Charcot Foot Overview and Types
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Questions and Answers

What is the role of the pro-inflammatory cells in patients with DNOAP (diabetic charcot foot)?

Mediator of osteoclastic resorption

What is the slow to rapidly progressive, non-infectious destruction of one or more bones and/or joints that is associated with neuropathy?

Charcot arthropathies

Early charcot joint will have a __________ ROM while over time, after about 8 weeks a charcot joint will have a ________ ROM.

Increased; Decreased

What are the two types of charcot arthropathies?

<p>Hypertrophic (charcot joints) and atrophic (diabetic osteolysis)</p> Signup and view all the answers

Diabetes is the only condition that can lead to charcot joint changes.

<p>False</p> Signup and view all the answers

If an individual with Charcot has an ulcer, their life expectancy is ____________.

<p>decreased</p> Signup and view all the answers

DNOAP (diabetic neuro-osteopathy) is more commonly bilateral in what patients?

<p>Juvenile-onset DM</p> Signup and view all the answers

What are the 2 theories of how an individual develops Charcot?

<ol> <li>Damage to trophic centers in anterior horn cells of the spinal cord (neurovascular); 2. Repetitive trauma to insensate foot (neurotraumatic)</li> </ol> Signup and view all the answers

What is the modern theory that was not previously theorized to cause charcot?

<p>Proinflammatory cytokines play a key role</p> Signup and view all the answers

When proinflammatory cytokines are released, what does it do to the bone?

<p>Mediate bone resorption via excess osteoclastic activity</p> Signup and view all the answers

What is the name of the signaling system that regulates the osteoclastic activation and survival in normal bone remodeling?

<p>RANKL/RANK</p> Signup and view all the answers

What is the name of the factor that protects the skeleton from excessive bone resorption?

<p>OPG; osteoprotegerin</p> Signup and view all the answers

RANKL-mediated osteoclastic resorption is the modus operandi in infection mediated resorption.

<p>False</p> Signup and view all the answers

When the OPG/RANKL signaling pathway causes an increased expression of bone matrix proteins in vascular smooth muscle cells, what does this cause?

<p>Vascular calcifications</p> Signup and view all the answers

Pain is the common complaint that brings individuals in that are suffering from charcot changes.

<p>False</p> Signup and view all the answers

If an individual has a severely painful charcot foot what is this suggestive of?

<p>Infection</p> Signup and view all the answers

What are the clinical symptoms of a charcot foot?

<p>Variable pain, swelling, deformity, impairment of activity, instability, crepitation</p> Signup and view all the answers

When looking at the Sanders-Frykeberg classification where is the most common pedal target of the charcot joint?

<p>Lisfranc Joint (tarsometatarsal joint) +/- the navicular cuneiform joint</p> Signup and view all the answers

According to Sanders-Frykberg classification, what is the anatomic pattern type 1?

<p>IPJs, phalanges, MPJs and distal metatarsals; atrophic changes; frequency around 10-20%; common plantar ulcerations</p> Signup and view all the answers

When looking at the IP joints in an individual with Sanders-Frykberg classification type 1 pattern, what are you most likely to see?

<p>Atrophic changes</p> Signup and view all the answers

In the Sanders-Frykeberg classification pattern 1, radiographically we will see ___________ changes.

<p>Atrophic</p> Signup and view all the answers

What is the Sanders-Frykberg classification type 2?

<p>Tarsometatarsal joint, Lisfranc's; most common</p> Signup and view all the answers

What are some frequent findings of an individual with a Sanders-Frykberg classification type 2 anatomic pattern?

<p>Tarsometatarsal joint, subluxations and dislocations, met bases override the cuneiforms, rocker bottom feet, severe adduction and plantarflexion of the rearfoot with abduction and dorsiflexion of the forefoot</p> Signup and view all the answers

What is Sanders-Frykberg classification type III?

<p>Choparts + NC, NC, TN, CC joints; 2nd most common; osteolysis of the navicular; dislocation of the navicular</p> Signup and view all the answers

What is Sanders-Frykberg classification type IV?

<p>Involves the ankle joint; severe destruction and instability; tibia may grind through os calcis to the ground</p> Signup and view all the answers

What is Sanders-Frykberg classification type V?

<p>Involves the calcaneus; seen with a posterior tubercle avulsion; least frequent 5% or less; suggestive of insufficiency fracture</p> Signup and view all the answers

What is type 1 of the Brodsky classification?

