow
assessment of the foot
Risk of increased pressure on other foot – fractures,
Ulceration
Instability in mobilisation

18. Other Offloading Measures18

19. Surgical Treatment of Charcot Foot
Consider if refractory to offloading, instability or recurrent ulceration
Correction of deformities unable to
be accommodated in offloading devices or footwear
Resection of infected bone, arthrodesis,
exostectomy, lengthening of Achilles tendon
Use of External Ilizarov frame

20. Rogers et al, 2011

21. Chronic deformity

22. Summary
Neuro-osteoarthropathy due to Diabetes-induced neuropathy and trauma –
Uncontrolled inflammatory process
Acutely swollen hot foot – clinical diagnosis with use of radiography
Primary treatment is offloading
Surgery may be required
Aim is to avoid chronic deformities increasing risk of recurrence and ulceration

23. NG19

24. Case study 1 51 year old female Type 1 Diabetes Mellitus - 1979
End-Stage Renal Failure secondary to Diabetic Nephropathy
Failed islet cell transplant for recurrent severe hypoglycaemia
Retinopathy – partially sighted
Peripheral Neuropathy
Hx several foot ulcerations and Right Charcot foot disease
Dec 2013

25. Left Charcot foot disease
Collapse of medial longitudinal arch
Deformity in 1st tarsometatarsal area
Fractures in 2nd and 3rd metatarsal bones
Due for left-sided revascularisation for possible corrective surgery

26. Right foot heel ulcer February 2015 – developed right heel fissure
Right Superficial Femoral Artery Occlusion on CT angiography – revascularised in view of tissue loss
Admitted in May 2015 for infected heel ulcer – Treated with IV antibiotics

27. Right foot heel ulcer
Slowly improved with offloading and IV antibiotics on haemodialysis (Ertapenem and Vancomycin)
Persistently poor diabetic control
Non-compliance with pressure offloading measures and other aspects of care

28. Right foot heel ulcer
Admitted in late July 2015 – deterioration and infection in ulcer
Fractures and subluxation
Total contact casting for maximal pressure offloading
Continuing on IV vancomycin on haemodialysis

29. Right Charcot foot disease
Likely Right foot charcot process
Antibiotics ongoing
Further fracturing despite casting
Poor candidate for surgery

30. Case study 2 78-year old lady Type 2 Diabetes Mellitus – 1986
Chronic Kidney Disease
Chronic left foot Charcot foot disease
Obesity
Peripheral arterial and venous disease
Admitted June 2015 for IV antibiotics

31. Old Charcot disease and ulceration
Chronic deformity creating new pressure point leading to tissue break down and ulceration
Total Contact Casting and aircast boot for offloading
Consideration of revascularisation but ulcer healed with conservative measures
Compression bandaging

32. Case Study 3 29-year old female Type 1 Diabetes Mellitus – 1996
Poor control – Recurrent Diabetic Ketoacidosis
Bilateral Charcot foot disease
Ankle affected
Left subtalar arthodesis and reconstruction with bone grafting – January 2015

33. Failure of arthrodesis and infected metalwork
Infected metalwork and malunion of subtalar arthrodesis – readmitted June 2015
Metalwork surgically removed – multiple washouts and debridements
VAC dressing, Casting and antibiotics
Future consideration of re- attempting arthrodesis and stem cell therapy

34. Key points
Pre-existing complications can affect management of these patients
Poor compliance e.g. with offloading
Risk of recurrent ulceration with chronic deformity
Charcot disease can occur sequentially in both feet!
Risk after prolonged immobilisation, infection or surgery in the foot
Charcot can occur after revascularisation and improved peripheral blood flow

35. Summary
Charcot is a chronic neuro-osteoarthropathy – Diabetes most common cause
Peripheral and autonomic neuropathy – uncontrolled self-sustaining inflammatory process
Be aware of acute presentations
Use of Radiography in conjunction with clinical signs
Offloading and surgery as treatment
Management can be very complex!

36. References
Molines L, Darmon P, Raccah C. Charcot’s foot: Newest findings on on its pathophysiology, diagnosis and treatment. Diabetes and Metabolism 36: , 2010
Rogers L, Frykberg R, Armstrong D, et al. The Charcot foot in Diabetes. Diabetes Care 34:2123–2129, 2011
Shapiro S, Stansberry K, Hill M, et al. Normal blood flow response and vasomotion in the Diabetic Charcot Foot. Journal of Diabetes and Its Complications 12: , 1998