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Raspovic KM, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Wukich DK. Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3653. [PMID: 37179484 DOI: 10.1002/dmrr.3653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin. METHODS We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted. RESULTS We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission. CONCLUSIONS There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease.
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Affiliation(s)
- Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Wukich DK, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Raspovic KM. Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023). Diabetes Metab Res Rev 2024; 40:e3646. [PMID: 37218537 DOI: 10.1002/dmrr.3646] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Garcia-Diez AI, Tomas Batlle X, Perissinotti A, Isern-Kebschull J, Del Amo M, Soler JC, Bartolome A, Bencardino JT. Imaging of the Diabetic Foot. Semin Musculoskelet Radiol 2023; 27:314-326. [PMID: 37230131 DOI: 10.1055/s-0043-1764386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Diabetic foot complications are increasingly prevalent in the world, leading to significant morbidity and driving up associated health care costs. Complex pathophysiology and suboptimal specificity of current imaging modalities have made diagnosis challenging, mainly in the evaluation of superimposed foot infection to underlying arthropathy or other marrow lesions. Recent advances in radiology and nuclear medicine have the potential to streamline the assessment of diabetic foot complications. But we must be aware of the specific strengths and weaknesses of each modality, and their applications. This review offers a comprehensive approach to the spectrum of diabetic foot complications and their imaging appearances in conventional and advanced imaging studies, including optimal technical considerations for each technique. Advanced magnetic resonance imaging (MRI) techniques are highlighted, illustrating their complementary role to conventional MRI, in particular their potential impact in avoiding additional studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Jenny Teresa Bencardino
- Division of Musculoskeletal Radiology, Department of Radiology, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Jones PJ, Davies MJ, Webb D, Berrington R, Frykberg RG. Contralateral foot temperature monitoring during Charcot immobilisation: A systematic review. Diabetes Metab Res Rev 2023; 39:e3619. [PMID: 36728905 DOI: 10.1002/dmrr.3619] [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: 09/16/2022] [Revised: 01/07/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
AIMS Contralateral temperature difference (CTD) is a frequently used marker of healing in Charcot neuro-osteoarthropathy (CN). We aimed to determine whether there is a consistent approach to CTD measurement during healing and the decision-making process around cessation of immobilisation. MATERIALS AND METHODS Medline, Scopus, and Web of Science were searched until February 2022 for peer-reviewed studies using keywords, including (('arthropathy' OR 'osteoarthropathy' OR 'osteopathy' OR 'neuroarthropathy') AND 'Charcot' AND ('temperature')), which returned 789 results excluding duplicates. Included studies monitored CTD in those with active CN to (i) assess the healing process and (ii) assist in determining the transition from immobilisation. RESULTS Thirty four studies in total (n = 677 participants) were shortlisted and 19 were included after full paper review. Average CTD at presentation varied from 1.6 to 8.0°C with insufficient data to determine if CTD was proportional to severity of Charcot. Evidence of a relationship between CTD and radiographic or scintigraphy-based markers of healing varied depending on the methodology employed. Threshold CTD for the cessation of immobilisation ranged from <1°C to <2°C. Most frequently it was <2°C sustained for 2-3 visits. Temperature was monitored typically every 2-6 weeks using handheld thermometry at CN site(s) after resting the feet for 15 min. Device type, accuracy/reliability, and ambient temperature were rarely reported. CONCLUSIONS Further research on CTD and radiographic and radiotracer markers is needed involving larger cohorts. Standardisation in reporting of thermometry device type, accuracy and reliability, foot resting times, and ambient temperature controls is essential to facilitate the comparison of studies, meta-analysis, and evaluation of different immobilisation interventions.
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Affiliation(s)
- Petra J Jones
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - David Webb
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Rachel Berrington
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
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Teh J, Sharp R, McKean D. Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot. Semin Musculoskelet Radiol 2022; 26:717-729. [PMID: 36791740 DOI: 10.1055/s-0042-1760219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.
