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Osteologie 2014; 23(02): 107-116
DOI: 10.1055/s-0037-1620046
Osteoporose und Diabetes mellitus
Schattauer GmbH

Behandlungsstrategien bei Charcot-Osteoarthropathie

Therapeutic approaches to neuropathic osteoarthropathy
S. Rammelt
1   UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden
,
H. Zwipp
1   UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden
,
W. Schneiders
1   UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden
› Author Affiliations
Further Information

Publication History

eingereicht: 18 January 2014

angenommen: 04 February 2014

Publication Date:
02 January 2018 (online)

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Zusammenfassung

Die neuropathische Osteoarthropathie („Charcot-Fuß”) ist eine schwere pathologische Alteration von Knochen, Gelenken und Weichteilen an Fuß und Sprunggelenk. Die Genese der Erkrankung ist multifaktoriell und noch nicht vollständig aufgeklärt. Ein entscheidender pathogenetischer Faktor ist der Verlust der Schutzsensibilität des Fußes; auslösend ist ein vom Patienten nicht immer wahrgenommenes, mitunter repetitives Trauma. Die frühe Phase der Erkrankung ist von einer entzündlichen Veränderung gekennzeichnet, die über proinflammatorische Zytokine vermittelt wird und von einer akuten Infektion beim diabetischen Fußsyndrom abgegrenzt werden muss. Der Diabetes mellitus ist die weitaus häufigste Ursache neuropathischer Veränderungen am Fuß, jedoch kann das Vollbild eines Charcot-Fußes bei Neuropathien jeder Genese und auch idiopathisch auftreten. Das Behandlungsziel beim Charcot- Fuß ist ein plantigrader, stabiler, infektfreier Fuß ohne Ulzeration und mit sicherer Gehfähigkeit in entsprechend angepasstem Schuhwerk. Aufgrund der unterschiedlichen Genese, des vielgestaltigen Krankheitsbildes und fehlender vergleichender oder gar randomisierter Studien gibt es keine höhergradige Evidenz zur Therapie. In vielen Fällen ist die konsequente Entlastung im Kontaktcast die Therapie der Wahl, um eine Konsolidierung der Knochen und Weichteile zu erzielen. Die Indikation zur operativen Stabilisierung ist gegeben bei hochgradiger Instabilität und Deformität, drohender Hautperforation durch knöcherne Prominenzen, therapierefraktären Ulzerationen und der Unmöglichkeit der orthopädischen Schuhversorgung. Zur Anwendung kommen stabile Arthrodeseverfahren, während konventionelle Osteosynthesen zwangsläufig zum Implantatversagen führen. Aufgrund des häufigen Versagens der konservativen Therapie insbesondere bei Befall des oberen Sprunggelenks wird die Indikation zur frühzeitigen Stabilisierung zunehmend großzügiger gestellt, um den Krankheits verlauf abzukürzen. Prolongierte Verläufe mit schwerwiegenden Komplikationen resultieren nach wie vor aus einer mangelnden Kenntnis des Krankheitsbildes mit verzögerter Diagnosestellung und inadäquater Therapie.

Summary

Neuropathic osteoarthropathy (“Charcot foot”) is a condition affecting the bones, joints, and soft tissues of the foot and ankle, and is characterized by inflammation in the earliest phase. The pathogenesis is multifactorial and the exact mechanisms remain to be elucidated. A crucial pathogenic factor is loss of protective sensibility of the foot and the disease is triggered by a single or repetitive trauma that may or may not be perceived by the patient. The early phase is characterized by inflammatory changes that are mediated by proinflammatory cytokines and have to be distinguished from an acute infection in a diabetic foot. Diabetes is the most frequent cause of neuropathic changes at the foot and ankle but the full clinical picture of a Charcot foot can be observed with neuropathies of all types and can even be idiopathic. The main treatment goal in Charcot foot is a plantigrade, stable foot that is free of infection and ulceration and allows the patient to walk with an orthopaedic shoe. Because of the different etiologies, the various manifestations and the lack of controlled and randomized clinical trials there is no high level of evidence for the best therapeutic approach. In a sizeable number of cases consequent offloading in a total contact cast is the treatment of choice to achieve bony and soft tissue consolidation. Surgical stabilization is indicated in cases of gross instability and deformity, threatening skin perforation by protruding bony prominences, recalcitrant ulcers or cases refractory to offloading and immobilization. Internal fixation consists of stable fusions while standard osteosynthesis will inevitably lead to implant failure. Given the common failures of nonsurgical treatment especially in neuropathic osteoarthropathy of the ankle early stabilization is increasingly favoured in order to shorten the course of the disease. Prolonged courses with severe complications are regularly seen with a lack of awareness, delayed diagnosis and inadequate treatment.

