Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Charcot Joint Resulting after Minor Injury in a Male with Uncontrolled Diabetes Joshua Ranta 1 OMS-III; Ashlyn Hill 2 , MD; Lindsay Tijattas-Saleski 1, 2 , DO; 1 Edward Via College of Osteopathic Medicine, Spartanburg SC 2 Prisma Health, Greer SC Abstract Case Report Conclusions

Patient Presentation: A 49-year-old male with a PMHx of type II diabetes, hypertension, congestive heart failure and chronic kidney disease presented to the ED with ”chest pain and trouble breathing”. He reported chest discomfort, palpitations, and SOB that have been ongoing for the past two weeks. His foot had an obvious deformity, and the patient reported chronic inflammation secondary to “coming down hard” on his foot a couple of weeks prior, for which he has been wearing an ankle brace. He notes chronic decreased sensation in his bilateral lower extremities. The patient admitted to irregular compliance with both his medications as well as infrequent evaluation by his PCP. Physical Exam Extremities: Right foot deformity on the plantar aspect of the arch, large nontender, non-erythematous mass, edema extending from the right foot up halfway through the calf. The calf is soft without erythema or tenderness (Figures 1 and 2) Neurologic: Decreased sensation of the bilateral lower extremities with feet significantly worse than the lower legs, Skin: warm and well-perfused. Normal in color. No skin lesions or ulcers Vascular: Dorsalis pedis pulse intact bilaterally with good capillary refill

Charcot Neuropathic Arthropathy is a common complication of chronic neuropathy with pathogenesis involving inflammation, fragmentation, coalescence, and remodeling of the bones of the foot. While this condition is relatively common, affecting up to 13% of diabetics, diagnosis is normally made after significant inflammation and remodeling has already taken place. 1 This case follows a 49-year-old Caucasian male with a past medical history of diabetes mellitus type 2, essential hypertension, heart failure with reduced ejection fraction, and chronic kidney disease who presented to the Emergency Department (ED) with chest pain and trouble breathing. His vital signs revealed hypertension, tachycardia, and tachypnea. His lower extremities were swollen and the right foot exhibiting obvious deformity in the plantar arch. X-rays were ordered of his foot and care was focused on his initial complaints. Testing proved negative in regard to his initial complaints and the patient was educated on managing his various comorbidities with special emphasis placed on recognizing worsening joint arthropathy. This case is a classic example of Charcot joint arthropathy and the social difficulties in effective education and treatment of individuals with this condition. • Charcot Joint Arthropathy was first described in 1868 by Jean Martin Charcot. Its pathogenesis is still not entirely elucidated but it is based on the principles of polyneuropathy and multifactorial bone degeneration It affects up to 13% of all diabetics. 2 • The normal disease progression involves inflammation, fragmentation, coalescence, and consolidation of bones most often seen in the feet. 2 • The active phase of the disease involves destruction of bone, ligaments, and nerve fibers while the inactive phase can last decades and shows feet with fallen arches, bone fragmentation, and significant deformity including “rocker - bottom” feet. 2 • X-rays are typically used for initial diagnosis, monitoring disease progression, and establishing plans of care. Clinical algorithms center around various angle and pitch measurements to describe the extent to which the arthropathy is progressing (Meary’s angle, cuboid height, calcaneal pitch, hindfoot-forefoot angle). 3 • MRIs are used to investigate possible infection, osteomyelitis, and bone marrow edema which is essential when evaluating placement and removal of casting. 3 • A total contact cast and “off loading” are usual methodologies of treating this condition and involve taking the load and pressure off the joints of the affected feet. 3 Charcot Joint Pathogenesis

References • Some studies have recommended use of bisphosphonates such as pamidronate to reduce inflammation surrounding bones as well reduce osteoclastic activity. These recommendations are in addition to TCC. 8 Conclusions • Treatment recommendations for patients with Charcot arthropathy follow a theory of off-loading in which Total Contact Casting (TCC) is used to take pressure off the joints of the foot to prevent further breakdown and encourage inflammation cessation. 3 • Surgical treatment may be utilized to realign bones of the foot as well as debride any tissues too far damaged in this chronic condition. 3 • Workup of the patient’s CC proved negative, and he was sent home with plans to follow up at his PCP. • The prognosis regarding Charcot Joint Arthropathy is a moderate one. Treatment is largely centered around prevention of worsening joint damage while managing other common comorbidities. 1 • While Charcot Arthropathy was the focus of this presentation, it is easily seen how this diagnosis is commonly undermanaged in the clinical setting due to the seriously debilitating nature of common comorbid conditions such as diabetic neuropathy and heart failure. 1 • This case also shows the unique social challenges and barriers to quality medical care that affect people with this condition including health literacy, access, and affordability. • X-rays are commonly used to diagnose and stage Charcot Arthropathy with the ideal patient being seen every 1-2 months during the active portions of inflammation, fragmentation, and consolidation of bones in the foot. 2 • MRI imaging may be utilized to effectively stage this illness in order to more accurately track involvement of soft tissues, tendons, and ligaments. 3

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Reports and Imaging

X-Ray (Figures 3 and 4) Midfoot fragmentation and subluxation bony sclerosis consistent with neuropathic arthropathy noted. Joint spaces are normally aligned. Distal tibiofibular articulation and tibiotalar articulation demonstrate no acute abnormality. Reactive periosteal new bone formation around the distal tibia and fibula suggest prior/remote avulsive injury. Soft tissue swelling without radiopaque foreign body or soft tissue gas.

The authors of this presentation would like to extend a thank you to the personnel at Edward Via College of Medicine Carolinas Campus as well as Prisma Health Greer.

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2024 Research Recognition Day