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Henderson R, Lakshmanan R, McLaughlin A, Bangash O, Saha S, Carey-Smith R. A complicated Chiari type 1 malformation and holocord syrinx as a likely cause for heel pain. Childs Nerv Syst 2024; 40:997-1003. [PMID: 38302572 DOI: 10.1007/s00381-024-06299-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Chiari malformations are a rare group of rhomboencephalic abnormalities involving the brain, craniocervical junction and spine. They may manifest in a variety of clinical presentations which relate to the variable involvement of the cerebellum, brainstem, lower cranial nerves, spinal cord and altered CSF flow dynamics. METHOD We report an unusual case of incidental diagnosis of a type I Chiari malformation with secondary cystic cerebellar tonsillar encephalomalacia and holocord syrinx following investigation of a 5YO girl presenting with heel swelling related to progressive neuropathic osteoarthropathy of the posterior calcaneal body and apophysis. RESULT The child was treated with decompressive suboccipital craniectomy and C1 laminectomy and tonsillar resection. Cerebellar tonsillar gliosis and cystic degeneration were confirmed on histopathology. Referral for ongoing engagement with occupational and physical therapy. CONCLUSION Most type I Chiari malformations in the paediatric population are incidental and asymptomatic. Neurological symptoms are typically mild and relate to altered CSF flow dynamics; however, we present a complex case of type I Chiari malformation with an unusual constellation of associated complications.
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Affiliation(s)
- Robert Henderson
- Department of Radiology, Perth Children's Hospital, Perth, WA, Australia.
- University of Western Australia, Crawley, Perth, WA, Australia.
- Department of Radiology, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.
| | - Rahul Lakshmanan
- Department of Radiology, Perth Children's Hospital, Perth, WA, Australia
- Centre for Neuromuscular and Neurological Disorders (Perron Institute), University of Western Australia, Nedlands, WA, Australia
| | - Aden McLaughlin
- Department of Radiology, Perth Children's Hospital, Perth, WA, Australia
| | - Omar Bangash
- Department of Neurosurgery, Perth Children's Hospital, Perth, WA, Australia
| | - Snigdha Saha
- Department of Neurosurgery, Perth Children's Hospital, Perth, WA, Australia
| | - Richard Carey-Smith
- University of Western Australia, Crawley, Perth, WA, Australia
- Department of Orthopaedics, Perth Children's Hospital, Perth, WA, Australia
- Orthopaedic and Sports Medicine Centre, West Perth, WA, Australia
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Goyal R, Gupta A, Bhatia N, Goel A, Gupta A. Minimally Invasive Treatment for Nonunion in an Unusual Pattern of Neuropathic Calcaneal Fracture: A Case Report. Cureus 2022; 14:e21718. [PMID: 35251793 PMCID: PMC8887687 DOI: 10.7759/cureus.21718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2022] [Indexed: 11/05/2022] Open
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Evran M, Sert M, Tetiker T, Akkuş G, Biçer OS. Spontaneous calcaneal fracture in patients with diabetic foot ulcer: Four cases report and review of literature. World J Clin Cases 2016; 4:181-186. [PMID: 27458594 PMCID: PMC4945589 DOI: 10.12998/wjcc.v4.i7.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/05/2016] [Accepted: 06/03/2016] [Indexed: 02/05/2023] Open
Abstract
Spontaneous calcaneal fractures in diabetic patients without obvious trauma may occur, sometimes accompanying diabetic foot ulcers. In the current study we report four cases who were hospitalized for diabetic foot ulcer with concomitant calcaneal fractures. There were four diabetic patients (one type 1 and three type 2) who registered with diabetic foot ulcers with coexisting calcaneal fractures, all of which were classified as Type A according to Essex Lopresti Calcaneal Fracture Classification. Two of the patients with renal failure were in a routine dialysis program, as well as vascular compromise and osteomyelitis in all of the patients. The diabetic foot ulcer of the 61 years old osteoporotic female patient healed with local debridement, vacuum assisted closure and then epidermal growth factor while the calcaneal fracture was then followed by elastic bandage. In two patients could not prevent progression of diabetic foot ulcers and calcaneal fractures to consequent below-knee amputation. The only patient with type 1 diabetes mellitus improved with antibiotic therapy and split thickness skin grafting, while the calcaneal fracture did not heal. In the current study we aimed to emphasize the spontaneous calcaneal fractures as possible co-existing pathologies in patients with diabetic foot ulcers. After all the medical treatment, amputation below knee had to be performed in 2 patients. It should be noted that other accompanying conditions such as impaired peripheral circulation, osteomyelitis, chronic renal failure, and maybe osteoporosis is a challenge of the recovery of calcaneal fractures and accelerate the progress to amputation in diabetic patients.
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Fosbøl M, Reving S, Petersen EH, Rossing P, Lajer M, Zerahn B. Three-phase bone scintigraphy for diagnosis of Charcot neuropathic osteoarthropathy in the diabetic foot - does quantitative data improve diagnostic value? Clin Physiol Funct Imaging 2015; 37:30-36. [PMID: 26147681 DOI: 10.1111/cpf.12264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/17/2015] [Indexed: 11/30/2022]
Abstract
AIM To investigate whether inclusion of quantitative data on blood flow distribution compared with visual qualitative evaluation improve the reliability and diagnostic performance of 99 m Tc-hydroxymethylene diphosphate three-phase bone scintigraphy (TPBS) in patients suspected for charcot neuropathic osteoarthropathy (CNO) of the foot. METHOD A retrospective cohort study of TPBS performed on 148 patients with suspected acute CNO referred from a single specialized diabetes care centre. The quantitative blood flow distribution was calculated based on the method described by Deutsch et al. All scintigraphies were re-evaluated by independent, blinded observers twice with and without quantitative data on blood flow distribution at ankle and focus level, respectively. The diagnostic validity of TPBS was determined by subsequent review of clinical data and radiological examinations. RESULTS A total of 90 patients (61%) had confirmed diagnosis of CNO. The sensitivity, specificity and accuracy of three-phase bone scintigraphy without/with quantitative data were 89%/88%, 58%/62% and 77%/78%, respectively. The intra-observer agreement improved significantly by adding quantitative data in the evaluation (Kappa value 0·79/0·94). The interobserver agreement was not significantly improved. CONCLUSION Adding quantitative data on blood flow distribution in the interpretation of TBPS improves intra-observer variation, whereas no difference in interobserver variation was observed. The sensitivity of TPBS in the diagnosis of CNO is high, but holds limited specificity. Diagnostic performance does not improve using quantitative data in the evaluation. This may be due to the reference intervals applied in the study or the absence of a proper gold standard diagnostic procedure for comparison.