Schlüsselwörter

Neurogene Osteoarthropathie - Charcot-Fuß - Entlastung - Osteosynthese - Arthrodese

Keywords

Neuropathic osteoarthropathy - Charcot foot - offloading - internal fixation - fusion
 

  • Literatur

  • 1 Abate M, Schiavone C, Pelotti P, Salini V. Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 2010; 23 (04) 997-1003.
    CrossrefPubMedGoogle Scholar
  • 2 Armstrong DG, Lavery LA, Liswood PJ. et al. Infrared dermal thermometry for the high-risk diabetic foot. Phys Ther 1997; 77 (02) 169-175. discussion 76–77..
    CrossrefPubMedGoogle Scholar
  • 3 Armstrong DG, Nguyen HC, Lavery LA. et al. Offloading the diabetic foot wound: a randomized clinical trial. Diabetes Care 2001; 24 (06) 1019-1022.
    CrossrefPubMedGoogle Scholar
  • 4 Asbury AK. Understanding diabetic neuropathy. N Engl J Med 1988; 319 (09) 577-578.
    CrossrefPubMedGoogle Scholar
  • 5 Assal M, Stern R. Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg Am 2009; 91 (04) 812-820.
    CrossrefPubMedGoogle Scholar
  • 6 Baumhauer JF, O’Keefe RJ, Schon LC, Pinzur MS. Cytokine-induced osteoclastic bone resorption in charcot arthropathy: an immunohistochemical study. Foot Ankle Int 2006; 27 (10) 797-800.
    CrossrefPubMedGoogle Scholar
  • 7 Birke JA, Sims DS. Plantar sensory threshold in the ulcerative foot. Lepr Rev 1986; 57 (03) 261-267.
    PubMedGoogle Scholar
  • 8 Catanzariti AR, Mendicino R, Haverstock B. Ostectomy for diabetic neuroarthropathy involving the midfoot. J Foot Ankle Surg 2000; 39 (05) 291-300.
    CrossrefPubMedGoogle Scholar
  • 9 Chantelau E, Onvlee GJ. Charcot foot in diabetes: farewell to the neurotrophic theory. Horm Metab Res 2006; 38 (06) 361-367.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Chantelau E, Richter A, Schmidt-Grigoriadis P, Scherbaum WA. The diabetic charcot foot: MRI discloses bone stress injury as trigger mechanism of neuroarthropathy. Exp Clin Endocrinol Diabetes 2006; 114 (03) 118-123.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Charcot JM. Sur quelques arthropathies qui paraissent dependre d’une lesion du cerveau ou de la moelle epiniere. Physiol Norm Pathol 1868; 01: 161-178.
    Google Scholar
  • 12 Connolly JF, Csencsitz TA. Limb threatening neuropathic complications from ankle fractures in patients with diabetes. Clin Orthop Relat Res 1998; 348: 212-219.
    Google Scholar
  • 13 Dayer R, Assal M. Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: a prospective cohort study. J Bone Joint Surg Br 2009; 91 (04) 487-493.
    CrossrefPubMedGoogle Scholar
  • 14 de Souza LJ. Charcot arthropathy and immobilization in a weight-bearing total contact cast. J Bone Joint Surg Am 2008; 90 (04) 754-759.
    CrossrefPubMedGoogle Scholar
  • 15 Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse. Foot Ankle Int 1996; 17 (06) 325-330.
    CrossrefPubMedGoogle Scholar
  • 16 Eichenholtz SN. Charcot joints. Springfield, IL: Charles C. Thomas; 1966
    Google Scholar
  • 17 Fabrin J, Larsen K, Holstein PE. Long-term followup in diabetic Charcot feet with spontaneous onset. Diabetes Care 2000; 23 (06) 796-800.
    CrossrefPubMedGoogle Scholar
  • 18 Fleischli JE, Anderson RB, Davis WH. Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int 1999; 20 (02) 80-85.
    CrossrefPubMedGoogle Scholar
  • 19 Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int 2013; 34 (11) 1541-1547.
    CrossrefPubMedGoogle Scholar
  • 20 Hamann C, Kirschner S, Gunther KP, Hofbauer LC. Bone, sweet bone - osteoporotic fractures in diabetes mellitus. Nat Rev Endocrinol 2012; 08 (05) 297-305.
    CrossrefPubMedGoogle Scholar
  • 21 Hastings MK, Johnson JE, Strube MJ. et al. Progression of foot deformity in Charcot neuropathic osteoarthropathy. J Bone Joint Surg Am 2013; 95 (13) 1206-1213.
