Charcot Arthropathy
Definition: Charcot, also known as diabetic neuropathic arthropathy is a syndrome affecting patients with peripheral neuropathy (the loss of sensation and ability to feel pain, pressure or temperature). Neuropathy causes laxity of ligaments in the feet and bone weakness which can lead to dislocations, fractures and foot deformity over time, even in the absence of trauma. Peripheral neuropathy can be caused by many conditions in addition to diabetes including chronic alcoholism, leprosy, syphilis and polio.
Symptoms: Patients often develop sudden warmth, redness, and swelling of one foot or ankle after a minor trauma. The tarsal and tarsalmetatarsal joints are most commonly affected. The involved foot usually has a collapsed arch with bony prominences that can lead to pressure ulcerations. Pain is usually mild even in the presence of significant fractures or deformities.
Diagnosis: Charcot can be staged from 0-3 based on physical exam and radiograph findings. Stage 0: Inflammatory- warmth, redness and swelling are present without abnormality seen on x-ray. Stage 1: Development- warmth, redness and swelling with fracture or dislocation on x-ray. Stage 2: Coalescence- decreased warmth, redness and swelling with signs of fracture healing/new bone formation on x-ray. Stage 3: Remodeling- no warmth, redness or swelling with chronic bony deformity on x-ray.
Nonsurgical Treatment: Early diagnosis and treatment with immediate offloading of the foot are the most important prognostic factors for achieving a good outcome. In earlier stages of the disease casting and non-weightbearing is used to offload and protect the affected foot. Gradual progression to normal weightbearing is then permitted with the use of a protective splint, orthosis, or brace. Frequent follow up is needed to monitor healing and disease progression.
Surgical Treatment: For stage 3 patients with instability, significant debilitating deformity or bony prominences that lead to chronic ulcers surgery may be indicated. Surgical interventions include open reduction and internal fixation, joint fusions, exostectomy (removal of a bony prominence), and/or osteotomies (making a cut in a bone to correct the alignment of the foot).
Recovery after surgery will depend on the procedure performed and will be thoroughly discussed before your surgery. Healing after surgery can take twice as long in the diabetic foot with longer periods of non-weightbearing required after surgery.
Diabetic Foot Ulcer
Definition: For patients with type 1 or type 2 diabetes the risk of developing a foot ulcer is 34%. Of all the non-traumatic amputations preformed in the United States each year, diabetic foot ulcers account for 2/3. Several risk factors give diabetics an increased likelihood of developing foot ulcers including neuropathy (the loss of protective sensation of pain and pressure in the foot), foot deformity and vascular disease.
Diagnosis: An ulcer can be classified by a grading and staging system. Grades 0 to 3 are based on the depth of the ulcer and involvement of tendon, capsule or bone. Stages A-D are based on the presence or absence of infection and ischemia. Wound cultures and x-ray may be used to check for the presence of infection and bone involvement. Referral to a vascular specialist may be needed to assess peripheral arterial disease and limb ischemia.
Treatment: Treatment of diabetic foot ulcers begins with debridement (trimming) of dead tissue around the ulcer site to promote healing. A dressing is applied to keep the ulcer clean and limit excess fluids. Pressure reduction on the ulcer is then accomplished with mechanical offloading including a total contact cast, cast walker, knee walker, shoe modifications or metatarsal pads depending on the size and location of the ulcer. In cases of extensive open wounds or infection the wound may need more aggressive debridement in the operating room. A wound vacuum may be placed after the procedure to increase blood flow to the wound, reduce swelling and promote the formation of granulation tissue. Other adjunct therapies are also available and can be discussed with your provider.
Preventative foot care: Prevention is key to maintaining healthy feet. Preventative measures include quitting smoking, avoiding walking barefoot (even at home), trimming toenails routinely, drying the foot well after showering, checking the feet for ulcers daily, wearing custom shoes if foot deformities are present to prevent rubbing, and changing your socks daily.
Steroid Injections
What is a steroid joint injection and what does it treat?
A steroid injection is a minimally invasive procedure using aseptic technique in which a corticosteroid (methylprednisolone or betamethasone) and local anesthetic (lidocaine and/or bupicivaine) are delivered directly into the joint to provide localized relief of inflammation and pain. Injections are effective in providing conservative management for painful joint conditions such as osteoarthritis, rheumatoid arthritis, and gout. The ankle, subtalar, and metatarsalphalangeal (MTP) joints are the most commonly injected. The relief obtained from a steroid joint injection will usually last several months. If the injection is effectively alleviates a patient’s pain and allows increased activity it can be repeated every 3 months as needed. In some cases, as the joint disease worsens the steroid injections lose efficacy and a surgical discussion may need to take place.
What does recovery look like after a steroid joint injection?
After a joint injection a band aid will be applied and you will be able to walk out of clinic on your own. You may experience increased swelling and soreness in the joint for 1-2 days after the injection and can adjust your activity accordingly. You can ice the injection site for 15 minutes every 3 hours as needed for pain relief. Heat should not be applied. Hot tubs and hot baths should be avoided for 2 days, hot showers are fine.
What are the risks of a steroid joint injection?
Steroid injections within a joint are usually well tolerated but there are possible risks to be aware of. These include: 1) a temporary increase in blood sugar, 2) temporary flare of pain and inflammation within the joint, 3) thinning of skin or soft tissue around the injection site, 4) whitening or lightening of skin around the injection site, 5) cartilage damage, 6) joint injection, 7) weakening of nearby ligaments and tendons.