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Affiliation(s)
- James Teh
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Robert Sharp
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - David McKean
- Stoke Mandeville Hospital Buckinghamshire Healthcare NHS Trust
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6
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Ahluwalia R, Armstrong DG, Petrova N, Papanas N, Edmonds M. Stage 0 Charcot Neuroarthropathy in the Diabetic Foot: An Emerging Narrow Window of Opportunity? INT J LOW EXTR WOUND 2022; 21:374-376. [PMID: 33960848 DOI: 10.1177/15347346211011844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In a world where popular culture and concepts can become the norm without all the rigors of normal scrutiny, our attention is focused on identifying Charcot neuroarthropathy (CN) at a stage before radiological bone destruction occurs. The rationale is that early recognition can prevent a destructive chain of events and thus potentially reduce the burden to patients and health care providers. In this article, we describe the evolution of stage 0 CN, and the use of modern imaging in characterizing the abnormalities recognized by these modalities and how they aid our understanding and supplement our knowledge. We review the potential of these imaging modalities, assessing how far we have come in characterizing stage 0 and if we have robust criteria for the identification of stage 0 in the natural history of CN.
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Affiliation(s)
| | | | - Nina Petrova
- 8948King's College Hospital, London, UK
- King's College, London, UK
| | | | - Michael Edmonds
- 8948King's College Hospital, London, UK
- King's College, London, UK
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Tram NK, Chou TH, Patel S, Ettefagh LN, Go MR, Atway SA, Stacy MR. Novel Application of 18F-NaF PET/CT Imaging for Evaluation of Active Bone Remodeling in Diabetic Patients With Charcot Neuropathy: A Proof-of-Concept Report. Front Med (Lausanne) 2022; 9:795925. [PMID: 35252240 PMCID: PMC8896741 DOI: 10.3389/fmed.2022.795925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Charcot neuropathic osteoarthropathy (CN) is a serious and potentially limb-threatening complication for patients with diabetes mellitus and peripheral arterial disease. In recent decades, nuclear medicine-based approaches have been used for non-invasive detection of CN; however, to date, a positron emission tomography (PET) radionuclide specifically focused on targeted imaging of active bone remodeling has not been explored or validated for patients with CN. The radionuclide 18F-sodium fluoride (NaF) has historically been used as a bone imaging probe due to its high sensitivity for targeting hydroxyapatite and bone turnover, but has not been applied in the context of CN. Therefore, the present study focused on novel application of 18F-NaF PET/computed tomography (CT) imaging to three clinical cases of CN to evaluate active bone remodeling at various time courses of CN. PET/CT imaging in all 3 cases demonstrated focal uptake of 18F-NaF in the bones of the feet afflicted with CN, with bone retention of 18F-NaF persisting for up to 5 years following surgical reconstruction of the foot in two cases. On a group level, 18F-NaF bone uptake in the CN foot was significantly higher compared to the healthy, non-CN foot (p = 0.039). 18F-NaF PET/CT imaging may provide a non-invasive tool for monitoring active bone remodeling in the setting of CN, thereby offering novel opportunities for tracking disease progression and improving treatment and surgical intervention.
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Affiliation(s)
- Nguyen K. Tram
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Surina Patel
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Laila N. Ettefagh
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Michael R. Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Said A. Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Mitchel R. Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
- *Correspondence: Mitchel R. Stacy
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8
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Lauri C, Capriotti G, Uccioli L, Signore A. PET imaging in diabetic foot infections. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00083-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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9
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:11552. [PMID: 34768982 PMCID: PMC8584017 DOI: 10.3390/ijms222111552] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/27/2022] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Andrew P. Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA;
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Robert W. Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Dane K. Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Orhan K. Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
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10
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:ijms222111552. [PMID: 34768982 DOI: 10.3390/ijms222111552.pmid:34768982;pmcid:pmc8584017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 05/27/2023] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Andrew P Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Robert W Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
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11
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Griffiths DA, Kaminski MR. Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study. J Foot Ankle Res 2021; 14:44. [PMID: 34130722 PMCID: PMC8204579 DOI: 10.1186/s13047-021-00477-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 04/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies. METHODS This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher's exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated. RESULTS Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants. CONCLUSIONS The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.