    CrossrefPubMedGoogle Scholar
  • 22 Hedlund LJ, Maki DD, Griffiths HJ. Calcaneal fractures in diabetic patients. J Diabetes Complications 1998; 12 (02) 81-87.
    CrossrefPubMedGoogle Scholar
  • 23 Herbst SA, Jones KB, Saltzman CL. Pattern of diabetic neuropathic arthropathy associated with the peripheral bone mineral density. J Bone Joint Surg Br 2004; 86 (03) 378-383.
    CrossrefPubMedGoogle Scholar
  • 24 Hofbauer LC, Schoppet M. Clinical implications of the osteoprotegerin/RANKL/RANK system for bone and vascular diseases. JAMA 2004; 292 (04) 490-495.
    CrossrefPubMedGoogle Scholar
  • 25 Holmes Jr. GB, Hill N. Fractures and dislocations of the foot and ankle in diabetics associated with Charcot joint changes. Foot Ankle Int 1994; 15 (04) 182-185.
    CrossrefPubMedGoogle Scholar
  • 26 Hopfner S, Krolak C, Kessler S, Tiling R. Präoperative Bildgebung bei diabetisch-neuropathischer Osteoarthropathie: Ist der zusatzliche Einsatz von (18)F-FDGPET sinnvoll?. Nuklearmedizin 2006; 45 (01) 15-20.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Illgner U, Podella M, Rummler M. et al. Rekonstruktive Chirurgie beim Charcot-Fuß: 5-Jahres- Langzeitoutcome. Orthopäde 2009; 38 (12) 1180-1186.
    CrossrefPubMedGoogle Scholar
  • 28 Jeffcoate WJ, Game F, Cavanagh PR. The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet 2005; 366 (9502): 2058-2061.
    CrossrefPubMedGoogle Scholar
  • 29 Johnson JE. Operative treatment of neuropathic arthropathy of the foot and ankle. J Bone Joint Surg [Am] 1998; 80: 1700-1709.
    CrossrefGoogle Scholar
  • 30 Kiuru MJ, Pihlajamaki HK, Ahovuo JA. Bone stress injuries. Acta Radiol 2004; 45 (03) 317-326.
    CrossrefPubMedGoogle Scholar
  • 31 Klenerman L, Laing P. Operative Therapie des diabetischen Fußes. In: Wülker N, Stephens M, Cracciolo A. Hrsg. Operatinsatlas Fuß und Sprunggelenk. Stuttgart: Ferdinand Enke; 1998: 383-390.
    Google Scholar
  • 32 Klenerman L, McCabe C, Cogley D. et al. Screening for patients at risk of diabetic foot ulceration in a general diabetic outpatient clinic. Diabet Med 1996; 13 (06) 561-563.
    CrossrefPubMedGoogle Scholar
  • 33 Koller A, Hafkemeyer U, Fiedler R, Wetz HH. Rekonstruktive Fußchirurgie bei diabetisch-neuropathischer Osteoarthropathie. Orthopäde 2004; 33 (09) 983-991.
    PubMedGoogle Scholar
  • 34 Levin ME. Diabetic foot ulcers: pathogenesis and management. J ET Nurs 1993; 20 (05) 191-198.
    PubMedGoogle Scholar
  • 35 Lin SS, Lee TH, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-Achilles lengthening and total contact casting. Orthopedics 1996; 19 (05) 465-475.
    PubMedGoogle Scholar
  • 36 Mabilleau G, Edmonds ME. Role of neuropathy on fracture healing in Charcot neuro-osteoarthropathy. J Musculoskelet Neuronal Interact 2010; 10 (01) 84-91.
    PubMedGoogle Scholar
  • 37 McGarvey WC, Trevino SG, Baxter DE. et al. Tibiotalocalcaneal arthrodesis: anatomic and technical considerations. Foot Ankle Int 1998; 19 (06) 363-369.
    CrossrefPubMedGoogle Scholar
  • 38 Mittlmeier T, Klaue K, Haar P, Beck M. Charcot- Fuß. Eine Standortbestimmung und Perspektiven. Unfallchirurg 2008; 111 (04) 218-231.
    CrossrefPubMedGoogle Scholar
  • 39 Mittlmeier T, Klaue K, Haar P, Beck M. Should one consider primary surgical reconstruction in charcot arthropathy of the feet?. Clin Orthop Relat Res 2010; 468 (04) 1002-1011.
    CrossrefPubMedGoogle Scholar
  • 40 Mueller MJ, Sinacore DR, Hastings MK. et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am 2003; 85 (A-8): 1436-1445.
    CrossrefPubMedGoogle Scholar
  • 41 Myerson MS, Henderson MR, Saxby T, Short KW. Management of midfoot diabetic neuroarthropathy. Foot Ankle Int 1994; 15 (05) 233-241.
    CrossrefPubMedGoogle Scholar
