68 years old diabetic male comes to clinic with pain in the left foot and difficulty walking since two months. He also have HTN and Dyslipidemia. But all the three conditions are fairly controlled. He is a non smoker and non alcoholic. His uric acid levels are 7.1, HbA1c 7.1 %, ESR 28, TSH 2.8. X ray foot was taken. Diagnosis and management based on brief history & x ray findings ?

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Charcot Arthropathy: Also known as Charcot Foot & Ankle is a Syndrome (in patients who have neuropathy or loss of sensation) which includes fracture of bones & dislocation of joints occurring with minimum or no known trauma.It is much more likely to be a sequalae of neuropathy than of infection.Many patients donot have pain.However, patients of Charcot arthropathy who have pre existing neuropathy, may present with pain due to pre existing neuropathy;pain is usually absent in such an arthropathy. Differential Diagnosis: Since the given patient has pain Left foot with difficulty in walking & X-ray lateral view shows disorganisation & dislocation of joints ,osteopenia,osteosclerosis ,cystic change of bones.Rocker-Bottom deformity is seen.There is an hyperluscent area below calcaneus which could be gas.Absence of changes of gout. So in a diabetic patient, the following conditions (with or without neuropathy)could be thought: 1.Foot ulcer/abscess. 2.Osteomyelitis 3.Nervous System Damage: leading to: a)Directly contributing to foot disorders. b)Cellulitis, soft tissue infections. C)Neuropathy: sensory ,motor or autonomic. 4.Infected Neuropathic Osteoarthropathy: a)Chronic Neuropathic Osteoarthropathy predisposes to foot ulcer formation. b)Rocker- Bottom deformity. C)Osteomyelitis cuboid bone irrespective of neuropathy. About 50% of patients of neuropathic osteoarthropathy when present with pain,no bony changes are seen initially, but later on when such changes appear on x- ray, in the Charcot Foot/Ankle ,pain is usually not present. ln absence of an ulcer, a patient is unlikely to have osteomyelitis.ESR>70 mm/hr, is highly specific for osteomyelitis. INVESTIGATIONS & their Indications: 1.X-ray left foot AP view 2.Bone scan in mild suspicion of infection. 3.MRI in moderate to severe suspicion of infection to look for a sinus tract,an ulcer,abscess ,sub chondral cysts or bone marrow odema (to rule out osteomyelitis). MRl with contrast is done in diabetic patients to distinguish viable from non viable tissue essentially required during debridement/ amputation of diabetic foot. 4.Tissue Biopsy to confirm Diagnosis & settle microbial issues before operative treatment.
Thanks Dr. Verma.
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diabetic charcoat foot,there is fusion of cuboid,cuniforms and metatarsal,metatarsophalangeal angel is disturbed,calcaneal angel is reduced,it is due to diabetic neuropathy, repeated trauma,fractures are not taken care of due to loss of sensation..mangment ll be proper immobilization,braces,customized shoes,and in some cases surgery,in some cases osteomylitis may complicate so case selective amputation may have to be done
Clinically, this elderly male has pooly controlled diabetes (HBA1C=7.1%),feature of Metabolic Syndrome (Hypertension, Dyslipidemia, Hyperuricemia & Raised ESR). Our esteemed Doctors have labelled bony changes in x-ray left foot as Charcot foot .ln my next post,I will attempt to differentiate it from other similar conditions in the setting of diabetes .
Thank you.
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REFERENCE: 1.Jonathan C. Baker etal: Diabetic Musculoskeletal Complications & Their Mimics. Radiographics 2012; 32:1959-1974
first gett MRI of foot with CT cuts, see if there is any marrow edema or not
Sir y MRI?? What r u suspecting?? It's clear neuropathic joint..
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? charcot foot ??gouty arthritis
? charcot foot..
is there disalignment in lower end of tibia and calcaneium ?osteoporosis is present-need ankle brace with o.porotic tt with physio
Neuropathic joint midtarsal joints Foot wear modification Treat hyperuricemia
In diabetic neuropathic joint is most common in foot and ankle joints..
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