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Affiliation(s)
| | - Michelle R Kaminski
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia. .,Department of Podiatry, St Vincent's Hospital Melbourne, Melbourne, Victoria, 3065, Australia.
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12
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Ahluwalia R, Bilal A, Petrova N, Boddhu K, Manu C, Vas P, Bates M, Corcoran B, Reichert I, Mulholland N, Kavarthapu V, Vivian G, Edmonds M. The Role of Bone Scintigraphy with SPECT/CT in the Characterization and Early Diagnosis of Stage 0 Charcot Neuroarthropathy. J Clin Med 2020; 9:jcm9124123. [PMID: 33371286 PMCID: PMC7767116 DOI: 10.3390/jcm9124123] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023] Open
Abstract
We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who underwent 3 phase bone scintigraphy with “High Resolution” SPECT/CT. The imaging demonstrated that Stage 0 Charcot foot has a distinct bone pathology, which can be classified into three groups: (1) fractures on Computed Tomography (CT) with accompanying focal uptake of tracer on SPECT, (2) bony abnormalities apart from fracture on CT with focal uptake of tracer on SPECT, and (3) normal CT but focal bony uptake of tracer on SPECT. The CT component of SPECT/CT detected bony fractures in 59% of patients. Early treatment with below knee cast and follow-up for 24 months showed only 4 patients who developed Stage 1 Eichenholtz Charcot foot. Our findings support the use of 3 phase bone scintigraphy with SPECT/CT in the characterization and early diagnosis of CN. Stage 0 Charcot foot has a distinct bone pathology which requires urgent treatment to prevent progression to Stage 1 Eichenholtz Charcot foot. If SPECT/CT is unavailable, CT alone will detect bone fracture in 59% patients.
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Affiliation(s)
- Raju Ahluwalia
- Department of Orthopedics, King’s College Hospital, London SE5 9RS, UK; (A.B.); (K.B.); (I.R.); (V.K.)
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
- Correspondence: ; Tel.: +44-02-032-991-306
| | - Ahmad Bilal
- Department of Orthopedics, King’s College Hospital, London SE5 9RS, UK; (A.B.); (K.B.); (I.R.); (V.K.)
| | - Nina Petrova
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
- Department of Diabetes, Faculty of Life Sciences and Medicine, King’s College, London SE5 9RS, UK
| | - Krishna Boddhu
- Department of Orthopedics, King’s College Hospital, London SE5 9RS, UK; (A.B.); (K.B.); (I.R.); (V.K.)
| | - Chris Manu
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
| | - Prashanth Vas
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
- Department of Diabetes, Faculty of Life Sciences and Medicine, King’s College, London SE5 9RS, UK
| | - Maureen Bates
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
| | - Ben Corcoran
- Department of Nuclear Medicine, King’s College Hospital, London SE5 9RS, UK; (B.C.); (N.M.); (G.V.)
| | - Ines Reichert
- Department of Orthopedics, King’s College Hospital, London SE5 9RS, UK; (A.B.); (K.B.); (I.R.); (V.K.)
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
| | - Nicola Mulholland
- Department of Nuclear Medicine, King’s College Hospital, London SE5 9RS, UK; (B.C.); (N.M.); (G.V.)
| | - Venu Kavarthapu
- Department of Orthopedics, King’s College Hospital, London SE5 9RS, UK; (A.B.); (K.B.); (I.R.); (V.K.)
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
| | - Gill Vivian
- Department of Nuclear Medicine, King’s College Hospital, London SE5 9RS, UK; (B.C.); (N.M.); (G.V.)
| | - Michael Edmonds
- Diabetic Foot Clinic, King’s College Hospital, London SE5 9RS, UK; (N.P.); (C.M.); (P.V.); (M.B.); (M.E.)
