SLR - June 2014 - Fraaz Sayeed
Reference: Chantelau EA, Grutzner G. Swiss Med Wkly. 2014 Apr 24; 144.
SCIENTIFIC LITERATURE REVIEW
Reviewed By: Fraaz Sayeed, DPM
Residency Program: Saint Vincent Hospital/WMC, Worcester, MA
Podiatric Relevance: The Eichenholtz classification for Charcot joints is the most commonly used reference criteria applied for diagnosing Charcot foot in the United States of America. Initially published in a monograph in 1966 entitled “Charcot joints,” Dr. Sidney N. Eichenholtz detailed three stages for Charcot joints based on radiographic findings. The first phase included the developmental or destructive phase, followed by the coalescence stage, and finally the reconstructive or reconstitution phase. However, the description was amiss of the earliest, non-deforming, x-ray negative inflammatory stage of acute Charcot that can only be visualized through an MRI – otherwise known as “stage 0.” If treated early during stage 0, the deformity can often heal without significant arthropathy. This article proposes the creation of a new classification system utilizing the advanced imaging modalities of MRI and CT findings that supersedes the limitations presented by Eichenholtz’ staging criteria.
Methods: A proposal for a new classification of the Charcot foot based on MRI and CT scans was introduced in this article. The classification looked at four distinct clinicopathological categories of the Charcot foot and broke them down into two stages and two grades for each stage. The two grades would be differentiated based on the presence or absence of cortical fractures. Grade 0 constituted the absence of fractures while grade 1 would include the presence of 1 or more fractures. The Kiuru classification system was used a reference point for creating this new classification system.
Results: The results of this article indicate that by using CT/MRI for a Charcot foot, several categories can be used to help determine the clinicopathological changes that are occurring. Essentially, this new system breaks down the deformity into either active or inactive stages with a grade given as well to determine the severity of the deformity. An active stage includes qualities of inflammation while an inactive stage is the lack thereof.
These categories can be defined into four distinct clinicopathological findings. An active stage/grade 0 shows mild inflammation with no gross deformity with CT/MRI findings illustrating signs of bone marrow edema and soft tissue edema. An active stage/grade 1 can include severe inflammation with gross deformity. CT/MRI findings find the presence of fractures with cortical disruption along with bone marrow edema and soft tissue edema.
An inactive stage/grade 0 shows no inflammation and no gross deformities clinically. Likewise, no abnormal imaging will be found on CT/MRI. However, with an inactive stage/grade 1 although there would be no presence of inflammation clinically, there would still be persistent gross deformities noted with possible ankylosis. On CT/MRI a myriad of findings including residual bone marrow edema, cortical callus, joint effusion, joint destruction, joint dislocation, among other bone/joint changes can be seen.
Conclusions: Advancements made in medical imaging technology have rendered the Eichenholtz classification system for Charcot joints incomplete. X-ray based staging for Charcot deformities are incomplete with deficiencies in the detection of acute skeletal and inflammatory changes. MRI and CT scans may be far more useful and sensitive in distinguishing early signs of acute Charcot in the diabetic foot. The clinicopathological CT/MRI features of the proposed staging categories presented in this article is one possible method in the earlier detection, treatment, and prognosis of the Charcot foot.