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Affiliation(s)
- M Fosbøl
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, Herlev, Denmark.,Department of Clinical Physiology Nuclear Medicine & PET, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - S Reving
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, Herlev, Denmark
| | | | - P Rossing
- Steno Diabetes Center, Gentofte, Denmark.,Health Aarhus University, Aarhus, Denmark.,NNF CBMR University of Copenhagen, Copenhagen, Denmark
| | - M Lajer
- Steno Diabetes Center, Gentofte, Denmark
| | - B Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, Herlev, Denmark
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Milne TE, Rogers JR, Kinnear EM, Martin HV, Lazzarini PA, Quinton TR, Boyle FM. Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review. J Foot Ankle Res 2013; 6:30. [PMID: 23898912 PMCID: PMC3737070 DOI: 10.1186/1757-1146-6-30] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 07/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charcot Neuro-Arthropathy (CN) is one of the more devastating complications of diabetes. To the best of the authors' knowledge, it appears that no clinical tools based on a systematic review of existing literature have been developed to manage acute CN. Thus, the aim of this paper was to systematically review existing literature and develop an evidence-based clinical pathway for the assessment, diagnosis and management of acute CN in patients with diabetes. METHODS Electronic databases (Medline, PubMed, CINAHL, Embase and Cochrane Library), reference lists, and relevant key websites were systematically searched for literature discussing the assessment, diagnosis and/or management of acute CN published between 2002-2012. At least two independent investigators then quality rated and graded the evidence of each included paper. Consistent recommendations emanating from the included papers were then fashioned in a clinical pathway. RESULTS The systematic search identified 267 manuscripts, of which 117 (44%) met the inclusion criteria for this study. Most manuscripts discussing the assessment, diagnosis and/or management of acute CN constituted level IV (case series) or EO (expert opinion) evidence. The included literature was used to develop an evidence-based clinical pathway for the assessment, investigations, diagnosis and management of acute CN. CONCLUSIONS This research has assisted in developing a comprehensive, evidence-based clinical pathway to promote consistent and optimal practice in the assessment, diagnosis and management of acute CN. The pathway aims to support health professionals in making early diagnosis and providing appropriate immediate management of acute CN, ultimately reducing its associated complications such as amputations and hospitalisations.
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Affiliation(s)
- Tamara E Milne
- Podiatry Department, Ipswich General Hospital, Brisbane, Australia
| | - Joseph R Rogers
- Podiatry Department, Launceston General Hospital, Launceston, Australia
| | - Ewan M Kinnear
- Podiatry Department, The Prince Charles Hospital, Brisbane, Australia
| | - Helen V Martin
- Podiatry Department, The Prince Charles Hospital, Brisbane, Australia
| | - Peter A Lazzarini
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Thomas R Quinton
- Prosthetics, Orthotics and Podiatry Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Frances M Boyle
- School of Population Health, University of Queensland, Brisbane, Australia
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Lowery NJ, Woods JB, Armstrong DG, Wukich DK. Surgical management of Charcot neuroarthropathy of the foot and ankle: a systematic review. Foot Ankle Int 2012; 33:113-21. [PMID: 22381342 DOI: 10.3113/fai.2012.0113] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the foot and ankle is an extremely challenging clinical dilemma and surgical management can be highly complicated. The current literature on this topic is comprised of manuscripts that are retrospective case series and expert opinions. Furthermore, surgery in patients with CN of the foot and ankle is guided by studies with low levels of evidence to support our current surgical practices. METHODS A Medline/CINAHL search was performed and a systematic review of articles discussing the surgical management of CN was undertaken. RESULTS Ninety-five articles fit the inclusion criteria for our study. As hypothesized, all reports detailing the surgical management of Charcot neuroarthropathy constituted Level IV or V evidence. CONCLUSION Surgical algorithms for the treatment of CN of the foot are based almost entirely on level four or five evidence. Uncontrolled retrospective case series and case reports guide the use of exostectomy, fusion, and Achilles tendon lengthening for CN. There is inconclusive evidence concerning timing of treatment and use of different fixation methods. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.
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Abstract
The principles of fusion of a Charcot joint arise from the assertion that successful fusion requires removal of all cartilage, debris, and sclerotic bone. The authors believe that reconstruction can prevent amputation in patients who have unbraceable or unstable deformities, or recurrent ulcerations. The goal with any Charcot reconstruction procedure is to achieve a plantigrade foot free of ulceration, and to prevent any future collapse, deformity, or ulcerations. The authors strongly believe arthrodesis of unstable joints of the Charcot neuropathic foot can lead to limb salvage and better quality of life.
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Affiliation(s)
- Panagiotis Panagakos
- Foot and Ankle Care Associates, LLC, Hahnemann University Hospital, Overlook Hospital, Staten Island, NY 10305, USA
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