- Department of Diabetes, Faculty of Life Sciences and Medicine, King’s College, London SE5 9RS, UK
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Gooday C, Gray K, Game F, Woodburn J, Poland F, Hardeman W. Systematic review of techniques to monitor remission of acute Charcot neuroarthropathy in people with diabetes. Diabetes Metab Res Rev 2020; 36:e3328. [PMID: 32315511 DOI: 10.1002/dmrr.3328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/17/2020] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
AIM The management of acute Charcot neuroarthropathy relies on off-loading which is costly and time-consuming. Published studies have used monitoring techniques with unknown diagnostic precision to detect remission. We performed a systematic review of techniques for monitoring response to offloading in acute Charcot neuroarthropathy. MATERIALS AND METHODS We included studies of off-loading which evaluated or described monitoring techniques in acute Charcot neuroarthropathy. PubMed, EMBASE, CINAHL and Cochrane databases were searched (January1993-July 2018). We extracted data from papers including study design, setting, population, monitoring techniques and treatment outcomes. We also extracted information on the cost, clinical applicability, sensitivity and specificity, safety and participant acceptability of the monitoring techniques. RESULTS We screened 1205 titles, 140 abstracts and 45 full-texts, and included 29 studies. All studies were of low quality and at high risk of bias. In seven studies, the primary aim was to evaluate monitoring techniques: three evaluated magnetic resonance imaging, two thermography monitoring, one three-phase bone scanning and one Doppler spectrum analysis. The remaining 22 observational studies reported treatment outcomes and described the monitoring techniques used to assess the Charcot neuroarthropathy. Heterogeneity prevented the pooling of data. Very few studies included data on cost, clinical applicability, sensitivity and specificity, safety and patient acceptability of the monitoring techniques used. CONCLUSION Multiple techniques have been used to evaluate remission in acute Charcot neuroathropathy but uncertainty remains about their effectiveness. We recommend further research into the influences of different monitoring techniques on treatment outcomes.
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Affiliation(s)
- Catherine Gooday
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Katie Gray
- Podiatry Department, Derbyshire Community Health Services NHS Foundation Trust, Chesterfield, UK
| | - Frances Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jim Woodburn
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich, UK
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Diabetic Foot Infections: The Diagnostic Challenges. J Clin Med 2020; 9:jcm9061779. [PMID: 32521695 PMCID: PMC7355769 DOI: 10.3390/jcm9061779] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot infections (DFIs) are severe complications of long-standing diabetes, and they represent a diagnostic challenge, since the differentiation between osteomyelitis (OM), soft tissue infection (STI), and Charcot’s osteoarthropathy is very difficult to achieve. Nevertheless, such differential diagnosis is mandatory in order to plan the most appropriate treatment for the patient. The isolation of the pathogen from bone or soft tissues is still the gold standard for diagnosis; however, it would be desirable to have a non-invasive test that is able to detect, localize, and evaluate the extent of the infection with high accuracy. A multidisciplinary approach is the key for the correct management of diabetic patients dealing with infective complications, but at the moment, no definite diagnostic flow charts still exist. This review aims at providing an overview on multimodality imaging for the diagnosis of DFI and to address evidence-based answers to the clinicians when they appeal to radiologists or nuclear medicine (NM) physicians for studying their patients.
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Chou TH, Stacy MR. Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia. Mol Imaging Biol 2019; 22:245-255. [PMID: 31482412 DOI: 10.1007/s11307-019-01425-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA. .,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
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16
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Rosskopf AB, Loupatatzis C, Pfirrmann CWA, Böni T, Berli MC. The Charcot foot: a pictorial review. Insights Imaging 2019; 10:77. [PMID: 31385060 PMCID: PMC6682845 DOI: 10.1186/s13244-019-0768-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 07/12/2019] [Indexed: 01/05/2023] Open
Abstract
Charcot foot refers to an inflammatory pedal disease based on polyneuropathy; the detailed pathomechanism of the disease is still unclear. Since the most common cause of polyneuropathy in industrialized countries is diabetes mellitus, the prevalence in this risk group is very high, up to 35%. Patients with Charcot foot typically present in their fifties or sixties and most of them have had diabetes mellitus for at least 10 years. If left untreated, the disease leads to massive foot deformation. This review discusses the typical course of Charcot foot disease including radiographic and MR imaging findings for diagnosis, treatment, and detection of complications.
