Charcot of the Calcaneus
Section snippets
Pathophysiology
The pathophysiology of Charcot calcaneus includes both mechanical and physiologic factors. The Charcot foot has autonomic neuropathy of vasoregulation leading to increased blood flow and bony resorption in affected feet [9]. Not all patients demonstrate peripheral vascular disease. Impaired sensitivity combined with traumatic events regardless of magnitude are the hallmarks of this disorder. Mechanically, the neuropathic ankle offers significantly greater biomechanical challenges because of the
Diagnosis
Charcot of the calcaneus is similar to that in other joints in that early diagnosis is imperative. The time to initial treatment is essential. Unfortunately, commonly there is a delay in recognition. The diagnosis is delayed or missed in as many as 25% of patients [12]. The clinical findings will vary depending on the stage of presentation. As noted in early stages, the swelling and skin changes can be quite striking. Distinguishing this stage from an infectious process can be challenging;
Classification
Classification of Charcot arthropathy, as with any system, is designed to suggest appropriate treatment options. Brodsky's classification describes three patterns for the Charcot foot: type 1 involves the midfoot, type 2 involves the hindfoot, and type 3A involves the ankle. Type 3B includes fracture of the calcaneus in his classification. A type 3B involves the calcaneal tuberosity. The primary problem was thought to be mechanical with joint involvement being secondary. The loss of calcaneal
Patterns of injury
Calcaneus injury occurs in three main patterns: posterior avulsion, joint depression, or anterior process fracture. Each has a different natural history. El-Khoury and Kathol [18] described four patients with avulsion fracture of the posterior tubercle of the calcaneus [19]. This finding was unusual in that the patients had no or minimal prior trauma, and all were diabetics with neuropathy. Biehl and coauthors [19] in 1993 presented cases of tuberosity fractures in neuropathic diabetics. This
Management
The goals of treatment of Charcot arthropathy are to decrease the inflammation, encourage bone healing, and prevent further deformity [21]. Prolonged immobilization via total contact casting and bracing are used commonly to stabilize the foot in an as anatomic position as possible while reducing edema until the foot reaches the resolution phase [22]. When a patient has deformity of the foot or ankle that is severe to the point at which management with a custom brace or footwear is not feasible,
Debridement and exostectomy
Surgical treatment with ulcers present has been attempted with dismal results. Thompson and Clohisy performed surgery on patients with open plantar ulcerations. These procedures resulted in a 25% incidence of deep infections. This is compared with a zero incidence of deep infections when the procedure was performed on a patient with intact skin [15]. As the deformities of the calcaneus increase, total contact casting becomes less of a viable option.
Farber and coauthors [8] realized the
Arthrodesis
When total contact casting, debridement, and exostectomy fail, the surgeon must consider arthrodesis. Arthrodesis historically has been considered a salvage procedure. Thompson and Clohisy [26] looked at deformity owing to Charcot arthropathy in the region of the ankle or tarsal bones. Each of the five extremities that had deformity in the region of the ankle and hindfoot had substantial loss of bone that resulted in instability and severe malalignment. They found that the frequency of failed
Summary
Charcot of the calcaneus, although not as prolific as midfoot deformation, still results in significant morbidity. Current treatment centers on methods proven effective for other joints in the foot. Most neuropathic conditions of the calcaneus can be managed reasonably nonoperatively. In cases of severe deformity or ulceration, surgical management may be the more conservative approach. The surgical principles of proper soft tissue balancing and handling are critical. As the diabetic population
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Biomechanical behavior of bone. Fractures in Charcot neuroarthropathy
2022, The Essentials of Charcot Neuroarthropathy: Biomechanics, Pathophysiology, and MRI FindingsSalvage Arthrodesis for Charcot Arthropathy
2012, Clinics in Podiatric Medicine and SurgeryCitation Excerpt :Charcot osteoarthropathy, also known as neuropathic osteoarthropathy, is a syndrome that results in the destruction of single or multiple joints leading to permanent joint deformity.1 Joint changes as a result of neuropathic change were first described by Musgrave in 1703.1 Most commonly credited with modern day definition of this condition is Jean Marie Charcot2 for his 1868 analysis of neuropathic osteoarthropathy in patients with tabes dorsalis.
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2024, Child's Nervous SystemThree-phase bone scintigraphy for diagnosis of Charcot neuropathic osteoarthropathy in the diabetic foot – does quantitative data improve diagnostic value?
2017, Clinical Physiology and Functional ImagingDeveloping an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: A systematic review
2013, Journal of Foot and Ankle ResearchSurgical management of charcot neuroarthropathy of the foot and ankle: A systematic review
2012, Foot and Ankle International