Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK. So I'm presenting on acute Charcot neuroarthropathy, I'll make it as pain free as possible. Um So this is something that you probably will encounter in real life, whether or not you'll encounter in the exam. I've got no idea. But um we'll just do a whistle stop tour through. So firstly, just make sure you've got some kind of definition for the exam. Uh It's essentially a progressively destructive process. Um It's sometimes triggered by microtrauma. It can sometimes be due to, you know, the neuroischemic aspect of a diabetic foot. Um e essentially, if it's not halted early, it can result in severe deformity of the foot. Um One of the most important things I want to stress here is that we differentiate between acute charco neuropathy and burnt out Charcot arthropathy with residual deformity. It's really important because when you're seeing these patients, um who've got a history of Charcot, it can be really misleading when you say somebody's got Charcot foot, uh you need to know whether they need to be immobilized as a matter of urgency in order to prevent progressive deformity or whether you need to be dealing with a potential risk of ulceration. So just remember that someone can have an acute Charcot neuroarthropathy or they can have a burnt out Charcot arthropathy. It's equally important to know whether someone's got a history of um, Charcot in the past as it um has a so de de determining in fact on your interpretation of their x-. So the relevance is that if it's caught early enough, it can be halted, which is why we explain to patients so much that they have to check their feet every single day. Um If it doesn't get caught early, as we mentioned, it can cause progressive deformity. This can essentially lead to ulceration and infection and then amputation. There's a massive uh correlation between uh major amputation and reduction in life expectancy. Essentially, we just need to educate everybody that um this requires a multidisciplinary approach. Uh As long as everyone's got a basic understanding of it, we can save so many more limbs and so many more lives. So essentially, we just need to stop the repetitive process. There might be uh a primary injury, it could be something as subtle as perhaps tripping over a curb or stabbing your toe. Um and it just causes this micro trauma and then you get this uncontrolled inflammation. And if you're not immobilized, and the reason why you wouldn't be immobilized is because a diabetic might not feel the pain. So your eye might hop um on the other foot. If we, you know, injure one side, we might rest it for a little while, but a diabetic will just continue to walk on this foot, which might, you know, otherwise be inflamed, swollen red. Um And, and unless we can halt it at one of the early stages, we'll just get a progressive deformity, the importance of um halting this process early. I just want to highlight this to you. I was teaching the trainees in my region. So I work in the northwest of England and they were all pretty shocked by this figure. But all the literature suggests that between 50 70% of patients will die within five years of a major amputation. So that's 5 to 7 out of 10 people. It's a massive um burden, as you can imagine. And a lot of these ulcerations causing infection ultimately come back to an untreated or poorly treated Charcot. So there's lots of guidelines which you can quote um nice guidelines. Um They cover Charcot diabetic foot infection and diabetic foot ulcers. They're all based on the multidisciplinary team approach and these guidelines that were published in 2016 e essentially again, stressing the multidisciplinary approach, these guidelines, I think they include everybody except the vascular team. Now, verity is working really, really hard. So Miss Carol um to get the vascular to uh come on board with some updated guidelines, essentially managing ulceration, but also through to charcoal. Just something to be aware of. You can download these so acute Charcot arthropathy presents quite innocuously. People can say, oh, I couldn't get my foot into my normal shoe. My foot's a bit more swollen than the usual unless they've got a history of previous Charcot or diabetics in the family who have experienced it. They might not actually know what's going on and they might, um, just present with this slightly red inflamed foot. So you've got to think about the differential diagnosis. So like with anybody, anybody can have trauma. So think the patient could just simply have a stress fracture or a traumatic fracture with a background of incidental diabetes, especially if their diabetes is well controlled and they still have some sensation. It might just be a cellulitis, you know, they're prone to infection. So it could just be related to that. Um, is it a deep infection? Could it be osteomyelitis? Um But always have at the forefront of your mind in a diabetic or anybody with um peripheral neuropathy, could this be an acute Charcot neuroarthropathy? So only 25% report some kind of history of injury. But you know, how many times do we stub our toe, you know, throughout a week and just don't even think about it. So I'm not surprised that a lot of diabetics might not remember. Um So they might not realize that they don't, that they have a neuropathy. Uh I certainly know that when I've admitted patients with raging foot infections and I asked them. Have you got any altered sensation? They also know my sensation is perfect. You know, I can feel everything and you actually find they've got a really dense neuropathy. And as we talked about, it's not just diabetes, that's always what comes to the forefront of