Keys To Identifying Patients At Risk For Charcot Foot

It is well known that patients who present with the acute or chronic Charcot joint require a tremendous amount of time, energy and effort in both patient education and proactive management in an attempt to reduce the risk of limb loss.

One problem that all of us share is the challenge of identifying patients at risk for the Charcot foot. These patients present, often for the first time, with relatively benign complaints that can evolve into limb threatening pathology. As many patients are unaware of their diabetic condition, none would suspect being at risk for the development of a devastating, progressive, osteolytic destruction of bone and joint, which may occur in the face of neuroarthropathy.

In fact, the vast majority of patients have never heard the term “Charcot joint” spoken. Currently, patients are uneducated about this condition, some physicians are poorly educated about this condition and many physicians who are educated about the Charcot foot have not implemented a plan for proactive identification of the patient at risk for this condition. This fact in and of itself leaves the community of patients at risk for Charcot foot in more danger for developing a limb-threatening condition such as neuropathic destruction of bone and joint.

As a community, it may be best if we join forces and develop a patient profile for those at risk for developing the Charcot foot. This would allow physicians to identify the subset of patients who may be at a higher risk for developing neuropathic joint disease. In doing this, we would be taking a large step forward in the identification, prevention and management of the condition. After all, avoidance of the condition is the most effective way of preventing threat to the limb. As the earliest identification of those patients at risk would coincidently place them on a path of general health management, our methods in addressing this potentially limb threatening and morbid condition would be greatly enhanced.

If we can agree that devising a patient profile for the Charcot foot is reasonable, the next step is determining the fundamental elements that seem to be involved in its origin. Since the precise etiology of the Charcot joint remains undeclared, there has been a necessary focus upon the contributing factors associated with neuropathic destruction of bone in general.

The quagmire of thought that evolves when encountering the neuropathic joint is often counterintuitive and has been discussed in the current literature. Consider the fact that the most common systemic condition associated with the Charcot joint is diabetes mellitus. While the disease of diabetes mellitus is quite common, the acute or chronic Charcot joint is truly rare. Where the neuropathic sensory loss is considerable in this population, it is typically bilateral and symmetrical in nature. This stocking and glove distribution is in contrast to the Charcot joint, which presents as a unilateral, asymmetric, inflammatory destruction of soft tissues and joints.

Despite the fact that the secondary manifestations of diabetes are often progressive, the destruction of the Charcot joint is in fact self-limiting. Quite frankly, it is the “burned out” Charcot joint that I see most commonly in my office. When we consider the severity of the joint destruction we often see in Charcot disease, it is often suspected to be a de novo process or one associated with trivial trauma or elective surgery, the likes of which are consistently out of proportion to the degree of joint destruction at hand. Accordingly, it remains a very difficult condition to wrap your intellect around.

My suggestion is to look at the Charcot joint much like we look at metabolic syndrome and engage patients who have a given set of characteristics in an enhanced medical workup in the name of prevention of the disease. Call it Syndrome “C” for the Charcot joint and encourage the foot and ankle physician community to be aware of it.

Developing A Charcot Patient Profile

To begin the development of the patient profile, it is prudent to first be aware of some of the most commonly associated characteristics of the disease and build a foundation from there. Given the fact that there are only a few common links that unite the population of Charcot patients, this first stage in generating a patient profile is no great leap.

To date, based upon my interpretation of what has been reported and discussed in the current literature, the Charcot patient profile should include the following list of characteristics.

* Longstanding diabetes (greater than 10 years in duration)
* Profound neuropathy. Peripheral sensory loss may be more evident than associated motor dysfunction.
* Autonomic dysfunction
* Arterial calcifications
* Uncontrolled hyperglycemia

It is my hope that the second stage in developing a patient profile for the development of the Charcot foot will include a finite set of serologic testing that will further elucidate characteristics that promote this often profound osteoclastic destruction of joints in this subset of patients.

Of all that we try to understand about the Charcot foot, despite the in-depth study and discussion of the condition, there always seem to be more questions posed than answers developed. Indeed, the Charcot foot remains one of the most perplexing conditions for the foot and ankle specialist. If we can create a collective focus on this disease and be more diligent in identifying it, I believe we can have a major positive impact on this devastating, limb-threatening disease.



Anonymoussays: November 9, 2009 at 4:06 pm

I would be interested if there is anyone out there that has already begun a standard set of serologic testing for patient's that fit the Charcot profile. Is anyone running specific serologic testing when they encounter a Charcot patient? I understand that many run a compete metabolic profile (CMP), CBC, HgbA1C and CRP in preparation for bisphosphonate therapy. My question is "Do you have specific serologic testing that you do for patient's that you feel are at risk for developing Charcot joint or have an active or Chronic Charcot joint.

Some have begun serologic testing prior to surgical intervention for more common conditions such as stress fracture repair. The suspicion is that some of these patient's may have an underlying metabolic bone disease. In response to this suspicion a serologic screening including Vitamen D, calcium, Alk Phos(bone), and collagen has been performed.

Please advise regarding your personal practice and thanks in advance for your response.

Molly

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Anonymoussays: November 21, 2009 at 12:38 am

Isn't Charcot foot due to a lack of proprioception, therefore a result of dorsal column disease?
I remember being taught that B12 deficiency can effect the dorsal columns.
One of the side effects of Metformin results in a B12 deficiency. Clinically, I have found that those patients on Meformin for several years have proprioceptive defects, while it is rare for those not on Metformin to have this deficiency.

Stanley Beekman DPM

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Anonymoussays: January 24, 2010 at 8:15 pm

Stanley,

I appreciate your comment on vitamin B-12 deficiency associated with the use of metformin and agree that anything that leads to a decrease in proprioception would increase the risk of falling.

I do not think that anyone has concluded that the Charcot foot is the result of loss of proprioception. In fact the dorsal column lesion has been simulated in animal studies that date many decades back which concluded that the dorsal column lesion alone could not account for the Charcot foot however it is an important common link to the condition just as long standing diabetes and an elevated HgbA1C are.

You comment is appreciated and I apologize for not becoming aware of your response before this time. Thank you for your insight as it is enlightening.

Molly

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