<p>Tarsometatarsal &amp; NC joints</p> Signup and view all the answers

What is the most common type joint deformity that is seen with the Brodsky classification?

<p>Type 1; tarsometatarsal N-C; classic Cube Foot</p> Signup and view all the answers

Type 1 of the Brodsky classification rarely results in chronic instability.

<p>True</p> Signup and view all the answers

Brodsky classification type 2 has what joints involved?

<p>STJ, TN and/or CC; 'triple joints'</p> Signup and view all the answers

Type 2 of the Brodsky classification rarely results in chronic instability.

<p>False</p> Signup and view all the answers

What joints are involved in type 3a Brodsky classification?

<p>Talocrural joint; frequency at 10%</p> Signup and view all the answers

Type 3a of the Brodsky classification requires the longest time for bony healing.

<p>True</p> Signup and view all the answers

What portion of the foot is involved in an individual with a type 3b Brodsky classification?

<p>Posterior calcaneal tuberosity; seen with achilles avulsion; less than 5%; see secondary collapse of the distal foot</p> Signup and view all the answers

When there is inflammatory soft tissue swelling and severe subluxation with marked new bone formation in the midfoot on an x-ray, what condition might this indicate?

<p>Profound fragmentation</p> Signup and view all the answers

What are the 5 Ds of the charcot foot?

<p>Destruction, Density, Debris, Disorganization, Dislocation</p> Signup and view all the answers

What are the major differences between post traumatic OA and Charcot?

<p>In Charcot there is massive swelling, many osseous fragments, laxity and articular subluxation/dislocation, joint space loss with ankylosis, calcification of vessels, lack of osteoporosis</p> Signup and view all the answers

Any patient with diabetes that presents with a hot swollen foot, what should you think?

<p>Charcot</p> Signup and view all the answers

When looking at the Eichenholtz classification, what are the progressive radiographic stages that are seen?

<p>Development, Coalescence, Reconstruction</p> Signup and view all the answers

What is the primary radiographic finding of the Eichenholtz classification stage 1 'development' classification?

<p>Fragmentation; intra-articular fracture typical seen with bony dissolution and fragmentation</p> Signup and view all the answers

In the developmental stage I of Eichenholtz classification the ROM is ____________.

<p>Increased as a result of subluxation and dislocation</p> Signup and view all the answers

Clinically, an individual in stage 1 of the Eichenholtz classification will present with what?

<p>Hyperemic, hot, swollen joint +/- pain</p> Signup and view all the answers

Subchondral osteopenia is an acute phase finding.

<p>True</p> Signup and view all the answers

Stage 2 of the Eichenholtz Classification is what?

<p>Coalescence stage</p> Signup and view all the answers

What occurs in the coalescence stage, stage 2 of Eichenholtz Classification?

<p>Coalescing new bone forms at sites of fracture fragmentation; beginning of the repair to try and heal; absorption of fine bony debris</p> Signup and view all the answers

In what stage of Eichenholtz Classification do we see an increase in sclerosis?

<p>Stage 2; coalescence stage</p> Signup and view all the answers

In Eichenholtz Classification stage 2, there is a loss of vascularity from fragmentation and disorganization which results in what?

<p>Sclerosis at the bone ends</p> Signup and view all the answers

What is the radiographic hallmark of Stage 2 Coalescence stage Eichenholtz Classification?

<p>Sclerosis</p> Signup and view all the answers

What is stage 3 of the Eichenholtz Classification?

<p>Reconstruction stage (healing)</p> Signup and view all the answers

In which stage of Eichenholtz Classification would you find a decreased ROM of the foot?

<p>Stage 3 = Reconstruction</p> Signup and view all the answers

What do we see occurring in stage 3 of Eichenholtz Classification?

<p>Bony consolidation and healing; contours tend to smooth and the residual deformity disappears; some resolution of sclerosis; decrease swelling with decrease ROM</p> Signup and view all the answers

What are the signs of healing?

<p>Number of fragmentation reduced; fragment contours become distinct; smaller fragments resorbed; cortical defects fill in</p> Signup and view all the answers

What is stage zero Charcot also known as?

<p>Charcot in situ</p> Signup and view all the answers

What are the radiographic findings of an individual with stage 0 Charcot?

<p>No radiographic changes noted; swelling, local warmth, and possible instability due to ligamentous laxity</p> Signup and view all the answers

Individuals that are termed to be at stage zero are said to be an _____________ patient.

<p>At risk</p> Signup and view all the answers

When is it critically important to make the diagnosis of Charcot before the destruction and collapse occurs?

