Key Insights On Surgical Timing In Charcot Neuroarthropathy
The Charcot foot and ankle is a challenging clinical entity for the qualified foot and ankle surgeon. It is a progressive disease with insidious onset. Osteoarthropathy was originally described in 1703 but it wasn’t until 1868 that it was called Charcot neuroarthropathy due to Charcot’s work in linking the disease to tabes dorsalis and neuropathy.1,2 It was Jordan who linked this destructive disease — which is associated with joint dislocation, breakdown and pathologic fracture — with diabetes mellitus.3
Osteoarthropathy has an incidence ranging from 0.16 percent to 13 percent in all patients with diabetes, and may lead to an increased risk of amputation and higher mortality rates.4,5
There have been numerous classification schemes describing Charcot neuroarthropathy. However, the most commonly used classification was described by an American orthopedist in 1966.6 Eichenholtz classified Charcot into three radiographic stages.
Stage I. Usually referred to as the developmental or “hot” phase, Stage I Charcot presents with hyperemia and edema. Radiographic findings include joint subluxation, dislocation, debris formation and bony fragmentation.
Stage II. Usually referred to as the coalescent phase, Stage II shows debris absorption, sclerosis of bony ends and coalescence of bone fragments.
Stage III. Usually referred to as the remodeling phase, Stage III presents with marked decrease in redness and swelling. Radiographic findings include decreased sclerosis, remodeling of bony fragments and fragments fusing to the joint surfaces in an effort to recreate the architecture of the foot.
Stage 0. Researchers have recently described this stage as ranging from a clinically warm, edematous and painful foot to one with mild fracture or joint space widening without debris.7-9
In addition to classification, researchers have also described the patterns of Charcot, taking the more commonly affected joints into account.10
A Review Of Key Treatment Considerations
Surgical management is generally contraindicated in patients with Stage 0 Charcot or those who have active fragmentation and resorption of bone.11,12 (However, this thought process has been challenged in the recent literature. We will discuss this later in the article.)