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Is It Time For An MRI-Based Charcot Classification?

After decades of use, does the Eichenholtz classification for Charcot foot still hold up? A recent review in Swiss Medical Weekly argues that it is time for a new system.1 The authors of the review point out that Eichenholtz in 1966 described “three well defined stages,” namely the stage of development, the stage of coalescence and the stage of reconstruction and reconstitution, based on plain X-rays of 68 patients.1,2 However, the study argues that medical imaging has advanced and magnetic resonance imaging (MRI) is more sensitive than X-rays in detecting foot deformities. Indeed, the earliest, non-deforming inflammatory stage of the acute diabetic Charcot is only visible on MRI, according to the authors. They propose an MRI-based classification, composed of two severity grades (0 and 1, reflecting the absence or presence of cortical fractures) and two stages (active or inactive, reflecting the presence or absence of skeletal inflammation). I believe the Eichenholz system to be an important classification historically but it is not entirely helpful now. Over the last 20 years, I can't say that I could tell you precisely what "development, coalescence and reconstruction" actually mean clinically or radiographically. In 1997, we proposed a system in "Natural History of Charcot Neuroarthropathy" that implied "hot or not," in that the problem was either acute or "post-acute," with strategies to treat either.3 In 2011, the American Diabetes Association's Charcot Task Force modified this under the leadership of Lee Rogers, DPM, Lee Sanders, DPM, and Robert Frykberg, DPM, FACFAS.4 I believe that Chantelau and Grutzner’s proposal is really quite a logical MRI-based system that will help move us ahead, step by step.1 References 1. Chantelau EA, Grutzner G. Is the Eichenholtz classification still valid for the diabetic Charcot foot? Swiss Med Wkly. 2014;144:w13948. 2. Eichenholtz SN. Charcot joints. Charles C. Thomas, Springfield, IL, 1966. 3. Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot’s arthropathy in a diabetic foot specialty clinic. Diabet Med. 1997;14(5):357–63. 4. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011; 34(9):2123-9.
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