<p>Eichenholtz stage zero</p> Signup and view all the answers

How are we able to adequately image the extent of damage, fragmentation and lysis in an individual at stage 0 Charcot?

<p>CT, Tomography, or MRI (ancillary imaging)</p> Signup and view all the answers

What is the most reliable specialized test during the earliest stage of Charcot?

<p>Conventional triphasic bone scan</p> Signup and view all the answers

What are the major neuropathic differential diagnoses of Charcot with a predilection site of the foot/ankle?

<p>#1. Diabetes; #2. Chronic alcohol use; Meningomyelocele; Leprosy; Tabes dorsalis (knee, shoulder, hip); Syringomyelia (shoulder, elbow)</p> Signup and view all the answers

Who are some non-neuropathic mimickers of Charcot?

<p>Avascular necrosis; Mueller-Weiss syndrome and residual Kohler's disease; CPPD; severe DJD; chronic OM with septic A; chronic gouty arthritis</p> Signup and view all the answers

Study Notes

Charcot Foot Overview

  • Diabetic Neuro-Osteopathy (DNOAP) involves osteoclastic resorption mediated by pro-inflammatory cells.
  • Charcot arthropathies result in rapid destruction of bones and joints associated with neuropathy.
  • Early Charcot joint shows increased range of motion (ROM); however, after 8 weeks, the ROM decreases.

Types and Etiology of Charcot Arthropathies

  • Two charcot arthropathy types: hypertrophic (charcot joints) and atrophic (diabetic osteolysis).
  • Charcot can occur due to factors beyond diabetes, including juvenile-onset DM leading to bilateral DNOAP.
  • Key theories of development: neurovascular damage affecting trophic centers and repetitive trauma to insensate feet.
  • Modern understanding emphasizes the role of pro-inflammatory cytokines in Charcot development.

Radiographic Classification Systems

  • Sanders-Frykberg classification identifies common targets: Lisfranc Joint is highly affected.
  • Types within this system include:
    • Type 1: Involves IPJs, phalanges, MPJs; characterized by atrophic changes and common plantar ulcers.
    • Type 2: Lisfranc's joint; most prevalent with subluxations and notable deformations.
    • Type 3: Includes Chopart + navicular calcaneus; hallmark is navicular osteolysis.
    • Type 4: Ankle joint involvement; marked destruction and instability.
    • Type 5: Calcaneus involvement; rare, linked to insufficiency fracture.

Brodsky Classification

  • Type 1 involves tarsometatarsal joints and is commonly seen with "cube foot."
  • Type 2 affects STJ, TN, CC joints, associated with chronic instability.
  • Type 3a is linked to talocrural joint; characterized by prolonged healing times.
  • Type 3b includes avulsions at the posterior calcaneal tuberosity; leads to secondary collapse of the foot.

Clinical Features of Charcot Foot

  • Symptoms may include variable pain, swelling, deformity, and shoe fit issues; pain is less reported.
  • Evidence of infection includes severe pain in an otherwise asymptomatic Charcot foot.
  • The 5 Ds of Charcot foot: destruction, density, debris, disorganization, and dislocation.

Eichenholtz Classification Stages

  • Stage 1 (Development): marked by fragmentation, increased ROM, and clinical signs like swelling and heat.
  • Stage 2 (Coalescence): involves new bone formation, increased sclerosis, and absorption of fragments.
  • Stage 3 (Reconstruction): involves bony consolidation and healing, decreased swelling, and reduced ROM.
  • Stage 0 (Charcot in situ): presents no radiographic changes but marked by local warmth and potential instability.

Imaging and Diagnosis

  • Importance of early diagnosis in Eichenholtz stage zero to prevent subsequent destruction.
  • Specialized imaging such as CT, MRI, or triphasic bone scans aid in assessing damage at stage 0.
  • Differential diagnoses include diabetic neuropathy, chronic alcohol use, and other conditions mimicking Charcot.

Key Points on Treatment and Management

  • Analyze common presentations: hot swollen foot suggests Charcot until proven otherwise.
  • Early identification and imaging are critical to manage and prevent complications associated with Charcot foot.

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Description

This quiz covers the key concepts related to Charcot Foot and its types, focusing on the pathophysiology of Diabetic Neuro-Osteopathy (DNOAP) and the classification systems used to identify various manifestations. Participants will explore the etiology, radiographic classification, and implications of this condition, enhancing their understanding of Charcot arthropathies.

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