There are several classification systems used to classify Charcot arthropathy. The Eichenholtz classification of Charcot arthropathy is one such classification and uses a temporal-based approach 1. Another classification system is the Brodsky classification which uses an anatomical approach 1. Both classification systems have significantly changed the approach and management of Charcot arthropathy 2.
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Usage
The Eichenholtz classification uses a temporal-based approach and divides Charcot foot into different stages, according to radiographic and clinical criteria, with an additional treatment recommendation 1. It distinguishes the pathophysiology in terms of radiographic and clinical findings4.
Brodsky's classification, on the other hand, relies heavily on the anatomical distribution of the deformity. Although many anatomical classifications of Charcot were devised, Brodsky's classification remains one of the widely used classification systems1. Because both have limitations on their own, Eichenholtz and modified Brodsky's classification are used concurrently to facilitate Charcot arthropathy management1.
Eichenholtz classification
Stage 0 (prodromal)
It usually occurs with an acute sprain of the ankle or foot in the background of diabetic neuropathy 5.
clinical findings: joint edema, erythema and warm-to-touch
negative radiographic evidence (except MRI)
Treatment includes patient education on protective footwear and diabetic management. Regular monitoring with serial radiographs is also recommended to prevent progressive bone destruction1.
Stage 1 (fragmentation)
Stage 1 progresses as there is bony destruction resulting in ligamentous laxity and subluxation 1.
clinical findings: joint edema, erythema and joint instability
radiographic evidence: bone destruction, debris formation and/or dislocation
Clinicians suggest protective weight-bearing, ideally with total contact casting or pneumatic brace until complete resolution of stage 1, which could take up to 4 months 1.
Stage 2 (coalescence)
New bone formation begins in this stage and there are reduced clinical findings. Periarticular debris is absorbed and larger bone fragments form calluses 1.
clinical findings: decreased joint edema and erythema
radiographic evidence: absorption of debris, sclerosis formation
To facilitate bone healing, protective weight-bearing is continued and in some cases, Charcot restraint orthotic walker or clamshell ankle-foot orthosis is used 1.
Stage 3 (reconstruction)
The joint structure becomes more stable even with deformity present. Bone formation is more evident 1.
clinical findings: resolved joint edema, stable joint with fixed deformity
radiographic evidence: consolidation and remodeling of fracture fragments
For non-severe cases, conservative management is still recommended with custom inlay shoes for plantigrade feet. For non-plantigrade feet, a more aggressive approach is sought. If conservative methods fail, exostectomy is done to debride the bony prominence. Exostectomy is found to have a higher limb salvage rate (around 90%) 6.
Arthrodesis with internal fixation is recommended as a last resort before amputation of the foot for severe fixed deformity of the foot and ankle with recurrent ulcerations despite conservative therapy 6. However, there is a high incidence of incomplete bone union 6.
Brodsky Classification
Type 1
location: midfoot
joints involved: tarsometatarsal, naviculocuneiform
Type 2
location: hindfoot
joints involved: subtalar, talonavicular, calcanecuboid
Type 3
-
3A
location: ankle
joints involved: tibiotalar
-
3B
location: calcaneus
tuberosity fracture
Type 4
location: multiple joints
joints involved: sequential, concurrent
Type 5
location: forefoot
joints involved: metatarsophalangeal
History and etymology
The American orthopedic surgeon Sidney N. Eichenholtz identified clinical, radiographic and pathologic differences in Charcot arthropathy and published the classification in 1966, which consisted of three stages initially. The "prodromal" stage was added later by the Japanese T Shibata and colleagues 4.
The American orthopedic surgeon James W Brodsky adopted his classification after noticing limitations in Eichenholtz's stages 1. This classification system was also later modified and extended by the Canadian orthopedic surgeon Elly Trepman and colleagues to include fourth and fifth types 4.