our minds, but think about other things that can cause neuropathy such as alcohol induced neuropathy, spina bifida and even chemotherapy. So when you're examining the patients, you might just see a swollen red foot and ankle. And I certainly hope that that's all you see. If you're seeing the patient for the first time with deformity or even worse crepitus or literally a feeling of a bag of bones, then it's too late and they're probably well on their way to losing their leg. As you know, we need to check the pulses in everybody. Normally. Um vascularity is intact in patients with acute Charcot episodes. As it's considered a hyperemic response. They can have a reduced vascularity, but they have normally got sufficient blood supply, getting down to the foot. Um They might actually experience pain. So if you've had any dealings with diabetics, you'll probably find that um they get this really intense shooting pain, um which is neuropathic pain and they can feel that despite perhaps not being able to feel for a protective response. So, mainstay of examination, uh I would say it's gut instinct. If you examine enough diabetics, you'll just be able to see that it's Charcot, uh you can look for objective findings such as um alteration in temperature. So 1 ft might be slightly warmer than the other. Um You can't always rely on it, but it, it, it can be a good finding. You've got to remember some of these patients might have amputations, so they might not have a foot on the other side to compare to. Um So you've just got to use your judgment with that. Um I always get weight bearing radiographs on my patients. Um You can get an MRI scan. Uh I II work in a major trauma center and although I can get CT S at the drop of a hat, MRI si can't get them that quickly. Um And we're looking at the very, very early phases uh for diagnosis, perhaps if you're admitting the patient and you want to differentiate between infection and Charcot, then if you can admit the patient get an MRI that might be helpful. And there's occasional cases where you really can't work out what on earth is going on and the patient said do end up going to theater for a biopsy. Bone scans alone are really not helpful. Um They essentially just light up everywhere you can add in um technician or Indian label scans, which you know, they're a little bit helpful. But I mean, how often do we use them and how much access do we have to them, especially in district general hospitals and they're not particularly specific, they're expensive. So essentially, it's just clinical examination and good clinical judgment which you need to rely on. So, as I mentioned, we can use an MRI scan and that might just show some edema particularly in the early phases. And you'll get a classic picture. The musculoskeletal radiologists are fantastic at being able to distinguish between an Osteomyelitis perhaps um just an injury or an acute Charcot phase so early on, um I mean, this is quite a, a delayed on um x-ray here, but with a weight bearing X ray, if you're catching Charcot early, uh you might not be able to see the sort of fluffiness that you get surrounding the destroyed joints. If they've got a history of Charcot, because you'll have a lot of um callus from the previous healing, you might be able to see a soft tissue swelling, you know, with a shadow and you get um changes in the bone density. So remember these five Ds, um these are important for the exam. So when you've got an established appearance, then you'll get this destruction, then you get dislocation of the joints, you get debris disorganization, I call that sort of the fluffiness sort of cotton wool appearance surrounding the the joints and then you get a a sclerosis. So you get these thickened areas of bone. So there are classifications, you're not supposed to be asked classifications in the exam, but occasionally you do get asked them and if you can quote them. Um the examiners like it. Um This is the basic breakdown of the Brodsky classification showing that the majority of um acute shaker attacks are in the midfoot here in the List Frank region. So if in doubt, you know, that's what, what you'd be guessing for. Um You can work further back towards the hind foot and uh you know, you're getting much, much smaller presented to people affected, you can break this down further. You do not need to remember this. This is all of a or bullets. Um But just so you can realize that it can go as far as just affecting the Calcaneal tuberosity or it can involve a combination of areas that would be a type four. and then a type five which I rarely see, but I have seen it in the first MTP J once or twice and it just happens within the forefoot itself. So we've got Eicholtz staging, which is essentially going from the acute phase of fragmentation, which as it's developing, which is where you want to catch it and stabilize it through coalescence, which is what I call the settling phase and then consolidation, which is reconstitution and restitution. So, an additional part of the classification was added on um which was zero and this is just joint edema. You won't see it. This is your gut instinct when you're seeing this red hot, painful foot that won't fit into your normal shoes, you just have to have a high index of suspicion. And the only way you can really tell this objectively is via a bone scan or an MRI when you, oh, sorry, I'll get to go back when you start getting into your, your phase one of econ, you're getting joint fragmentation, the foot's really red hot and swollen and then providing the patient has been sufficiently immobilized. You'll get a reduction in the edema and swelling and this is the coalescent settling phase