Development of Charcot Neuroarthropathy in Diabetic Patients who Received Kidney or Kidney-Pancreas Transplants

Charcot Foot Offloading in Stage 0 Is Associated With Shorter Total Contact Cast Treatment and Lower Risk of Recurrence and Reconstructive Surgery: A Pilot Study

OBJECTIVE

Charcot foot (CF) requires prolonged offloading of the affected foot to decrease the risk of deformity. The earliest phase in active CF (stage 0) is characterized by inflammatory signs without established fractures or skeletal deformity. We investigated whether offloading in stage 0 influences duration of total contact casting (TCC), risk of recurrence, and future need for surgery.

RESEARCH DESIGN AND METHODS

All patients treated for active CF at Skåne University Hospital (Lund, Sweden) between 2006 and 2019 were screened for participation in a retrospective cohort study. CF events of included patients were classified as stage 0 or 1 according to X-ray and MRI reports.

RESULTS

A total of 183 individuals (median age 61 [interquartile range (IQR) 52-68] years, 37% type 1 diabetes, 62% men) were followed for a median of 7.0 (IQR 3.9-11) years. In 198 analyzed CF events, 74 were treated with offloading in stage 0 and 124 in stage 1. Individuals offloading in stage 0 had significantly shorter TCC duration (median 75 [IQR 51-136] vs. 111.5 [72-158] days; P = 0.001). The difference was sustained when including only MRI-confirmed CF. The risk of developing new ipsilateral CF events >1 year after introduced definitive footwear was lower in those treated with offloading in stage 0 (2.7% vs. 9.7%; P < 0.05). No individual treated with offloading in stage 0 underwent reconstructive surgery, compared with 11 (8.9%) treated with offloading in stage 1 (P < 0.01). Amputation rates were similar.

CONCLUSIONS

Offloading in stage 0 CF was associated with shorter TCC treatment, lower risk of a new CF event, and diminished need for reconstructive surgery. Future amputation risk was not affected.

Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic foot expert centers (The EPiChar Study)

AIM

To evaluate the real-life diagnosis and therapeutic means of Charcot Neuroosteoarthropathy (CN) in French-Belgian diabetic foot expert centers.

METHODS

We collected clinical characteristics, results of exams and therapeutic pathways of consecutive adult patients with diabetic osteoarthropathy seen in consultation or hospitalization from January 1 to December 31, 2019 in 31 diabetic foot expert centers. The primary outcome was to describe the diagnostic and management methods for CN according to patient clinical characteristics, the clinical-radiological characteristics of acute and chronic CN and discharge means.

RESULTS

467 patients were included: 364 with chronic CN and 103 in the acute phase. 101 patients had bilateral chronic CN. Most patients were male (73.4%), treated with insulin (73.3%), and with multicomplicated diabetes. In the acute phase, edema and increased foot temperature were present in 75% and 58.3% of cases, respectively. Diagnosis confirmation was usually by MRI and the mode of discharge was variable. In the chronic phase, orthopedic shoes were prescribed in 81.5% of cases.

CONCLUSIONS

This observational study highlights the diagnostic and therapeutic practices in 31 diabetic foot centers. Our results highlight that the use of MRI and the modalities of offloading, an essential treatment in the acute phase, need to be better standardized. Centers were highly encouraging about creating a patient registry.

Impact of Intensive Glycemic Treatment on Diabetes Complications-A Systematic Review

Diabetes complications can be related to the long duration of the disease or chronic hyperglycemia. The follow-up of diabetic patients is based on the control of chronic hyperglycemia, although this correction, if obtained rapidly in people living with severe chronic hyperglycemia, can paradoxically interfere with the disease or even induce complications. We reviewed the literature describing the impact of the rapid and intense treatment of hyperglycemia on diabetic complications. The literature review showed that worsening complications occurred significantly in diabetic microangiopathy with the onset of specific neuropathy induced by the correction of diabetes. The results for macroangiopathy were somewhat mixed with the intensive and rapid correction of chronic hyperglycemia having a neutral impact on stroke and myocardial infarction but a significant increase in cardiovascular mortality. The management of diabetes has now entered a new era with new therapeutic molecules, such as gliflozin for patients living with type 2 diabetes, or hybrid insulin delivery systems for patients with insulin-treated diabetes. Our manuscript provides evidence in support of these personalized and progressive algorithms for the control of chronic hyperglycemia.

The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm

It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.

Why the Risk of Developing Neuroarthropathy Is Higher After Simultaneous Kidney and Pancreatic Transplantation Compared to Kidney Transplantation Only: The Role of Euglycemia

Charcot’s neuroarthropathy is a destructive complication of the joint, which is often found in patients living with diabetes. Despite the fact that its description was published almost 100 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be updated. Its prevalence is low in patients living with diabetes, but this increases in particular situations such as peripheral neuropathy, as well as after simultaneous kidney-pancreas transplantation (SPKT) in patients living with type 1 diabetes. We suggest that the development of neuroarthropathy after SPK in not only due to glucocorticoid therapy, as described, but also to the rapid passage into euglycemia. The reduced prevalence of neuroarthropathy after only kidney transplantation compared to SPK seems to validate our hypothesis.

An overview of Charcot's neuroarthropathy

Charcot's neuroarthropathy is a destructive complication of the joints, which is often found in people with diabetes with peripheral neuropathy. Despite the fact that its description was published almost 130 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be described. Thanks to the use of bone remodelling, new therapeutic classes have emerged, we hope that this review will shed light on the pathology from its discovery through to the current state of knowledge on its classification, diagnosis and treatment methods.

The role of genetic factors and monocyte-to-osteoclast differentiation in the pathogenesis of Charcot neuroarthropathy

Charcot neuroarthropathy is a chronic, progressive condition of the skeletal system that affects some patients with diabetic neuropathy. It results in progressive destruction of bones of the foot and disorganisation of pedal joints and ligaments. Effective prevention and treatment for Charcot neuroarthropathy remain a challenge. Currently, there are no reliable repeatable markers to identify patients with diabetes who are at higher risk of developing Charcot neuroarthropathy. The pathogenesis underlying the development of Charcot neuroarthropathy also remains unclear. In this review, we provide an overview of the history, prevalence, symptoms, risk factors, diagnostics and treatment of Charcot neuroarthropathy. We also discuss the potential for OPG and RANKL gene variants to act as predictive markers for the development of Charcot neuroarthropathy. Finally, we summarise the latest research on the role of monocyte-to-osteoclast differentiation in the development of acute Charcot neuroarthropathy.

Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management

Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.