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Affiliation(s)
- Andrea B Rosskopf
- Radiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.
| | | | - Christian W A Pfirrmann
- Radiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Thomas Böni
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin C Berli
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
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17
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Sebastian AP, Dasgupta R, Jebasingh F, Saravanan B, Chandy B, Mahata KM, Naik D, Paul T, Thomas N. Clinical features, radiological characteristics and offloading modalities in stage 0 Acute Charcot's neuroarthropathy - A single centre experience from South India. Diabetes Metab Syndr 2019; 13:1081-1085. [PMID: 31336448 DOI: 10.1016/j.dsx.2019.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 01/14/2019] [Indexed: 11/27/2022]
Abstract
AIMS Stage 0 Acute Charcot's Neuroarthropathy (ACN)in Type 2 Diabetes patients is a challenging diagnosis with subtle clinical features and normal appearing plain radiographs of the affected foot. Delay in diagnosis can lead to progression of disease and irreversible deformities. There is a paucity of data on Stage 0 ACN from India. The aim of this study was to assess clinical and radiological characteristics and treatment outcomes in Indian Type 2 Diabetes patients with Stage 0 ACN. MATERIALS AND METHODS A comparative, case-control study was carried out amongst patients attending the Integrated Diabetes Foot Clinic at a tertiary care South Indian hospital. During the 3-year study period, a total of 1811 patients with Type 2 Diabetes Mellitus were screened. Of these, n = 10 patients with stage 0 ACN Charcot's arthropathy were identified based on clinical features and MRI imaging of the foot for confirmation of diagnosis. These were compared with an age and duration of diabetes-matched group of n = 50 patients without ACN as controls. RESULTS Our study identified 10 patients (0.5%) with Stage 0 Acute charcot neuroarthropathy (ACN) in the study population. Those with ACN had higher BMI, poorer glycaemic control and greater degree of peripheral neuropathy (p < 0.05). Clinically relative lack of pain and infrared thermometric temperature difference >2 °C in the affected foot were the most significant findings, while MRI foot was useful in early detection of active and severe stage 0 disease. Total contact cast was the preferred initial offloading modality, with delay in initiating complete immobilization leading to worse outcomes. CONCLUSIONS This is the first study to highlight the characteristic features of Stage 0 ACN in Indian Type 2 Diabetes patients. Thorough clinical evaluation, infrared thermometry and radiological findigs on MRI foot leads to early disease detection. Complete offloading, preferably with total contact casts can prevent disease progression and chronic deformities.
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Affiliation(s)
- Anjely P Sebastian
- Department of General Medicine, Christian Medical College, Vellore, 632 004, India
| | - Riddhi Dasgupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India.
| | - Felix Jebasingh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Bharathi Saravanan
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Bobeena Chandy
- Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, 632 004, India
| | - Koyeli Mary Mahata
- Department of Radiology, Christian Medical College, Vellore, 632 004, India
| | - Dukhabandhu Naik
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Thomas Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
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Chantelau EA, Antoniou S, Zweck B, Haage P. Follow up of MRI bone marrow edema in the treated diabetic Charcot foot - a review of patient charts. Diabet Foot Ankle 2018; 9:1466611. [PMID: 29713425 PMCID: PMC5918386 DOI: 10.1080/2000625x.2018.1466611] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/12/2018] [Indexed: 05/15/2023]
Abstract
Background: Ill-defined areas of water-like signal on bone magnetic resonance imaging (MRI), characterized as bone marrow edema or edema-equivalent signal-changes (EESC), is a hallmark of active-stage pedal neuro-osteoarthropathy (Charcot foot) in painless diabetic neuropathy, and is accompanied by local soft-tissue edema and hyperthermia. The longitudinal effects on EESC of treating the foot in a walking cast were elucidated by reviewing consecutive cases of a diabetic foot clinic. Study design: Retrospective observational study, chart review Material and methods: Cases with active-stage Charcot foot were considered, in whom written reports on baseline and follow-up MRI studies were available for assessment. Only cases without concomitant infection or skin ulcer were chosen, in whom both was documented, onset of symptomatic foot swelling and patient compliance with cast treatment. Results: From 1994 to 2017, 45 consecutive cases in 37 patients were retrieved, with 95 MRI follow-up studies (1-6 per case, average interval between studies 13 weeks). Decreasing EESC was documented in 66/95 (69%) follow-up studies. However, 29/95 (31%) studies revealed temporarily increasing, migrating or stagnating EESC. Conclusion: EESC on MRI disappear in response to prolonged offloading and immobilizing treatment; however, physiologic as well as pathologic fluctuations of posttraumatic EESC have to be considered when interpreting the MR images. Conventional MRI is useful for surveillance of active-stage Charcot foot recovery.