and through to consolidation. So you lose the fluffiness, the cotton wall appearance around the joints. You get resolution of the redness, swelling and temperature. Yeah. So this is just a comparison view. You can look at this in your own time. So treatment aims, no, they're largely non surgical. Uh What we want to do is a aim to avoid putting these patients through surgery if possible because they're massively high risk with their um end stage um di diabetic um disease. Uh We want to guide the patients through the stages. We want to stabilize them early, minimize further deformity, um prevent any ulceration. And then basically, it minimize the impact on the patient. They don't want to be coming to appointments, you know, forever. They don't want to be going through surgeries, they don't want postoperative complications. We just need to get them stabilized and able to function and look after themselves at home. So this is uh just a uh essentially a little schematic to show you that non removable knee high devices are, you know, the gold standard of treatment, that's essentially a plaster cast or a total contact cast. Not all units have the capability of putting on total contact casts. And certainly at the weekend, you haven't necessarily got specialist plaster technicians in. So you can use walking boots. Again, they're not brilliant. The seams can cause ulceration. Um due to the rubbing, there are specific diabetic walker boots that you can consider. Um And the worst scenario would be letting the patients wear their own footwear, but essentially, it's patient choice. So it's always gotta be down to a shared decision making. You can't force patients to go into plaster casts or go into boots. Um You just got to make sure your documentation is really clear if you decide to go with a non gold standard option. So this is total contact casting and essentially it was developed um back in the 19 thirties to deal with leprosy. Um It's considered the gold standard for unloading foot ulcers and acute sharp. When you have arthropathy, you can, you can have this type of cast which can include the toes or you can have a fish mouth opening. Some patients who are claustrophobic and it is a genuine thing. Um They are better with their toes exposed. Essentially, what it's doing is it's optimizing the mechanical environment. Evening out the plantar pressures and surprisingly 95% of patients don't deform any further once you've started the TCC protocol. However, the downside is that it's an art form. Not every pla tech is trained in how to put them on and it can take between 30 60 minutes per application. So this is just a paper, um, which will just demonstrate exactly how much, um, pressure it takes off. What it does is it, um, distributes the weight bearing, load up the size of the plaster cast and just evenly distributes a small amount of force through the plantar aspect of the foot, allowing that foot to settle. There are contraindications to total contact casting. So if somebody had a coexistent deep tissue infection or ulceration with exposed tendon joint or bone, um and they perhaps had lots of purulent discharge, then total contact casting would be out because you'd be constantly getting it wet. It would be structurally non viable. Arterial insufficiency is another one. providing you've got enough arterial supply down to the foot, it can be slightly reduced, but they need to have enough. Um, patients can refuse on the basis of claustrophobia or patient choice. And you might want to think about other contraindications such as patient body habitus. If they're severely obese, it can be really difficult to put them on. If they've got fragile skin, they might be prone to getting complications of um skin sores. Um fluctuating edema might mean that the cal might be up and down becoming too loose causing pressure sores. Um, and the patient just might not be able to comply with it. I've had a couple of these total contact casts put on myself during, um, courses and they are incredibly difficult to mobilize in. I've only ever had one put on 1 ft. But, you know, sometimes patients can get bilateral acute Charcot. Can you imagine walking around in two? It's bad enough if you would think about wearing removable boots. But um two total contact casts, I think I'd be on my bum for the rest of the um treatment. Ok. So the initial management is initially offloading, as we've said, if you can't offload them, then you might consider admitting them and some diabetic wards will admit them over the weekend because it's the safest option for them. But you've got to remember to include the MDT and this is a key point for the exam. If you get asked about management diabetic foot, it's multidisciplinary team involvement. That's the key. So if you've got a high index of suspicion, you've got early stages, you're awaiting diagnosis, the patient's refusing to be admitted, it's out of hours. Um then what you might do is put the patient in a diabetic walker boot. If you've got one, if you've just got a black boot, just put them in a black boot. But you need to refer them immediately to diabetic for MDT, make sure they're uh screened and, and seen as soon as possible. So once they've been seen by the MDT, they'll be put, well, once the diagnosis has been confirmed, they'll be put into a total contact cast. Um, they'll initially have weekly changes until the swelling settles. Um, at that point they'll switch to fortnightly changes, then they'll continue with this and it'll be months rather than weeks, it can take between six and nine months for a Charcot to settle sometimes longer. And if you rush it, it's a bit like being out of sport and then returning