What Is Charcot Arthropathy?

Charcot arthropathy, also known as Charcot neuroarthropathy or Charcot foot and ankle, is a syndrome in patients who have peripheral neuropathy, or loss of sensation, in the foot and ankle. Patients may experience fractures and dislocations of bones and joints with minimal or no known trauma.

Symptoms

Initially, there may be swelling, redness, and increased warmth in your foot and ankle. Later, when fractures and dislocations occur, there may be severe deformities, including collapse of the midfoot arch (often called rocker bottom foot) or instability of the ankle and hindfoot. The syndrome progresses through three general stages:

  • Stage 1 (acute, development-fragmentation): pain, marked redness, swelling, warmth; early X-rays show soft tissue swelling, and bony fragmentation and joint dislocation may be noted several weeks after onset
  • Stage 2 (subacute, coalescence): decreased redness, swelling, and warmth; X-rays show early bone healing
  • Stage 3 (chronic, reconstruction-consolidation): redness, swelling, warmth resolved; bone healing or non-union and residual deformity frequently are present


Causes

Charcot foot occurs in patients with peripheral neuropathy resulting from diverse conditions including diabetes mellitus, leprosy, syphilis, poliomyelitis, chronic alcoholism, or syringomyelia. Repetitive microtrauma that exceeds the rate of healing may cause fractures and dislocations. Changes in circulation may cause resorption of bone, weakening of the bone, and increasing susceptibility to fracture and dislocation. 

Charcot arthropathy may affect any part of the foot and ankle. Multiple regions may be involved. Fractures and dislocations frequently involve several bones and joints, with extensive fragmentation and deformity. 

Diagnosis

The time between the start of symptoms and a diagnosis may be several weeks or months. Often Charcot arthropathy is misdiagnosed initially because symptoms can mimic those of an injury or infection. Diagnosis is based on a high likelihood for this problem in patients with neuropathy. Increased redness, swelling, and warmth may be the only early signs. Immobilization and elevation can help to differentiate between infection and early Charcot. Some patients have pain. Early X-ray images may show soft tissue swelling with no bony changes, but repeat X-rays several weeks or months later may show bone and joint changes.

Treatments

Non-surgical: Non-surgical treatment includes a protective splint, walking brace, orthosis, or cast. Your foot and ankle orthopaedic surgeon may allow you to put weight on your foot in Stage 1 or Stage 2, but some surgeons recommend staying off your foot in all stages. After stable healing is noted in Stage 3, treatment includes accommodative footwear with protective orthoses.

Surgical: Select patients with instability in the early stages may be treated with open reduction and internal fixation and fusion. In the later stages, surgical options may include realignment osteotomy and fusion (correction of deformity) or ostectomy (removal of bony prominence that could cause an ulcer). 

Recovery

Healing may take several months. Healing times after surgery may be twice the usual duration than for someone with a non-diabetic foot. With Charcot foot and ankle, healing after fusion may require six months of protection and orthoses. 

Charcot foot and ankle may recur or flare up. Also, it is common for both feet to be affected, which can make the impairment permanent. Patients use protective footwear and orthoses, and limit standing and walking to that required for activities of daily living. Regular lifelong follow-up with a foot and ankle orthopaedic surgeon is required.

Risks and Complications

Severe deformities may include collapse of the midfoot arch (called rocker bottom foot) with associated plantar midfoot ulcer. Deformities may occur in any part of the foot and ankle and result in ulcers from bony pressure against the shoe or ground. Ulcers may become infected, and infections may be limb- and life-threatening. Some Charcot joints, such as the ankle, may heal with fibrous tissue (non-union) and this may result in gross instability ("floppy foot") that may predispose to ulcers and may be difficult to support with braces.

Why is it common to have a delay between the onset of signs and the diagnosis of Charcot foot?

The initial signs of Charcot foot are non-specific and typically are seen in other more common conditions such as infections and rheumatologic conditions. Many patients do not have pain or have pain from neuropathy that was pre-existing. Physicians who are not specialists in orthopaedic foot and ankle problems may see a Charcot foot very few times in an entire career, less frequently than other conditions such as septic arthritis, gout, rheumatoid arthritis and other inflammatory arthropathies. 

Does a delay between onset of signs and diagnosis worsen the prognosis?

Not necessarily. Some cases of Charcot arthropathy become unstable in the very early stages and have destabilized before the patient sees the doctor. Other cases may destabilize even if the foot and ankle are protected early in the course of the problem. Early protection may help decrease risk of further instability in some patients, but instability might occur despite early protection. The massive bony fragmentation may cause instability very differently than a fracture resulting from trauma in a non-neuropathic patient.

What is the overall prognosis?

If your foot and ankle are stable, can be put in a brace, and/or can be put in shoes, the prognosis overall is good. However, regular visits with a foot and ankle orthopaedic surgeon are important to ensure that there are no changes over time. Changes in position of the foot or ankle can lead to difficulty with shoes, orthoses, or potential ulceration and infection. 

In some cases the foot cannot be put in a shoe or brace, and the outcomes with conservative or surgical treatment are poorer. Persistent ulceration, infection, and unsuccessful treatment can lead to possible amputation.

 

Contributors/Reviewers: Sudheer Reddy, MD; Vinayak Sathe, MD

 

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