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A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle.

Schade VL, Andersen CA - Diabet Foot Ankle (2015)

Bottom Line: The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990.Surgical intervention remains controversial.A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

View Article: PubMed Central - PubMed

Affiliation: Vascular/Endovascular Surgery, Madigan Army Medical Center, Tacoma, WA, USA.

ABSTRACT
Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

No MeSH data available.


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Increased bone marrow edema consistent with Stage 0 acute Charcot of the midfoot.
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Figure 0006: Increased bone marrow edema consistent with Stage 0 acute Charcot of the midfoot.

Mentions: Several authors have recently advocated the early use of magnetic resonance imaging (MRI) to aid in diagnosis of acute Charcot (5, 6, 12, 13, 15, 17, 19, 20, 33, 38, 39) (Fig. 6). Chantelau and Poll performed an MRI on seven patients with Stage 0 Charcot within 2 weeks of obtaining radiographs which were read as negative for any osseous abnormalities (17). MRI revealed advanced stress bone injuries, microtrabecular fractures of the talus or calcaneus, edema of the adjacent soft tissues, and joint effusion with an average of four (range: 1–8) bones and five (range: 0–8) joints affected. These findings resolved after cast immobilization for 6 months (17). Schlossbauer confirmed these findings and correlated them with the amount of edema and pain found on physical examination (5). As these physical examination findings decreased with cast immobilization, the MRI findings decreased as well. Given these findings, the use of MRI was recommended to aid in determination of the appropriate duration of immobilization for conservative management of acute Charcot (5). Zampa performed a prospective study of 40 patients with acute Charcot foot that further expounded on this finding (20). Each patient had an MRI performed every 3 months until deemed healed or at a maximum of 12 months from initiation of immobilization. The average follow-up time was 8.2 months. The mean time to clinical healing was 6.8 months as determined by resolution of edema, erythema, and warmth. The mean time to resolution of MRI findings was 8.3 months. The recommendation was made to obtain an MRI at baseline and every 3 months until the patient is deemed clinically stable to correlate clinical healing with objective healing on MRI (20). Chantelau and Richter performed a retrospective, observational, exploratory cohort study of 59 patients (71 acute Charcot feet) whose management was based on MRI findings (21). The patients were followed over a 12-year time period. Early MRI was found to be instrumental in prompt diagnosis and initiation of treatment minimizing the risk for development of rigid foot deformities. When Stage 0 Charcot was diagnosed and immobilization initiated within 1 month of symptom onset, approximately 70% of patients healed without foot deformity with an average immobilization time of 4 months. This is in contrast to patients diagnosed in Stage 1 approximately 2 months after symptom onset who needed an average immobilization time of 5 months with approximately 30% healing without deformity of the foot. Results of this study lead to the conclusion that: 1) radiographs were insufficient in diagnosing midfoot fractures, 2) any bone marrow edema in the foot on MRI in a patient with peripheral neuropathy of any etiology was likely to progress to cortical fracture with continued unprotected ambulation, 3) the presence of cortical fractures was a significant marker for impending deformity development, 4) both Stage 0 and Stage 1 Charcot involving the tarsometatarsal and midtarsal joints required longer immobilization times, and 5) patients with type 1 diabetes were slightly younger, less obese, had a longer duration of diagnosis, and were more prone to recurrence of Charcot events than patients with type 2 diabetes (21). Given the ability of MRI to detect acute Charcot before any radiographic findings are visualized, the authors felt that the radiograph-based Eichenholtz classification does not encompass the full spectrum of the disease process and proposed a new classification for patients with peripheral neuropathy and an acutely swollen foot consisting of two stages and two grades. This classification system correlates clinical, computed tomography and MRI, and histopathology findings of Charcot and can be used to determine time for initiation and duration of treatment (6) (Table 1).


A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle.

Schade VL, Andersen CA - Diabet Foot Ankle (2015)

Increased bone marrow edema consistent with Stage 0 acute Charcot of the midfoot.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4368713&req=5

Figure 0006: Increased bone marrow edema consistent with Stage 0 acute Charcot of the midfoot.
Mentions: Several authors have recently advocated the early use of magnetic resonance imaging (MRI) to aid in diagnosis of acute Charcot (5, 6, 12, 13, 15, 17, 19, 20, 33, 38, 39) (Fig. 6). Chantelau and Poll performed an MRI on seven patients with Stage 0 Charcot within 2 weeks of obtaining radiographs which were read as negative for any osseous abnormalities (17). MRI revealed advanced stress bone injuries, microtrabecular fractures of the talus or calcaneus, edema of the adjacent soft tissues, and joint effusion with an average of four (range: 1–8) bones and five (range: 0–8) joints affected. These findings resolved after cast immobilization for 6 months (17). Schlossbauer confirmed these findings and correlated them with the amount of edema and pain found on physical examination (5). As these physical examination findings decreased with cast immobilization, the MRI findings decreased as well. Given these findings, the use of MRI was recommended to aid in determination of the appropriate duration of immobilization for conservative management of acute Charcot (5). Zampa performed a prospective study of 40 patients with acute Charcot foot that further expounded on this finding (20). Each patient had an MRI performed every 3 months until deemed healed or at a maximum of 12 months from initiation of immobilization. The average follow-up time was 8.2 months. The mean time to clinical healing was 6.8 months as determined by resolution of edema, erythema, and warmth. The mean time to resolution of MRI findings was 8.3 months. The recommendation was made to obtain an MRI at baseline and every 3 months until the patient is deemed clinically stable to correlate clinical healing with objective healing on MRI (20). Chantelau and Richter performed a retrospective, observational, exploratory cohort study of 59 patients (71 acute Charcot feet) whose management was based on MRI findings (21). The patients were followed over a 12-year time period. Early MRI was found to be instrumental in prompt diagnosis and initiation of treatment minimizing the risk for development of rigid foot deformities. When Stage 0 Charcot was diagnosed and immobilization initiated within 1 month of symptom onset, approximately 70% of patients healed without foot deformity with an average immobilization time of 4 months. This is in contrast to patients diagnosed in Stage 1 approximately 2 months after symptom onset who needed an average immobilization time of 5 months with approximately 30% healing without deformity of the foot. Results of this study lead to the conclusion that: 1) radiographs were insufficient in diagnosing midfoot fractures, 2) any bone marrow edema in the foot on MRI in a patient with peripheral neuropathy of any etiology was likely to progress to cortical fracture with continued unprotected ambulation, 3) the presence of cortical fractures was a significant marker for impending deformity development, 4) both Stage 0 and Stage 1 Charcot involving the tarsometatarsal and midtarsal joints required longer immobilization times, and 5) patients with type 1 diabetes were slightly younger, less obese, had a longer duration of diagnosis, and were more prone to recurrence of Charcot events than patients with type 2 diabetes (21). Given the ability of MRI to detect acute Charcot before any radiographic findings are visualized, the authors felt that the radiograph-based Eichenholtz classification does not encompass the full spectrum of the disease process and proposed a new classification for patients with peripheral neuropathy and an acutely swollen foot consisting of two stages and two grades. This classification system correlates clinical, computed tomography and MRI, and histopathology findings of Charcot and can be used to determine time for initiation and duration of treatment (6) (Table 1).

Bottom Line: The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990.Surgical intervention remains controversial.A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

View Article: PubMed Central - PubMed

Affiliation: Vascular/Endovascular Surgery, Madigan Army Medical Center, Tacoma, WA, USA.

ABSTRACT
Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

No MeSH data available.


Related in: MedlinePlus