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Affiliation(s)
- Ernst-A. Chantelau
- Department of Endocrinology and Diabetology, Diabetic Foot Clinic, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sofia Antoniou
- Department of Endocrinology and Diabetology, Diabetic Foot Clinic, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Brigitte Zweck
- Department of Endocrinology and Diabetology, Diabetic Foot Clinic, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Patrick Haage
- Department of Diagnostic and Interventional Radiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
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Affiliation(s)
- Andrew Dodd
- Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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20
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Thewjitcharoen Y, Sripatpong J, Parksook W, Krittiyawong S, Porramatikul S, Srikummoon T, Mahaudomporn S, Nakasatien S, Himathongkam T. Salient features and outcomes of Charcot foot - An often-overlooked diabetic complication: A 17-year-experience at a diabetic center in Bangkok. J Clin Transl Endocrinol 2018; 11:1-6. [PMID: 29725580 PMCID: PMC5928004 DOI: 10.1016/j.jcte.2018.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Charcot foot is a rare but a serious diabetic condition. Recognition of this often overlooked condition to provide timely and proper management is important for a better prognosis. Limited data on Charcot foot was available in Asians. AIMS The aim of this study is to describe salient features and outcomes of Charcot foot in Thai patients. METHOD We presented our experience of 40 cases of Charcot foot patients who were treated from 2000 to 2016 at Theptarin Hospital, Bangkok, Thailand. RESULTS A total of 40 Charcot foot patients were identified (13 acute, 27 chronic; mean age 58.7 ± 10.2 years; duration of diabetes 18.0 ± 8.8 years; T2DM 95%). The average serum HbA1c level was 9.2 ± 1.9%. While acute Charcot foot was frequently misdiagnosed as cellulitis in almost one-third of patients, osteomyelitis was a leading cause of misdiagnosis in 15% of chronic Charcot foot patients. Ulcer-free rate at 6 and 12 months were observed in 60% and 58% of patients, respectively. The mortality rate was 13% during a median follow-up period of 57 months. Only 61% of the patients resumed walking normally while almost one-fourth of them were wheelchair-bound. CONCLUSIONS Charcot foot in Thai patients mainly developed in long-standing poorly controlled type 2 diabetes with neuropathy, and presented late in the course of the disease. It was often misdiagnosed resulting in improper management and poor outcome which included amputation.
