Christopher Hendrix HOB III Presentation NeuroPathic ...€¦ · (Bunion Deformity) Hysteria and Neuropathic Feet - Christopher Hendrix 13. ... molded shoes, bracing, etc ... Microsoft

NeuroPathicOsteoArthropathy

5-Year Mortality Rates

Armstrong et al. Int Wound J. 2007;Dec;4(4):286. CA = Carcinoma.PAD = Peripheral artery disease.

Hysteria and Neuropathic Feet - Christopher Hendrix

1

Learning Objectives

Note differences between sensory, motor, and autonomic neuropathy

Impact each has in towards the development of Charcot Foot

Identify 3 components of an effective management plan

William Musgrave

British Physician and Antiquary 1655 – 1721 Practiced in Exeter Writings included topics of arthritis Credited with first reference to

Neuroarthrosis

Jean-Martin CharcotBorn 1825 – Paris, France29 November 1825 – 16 August 1893

Founder of modern neurology

Salpetriere Hospital

Recognized neurological changes

Described “Pied Tabe’tique”


2

Paul Wilson Brand, MD•July 17, 1914 - July 8, 2003

•Missionary Physician in India

•Recognized the effects of loss of sensation on hands•and feet of patients with Hansens Disease

•Advanced surgical techniques

•Total Contact Casting

•“The Gift of Pain”

CHARCOT Who’s Who in this room ?

FreudBabinskiToothTouretteMarie


3

“Eichenholz Classification” of

Disease Progression

STAGE 0 - ZERO

What’s the Diagnosis ???

CHARCOT


4

Charcot Foot

Charcot FOOT


5


Disease Progression

•Stage 1 – destruction •Stage 2 – coalescence •Stage 3 – consolidation

Brodsky Classification of Disease LOCATION

Type ITarsal-Metatarsal Jt.Lesser Tarsus


6

Type IIPeri-Talar

Type IIIaAnkle – TibioTalarType IIIbPosterior OsCalcis

Type IIIaAnkle – TibioTalarType IIIbPosterior OsCalcis


7

Trepman-Brodsky Type IV and Type V

Multiple sites and forefoot


8

CHARCOT

EVERY 30 SecondsA lower limb is lost due to the effects of Diabetessomewhere in the world

-International Diabetes Foundation


9

Assessment

ADA Recommendations

“All individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions.”

American Diabetes Association: Preventive foot care in people with diabetes. Diabetes Care: 26(1) S78-S79, January, 2003.

Neurological ExamSensory Neuropathy

Semmes-Weinstein monofilament 5.07-applies 10 grams of pressure.

Detects protective sensation. Patients C/O burning, tingling, numbness

in feet.


10

Neurological ExamMotor Neuropathy Causes weakness of the intrinsic

musculature of the foot. Over-powering of extrinsic musculature. Leads to dorsal contraction of digits

(hammer toes). Causes “slapping” of the foot during gait. Creates areas of increased plantar pressure,

especially along the metatarsal heads.

Neurological ExamSensory Neuropathy Loss of Protective Threshold Loss of Vibratory Sense Loss of Proprioception Profound Anesthesia Places Patient at Risk for Injury from

Chronic Micro Repetitive Traumas w/o Rocognition

Neurological ExamAutonomic Neuropathy Disturbances in the sympathetic nervous

system. Absence of sweat production, causing dry,

scaly skin. Alters vascular perfusion, increasing risk

for Charcot Arthropathy.


11

Semmes-Weinstein Monofilament

Simple Sensory Testing

Alcohol pad – cool sensationCotton wisp – light touchSW monofilament - protective

Semmes-Weinstein Monofilament

5.07 monofilament10g force


12

Mechanical

“High Pressure Areas”

Neuropathic

Musculoskeletal ExamOsseous deformities

Bunions Hammer Toes Bony Prominences Pes Cavus/Planus

Hallux Abducto Valgus(Bunion Deformity)


13

Osseous Deformities

NEUROARTHROPATHY

SPONTANEOUS PATTERNS OF FRACTURE AND DISLOCATION WITH A PREDILECTION FOR THE MIDFOOT

SEEN ONLY WITH SENSORY NEUROPATHY

DIABETES, ETOH, HEAVY METALS, LUETIC, IDIOPATHIC

Charcot NeuroarthropathyIncidence

An acute event will only develop in the presence of neuropathy

Neuroarthropathy will not occur in ischemic feet

13% of diabetics with sensory neuropathy will develop an event

80% of events affect Lisfranc’s joint or the midtarsal joint


14

Charcot NeuropathyPathogenesis

Tarsal prominence Reversal of Arch Intrinsic Atrophy Pull of the triceps Inadequate ability to

resolve midfoot shear

CHARCOT

CHARCOT


15

The Diagnosis of Acute Charcot Neuroarthropathy

High index of suspicion!!!!

Unilateral edema Unilateral warmth Elevated ESR, alkaline

phosphatase XRays may not be

helpful if fragmentation has not yet occurred


Disease Progression

STAGE 0 - ZERO

What’s the Diagnosis ???

Treatment of Acute Charcot Neuroarthropathy

The best treatment is early recognition and immobilization in a non WB cast

The incidence of acute Charcot in the other extremity during the period of treatment is significant (25-30%)

Protect contralateral limb Patients should be

confined to a wheelchair until consolidated


16

Treatment of acute Charcot events

Elevation Rest Compression Immobilization Accomodation with

molded shoes, bracing, etc

Surgical Intervention?

WHY TREAT? The bones are soft,

fractured, and displaced

The patient is neuropathic

The pt. may be anemic, may have poor vision, poor circulation, etc.

Medical management of acute Charcot events

Jude et al.Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. (N=39)

Level I evidence

Diabetologia. 2001 Nov;44(11):2032-7


17

CharcotDeformity

Off-load with a CROW Prosthesis

Surgical Salvage/Reconstruction

Surgical Intervention

Osseous Resection Tendon Transfer Charcot Reconstruction


18

Charcot Arthropathy:“Diabetic Patient’s Worst Nightmare!”

“There is nothing we can do for you”


19

Very Unstable!

Goals of Surgery

Before & After


20

CHARCOT-Long Term Bracing AFO Brace on Shoe CROW PTB Amputation

Total Contact Casting

Have to Control Swelling


21

Recommendations…..

Final ThoughtsThorough evaluation of patientThorough evaluation of neuropathyEtiology of NeuropathySelection of Treatment ModalitiesDynamic CareProactiveProtectivePreventitive


22

Patient Cases

Patient Case


23


24


25

Documents

Christopher Hendrix HOB III Presentation NeuroPathic ...€¦ · (Bunion Deformity) Hysteria and Neuropathic Feet - Christopher Hendrix 13. ... molded shoes, bracing, etc ... Microsoft