  • 42 Olmos PR, Cataland S, O’Dorisio TM. et al. The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with noninsulin-dependent diabetes. Am J Med Sci 1995; 309 (02) 76-82.
    CrossrefPubMedGoogle Scholar
  • 43 Osterhoff G, Boni T, Berli M. Recurrence of acute Charcot neuropathic osteoarthropathy after conservative treatment. Foot Ankle Int 2013; 34 (03) 359-364.
    CrossrefPubMedGoogle Scholar
  • 44 Pakarinen TK, Laine HJ, Honkonen SE. et al. Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases. Scand J Surg 2002; 91 (02) 195-201.
    CrossrefPubMedGoogle Scholar
  • 45 Pinzur MS. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int 2004; 25 (08) 545-549.
    CrossrefPubMedGoogle Scholar
  • 46 Pinzur MS. Neutral ring fixation for high-risk nonplantigrade Charcot midfoot deformity. Foot Ankle Int 2007; 28 (09) 961-966.
    CrossrefPubMedGoogle Scholar
  • 47 Rammelt S, Zwipp H. Revision of failed midfoot arthrodesis in Charcot arthropathy. 26th AOFAS Summer Meeting, National Harbor; Maryland, USA: July 7-10, 2010. Proceedings: 104-106.
    Google Scholar
  • 48 Rammelt S, Heim D, Hofbauer LC. et al. Probleme und Kontroversen in der Behandlung von Sprunggelenkfrakturen. Unfallchirurg 2011; 114 (10) 847-860.
    CrossrefPubMedGoogle Scholar
  • 49 Rammelt S, Pyrc J, Agren PH. et al. Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int 2013; 34 (09) 1245-1255.
    CrossrefPubMedGoogle Scholar
  • 50 Rogers LC, Bevilacqua NJ, Frykberg RG, Armstrong DG. Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle. J Foot Ankle Surg 2007; 46 (05) 372-375.
    CrossrefPubMedGoogle Scholar
  • 51 Rogers LC, Frykberg RG, Armstrong DG. et al. The Charcot foot in diabetes. Diabetes Care 2011; 34 (09) 2123-2129.
    CrossrefPubMedGoogle Scholar
  • 52 Saltzman CL, Hagy ML, Zimmerman B. et al. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet?. Clin Orthop Relat Res 2005; 435: 185-190.
    Google Scholar
  • 53 Sammarco VJ. Superconstructs in the treatment of charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin 2009; 14 (03) 393-407.
    CrossrefPubMedGoogle Scholar
  • 54 Sanders LJ, Frykberg RG. Diabetic neuropathic osteoarthropathy: The Charcot foot. In: Frykberg RG. ed. The high risk foot in diabetes mellitus. New York: Livingstone; 1991
    Google Scholar
  • 55 Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the foot and ankle. Clin Orthop Relat Res 1998; 349: 116-131.
    CrossrefPubMedGoogle Scholar
  • 56 Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy. J Bone Joint Surg Am 1990; 72 (05) 749-756.
    CrossrefPubMedGoogle Scholar
  • 57 Simon SR, Tejwani SG, Wilson DL. et al. Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000; 82-A (07) 939-950.
    PubMedGoogle Scholar
  • 58 Sinacore DR. Acute Charcot arthropathy in patients with diabetes mellitus: healing times by foot location. J Diabetes Complications 1998; 12 (05) 287-293.
    CrossrefPubMedGoogle Scholar
  • 59 Spraul M. Internationaler Konsensus über den Diabetischen Fuß/Internationale Arbeitsgruppe über den Diabetischen Fuß. Mainz: Kirchheim; 1999
    Google Scholar
  • 60 Wetz HH. Diabetisch-neuropathische Osteoarthropathie: Behandlungsergebnisse und orthopädisch-chirurgische Aspekte. Dtsch Ärztebl 1998; 43: 2701-2727.
    Google Scholar
  • 61 Wukich DK, Belczyk RJ, Burns PR, Frykberg RG. Complications encountered with circular ring fixation in persons with diabetes mellitus. Foot Ankle Int 2008; 29 (10) 994-1000.
    CrossrefPubMedGoogle Scholar
  • 62 Wukich DK, Sung W, Wipf SA, Armstrong DG. The consequences of complacency: managing the effects of unrecognized Charcot feet. Diabet Med 2011; 28 (02) 195-198.
    CrossrefPubMedGoogle Scholar
  • 63 Zwipp H, Rammelt S, Dahlen C, Reichmann H. Das Charcot-Gelenk. Orthopäde 1999; 28: 550-558.
    PubMedGoogle Scholar