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Affiliation(s)
- Yotsapon Thewjitcharoen
- Diabetes and Thyroid Center, Theptarin Hospital, 3858 Rama IV Rd, Klong Toey, Bangkok 10110, Thailand
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Berli M, Vlachopoulos L, Leupi S, Böni T, Baltin C. Treatment of Charcot Neuroarthropathy and osteomyelitis of the same foot: a retrospective cohort study. BMC Musculoskelet Disord 2017; 18:460. [PMID: 29145857 PMCID: PMC5691862 DOI: 10.1186/s12891-017-1818-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 11/08/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We evaluated treatment of osteomyelitis in the foot in the presence of Charcot neuroarthropathy, a devastating condition with progressive degeneration and joint destruction. We hypothesized that there was a difference in (1) amputation rate, (2) amputation level, (3) duration of antibiotic therapy, and (4) duration of immobilization for treatment of osteomyelitis within versus outside the Charcot zone. METHODS Forty patients (43 ft) diagnosed with Charcot neuroarthropathy and osteomyelitis of the same foot were retrospectively analyzed. Some patients were successfully treated for osteomyelitis at different sites on the same foot at different times, thus 60 cases of osteomyelitis were identified in 40 treated patients. Cases were divided according to osteomyelitis localization: Group 1 had osteomyelitis outside the active Charcot region; Group 2 had osteomyelitis within the active Charcot region. RESULTS Male patients (n = 29; mean age 58.2, range 40.1 to 77.5 years) were younger than female patients (n = 11; mean age 70.4, range 51.4 to 87.5, p = 0.02 years). Amputation rate was 52% overall (26/40 patients; 26/43 ft): 63% of 30 Group 1 cases and 40% of 30 Group 2 cases (p = 0.09). Amputation level (p = 0.009), duration of antibiotic treatment (p = 0.045) and duration of immobilization (p = 0.01) differed significantly between the groups. CONCLUSIONS Osteomyelitis within the Charcot region is associated with a higher level of amputation and longer durations of antibiotic therapy and immobilization. Osteomyelitis outside and within the Charcot affected region should be considered separately. If osteomyelitis occurs outside the active Charcot region, primary amputation may be preferred to internal resection. LEVEL OF EVIDENCE Retrospective cohort chart review study.
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Affiliation(s)
- Martin Berli
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, -8008, Zurich, CH, Switzerland.
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, -8008, Zurich, CH, Switzerland
| | - Sabra Leupi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, -8008, Zurich, CH, Switzerland
| | - Thomas Böni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, -8008, Zurich, CH, Switzerland
| | - Charlotte Baltin
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, -8008, Zurich, CH, Switzerland
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Diabetic osteoarthropathy care in Sweden - Need for improvement: A national inventory. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2017; 9:32-37. [PMID: 29067267 PMCID: PMC5651304 DOI: 10.1016/j.jcte.2017.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 12/19/2022]
Abstract
79% of the clinics had no guidelines for managing patients with osteoarthropathy. Only two clinics presented acceptable guidelines. Plain X-ray, was the common diagnostic method.
Aims Osteoarthropathy, a rare foot complication in patients with diabetes mellitus, calls for immediate and optimal management to prevent irreversible bone/joint destruction and risk of amputation. Awareness of the condition and adequate guidelines would minimize the consequences and the costs, both for the patient and for the society. We investigated the diabetic osteoarthropathy care in Swedish orthopedic clinics. Methods A questionnaire was distributed to 63 Swedish hospitals with emergency department for orthopedic patients. There was a 95% response rate. Results Most of the respondents (79%) specified absence of established procedures including guidelines for managing patients with osteoarthropathy. The most common diagnostic method was clinical diagnosis and plain X-ray (95%). MRI or scintigraphy was used by 19% and 10.5% respectively. As treatment method, 84% used a total contact cast, while 38% used orthoses. Treatment duration <3 months was reported in 4%, 3–6 months in 53% and 6–12 months in 28% of the clinics. Four clinics reported treatment duration >12 months and two clinics provided no treatment. Conclusion Our national inventory indicates a need for improvement in knowledge as well as guidance and organization at orthopedic clinics regarding optimal care of patients with diabetic osteoarthropathy.
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Sinacore DR, Bohnert KL, Smith KE, Hastings MK, Commean PK, Gutekunst DJ, Johnson JE, Prior FW. Persistent inflammation with pedal osteolysis 1year after Charcot neuropathic osteoarthropathy. J Diabetes Complications 2017; 31:1014-1020. [PMID: 28254346 PMCID: PMC5438890 DOI: 10.1016/j.jdiacomp.2017.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/19/2016] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
AIMS To determine local and systemic markers of inflammation and bone mineral density (BMD) in the foot and central sites in participants with diabetes mellitus and peripheral neuropathy (DMPN) with and without acute Charcot neuropathic osteoarthropathy (CN). METHODS Eighteen participants with DMPN and CN and 19 participants without CN had foot temperature assessments, serum markers of inflammation [C-reactive protein, (CRP) and erythrocyte sedimentation rate, (ESR)] and BMD of the foot, hip and lumbar spine at baseline and 1year follow-up. RESULTS CN foot temperature difference was higher compared to DMPN controls at baseline (4.2±1.9°F vs. 1.2±0.9°F, P<0.01) and after 1year (2.9±3.2°F vs. 0.9±1.1°F, P<0.01). Serum inflammatory markers in the CN group were greater at baseline and remained elevated 1year later compared to DMPN controls (CRP, P=0.02, ESR, P=0.03). All pedal bones' BMD decreased an average of 3% in the CN foot with no changes in hip or lumbar spine. DMPN controls' foot, hip and lumbar spine BMD remained unchanged. CONCLUSIONS Local and systemic inflammation persists 1 year after CN with an accompanying pedal osteolysis that may contribute to mid foot deformity which is the hallmark of the chronic Charcot foot.