too early, you'll end up with a recurrent flare up. You need to monitor foot temperature every time you have the cast change. And that's one of the indicators on whether they're settling and once they have settled, then they need to go back into custom footwear. If they had it already, it's important to note that their foot shape has probably changed even to a minor degree, which is going to put them at risk of ulceration if they go back into the old footwear. Therefore, they need a new urgent orthotic referral for consideration of as a bare minimum, total contact insoles and review of their footwear. They might need custom shoes, they might need braces. So that's why we involve our orthotist as part of our MDT. So there are surgical treatments early. It's rarely indicated. It can cause major problems if you operate on these early because of the severe amount of um inflammation. But if you're treating a patient with the total contact casting and they're still progressing, it's very difficult to know whether they're completely compliant with it. And you might want to think about um some form of immobilization that is even more robust, such as a circular frame, possibly a hindfoot nail. Um You, you want to plan for the burnt out Charcots with treatment that's going to stop them from recurrently ulcerating. So this is just a picture just to demonstrate one of the types of treatment for a burned out chakra. So you might just do a simple exostectomy, which would be a shaving off of that plantar exostosis from the rocker bottom deformity. And one of the more rigid ways of er healing this would be by this er beam fixation as you can see the picture on the right. So this is just a case example, just cos I find it easier to um remember these things that I've got something to base on and this is one of my patients. She's a 40 year old lady. She's a single mother and she's well known to the diabetic foot service with multiple um ulcerations. Previously, she's type one diabetic. She's lost the sight in her left eye previously, had a couple of toe amputations and she's actually had a, a baloney amputation with a prosthesis. Uh Anyway, she was at the hospital at one of her routine appointments when she had a hypoglycemic episode in the cafe and she collapsed and she sustained a traumatic angle fracture, as you can see in the pictures here and she had an ulceration on the hallux of the same side. So this isn't her, but this is one of the treatment options that we've got for early. So this isn't a Charcot. I want to make that really clear. She had a traumatic ankle fracture with a background of unstable diabetes. So it puts her at significantly high risk of triggering a Charcot process. So we call this pro tibial stabilization. So essentially, it's a big fat locking plate on the lateral side and then we whack a load of screws through the fibula into the tibia. When I do this, I usually use them in a locking mode, the other option. And this again, this isn't a picture of her. This is just for demonstration purposes. This is a total contact cast. So you can treat acute fractures in patients with diabetes. Um The same way as you would do an acute Charcot. So that's with total contact casting. And again, you know, you've seen patients with ankle fractures, we're constantly checking. Has the swelling gone down enough to operate. It's the same in a diabetic, they get ankle fractures, they're swollen, you put them in a cast, the swelling settles. So the only difference is they have the risk of ulceration in that cast because they can't feel it. So you've got to get them back for regular changes. Whilst that swelling settles with this poor patient. She um didn't tend to like attending her appointments because she told us that every time she attended hospital we gave her bad news, which was true. Um So she missed a few. Um I just want to highlight this QR code. So this is an evidence based introduction to Charcot arthropathy. So it's something that you might want to use one of your exam resources. So we initially treated this patient with a total contact casting. Um partly because uh of the ulceration on that side. So it would increase risk of infection if we introduced metalwork. However, as I stated, she didn't like attending appointments. And so when she did finally attend, um she had dislocated, she triggered a Charcot response. Uh she completely dislocated her ankle as you can see. And unfortunately, what that caused was skin issues. So now we've got a complicated situation of a patient with a persistent first mtp ulcer. On long term antibiotic suppression. She had poor vascularity. She had just about enough to get to um warrant surgery and warrant keeping that limb. Um She had a bologna amputation on the other side. Um relative non compliance because she hates coming to her appointments and you know, she's a single mother with young Children to care for. So what she ended up having was a hind foot nail uh in order to just stabilize it and the reason why we did this was to allow her to bear some weight. Um So this story didn't have a very good outcome. She then didn't attend any of her appointment. She got infected and she's now lost that leg. So her risk of death within the next few years is incredibly high, which is really very sad. So I want to just highlight again, this is the impact of major amputations. So 10% die before leaving hospital, 50% get contralat problems within three years and 50 to 75% die within five years of that major amputation. So take home message is that a red hot swollen foot is Charcot or acute Charcot in your arthropathy un until proven otherwise. And that's it. Thank you very much for your attention.