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Affiliation(s)
- David R Sinacore
- Applied Kinesiology Laboratory, Program in Physical Therapy, Campus Box 8502, Washington University School of Medicine, St. Louis, MO, 63108.
| | - Kathryn L Bohnert
- Applied Kinesiology Laboratory, Program in Physical Therapy, Campus Box 8502, Washington University School of Medicine, St. Louis, MO, 63108
| | - Kirk E Smith
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AK
| | - Mary K Hastings
- Applied Kinesiology Laboratory, Program in Physical Therapy, Campus Box 8502, Washington University School of Medicine, St. Louis, MO, 63108
| | - Paul K Commean
- Electronic Radiology Laboratory, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - David J Gutekunst
- Musculoskeletal Biomechanics Laboratory, Program in Physical Therapy, Doisy College of Health Sciences, Saint Louis University, St. Louis, MO
| | - Jeffrey E Johnson
- Foot & Ankle Service, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Fred W Prior
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AK
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24
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Edmonds M. The benefits of working together in diabetic foot care for the vulnerable patient. PRACTICAL DIABETES 2016. [DOI: 10.1002/pdi.1995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Petrova NL, Edmonds ME. Acute Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2016; 32 Suppl 1:281-6. [PMID: 26451965 DOI: 10.1002/dmrr.2734] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 01/29/2023]
Abstract
Charcot neuro-osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Charcot foot when the X ray is still negative (stage 0 or incipient Charcot foot). Recent advances in imaging modalities have enabled the detection of initial signs of inflammation and underlying bone damage before overt bone and joint destruction has occurred. Casting therapy remains the mainstay of medical therapy of acute CN. If timely instituted, offloading can arrest disease activity and prevent foot deformity. In cases with severe deformity, modern surgical techniques can correct the unstable deformity for improved functional outcome and limb survival. Emerging new studies into the cellular mechanisms of severe bone destruction have furthered our understanding of the mechanisms of pathological bone and joint destruction in CN. It is hoped that these studies may provide a scientific basis for new interventions with biological agents.
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MESH Headings
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/diagnosis
- Arthropathy, Neurogenic/physiopathology
- Arthropathy, Neurogenic/therapy
- Bone Density Conservation Agents/adverse effects
- Bone Density Conservation Agents/therapeutic use
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Diabetic Foot/complications
- Diabetic Foot/diagnosis
- Diabetic Foot/physiopathology
- Diabetic Foot/therapy
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/diagnosis
- Diabetic Neuropathies/physiopathology
- Diabetic Neuropathies/therapy
- Early Diagnosis
- Evidence-Based Medicine
- Fractures, Bone/complications
- Fractures, Bone/epidemiology
- Fractures, Bone/etiology
- Fractures, Bone/therapy
- Humans
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Postoperative Complications/prevention & control
- Precision Medicine
- Protective Devices/trends
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Risk Factors
- Severity of Illness Index
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | - M E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
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26
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Abstract
Charcot foot syndrome is an uncommon complication of diabetes but is potentially devastating in its consequences. Outcome is made worse by widespread professional ignorance leading to delayed diagnosis, but it is also hampered by lack of understanding of its causes and lack of treatments with proven effectiveness, other than offloading. There remains a desperate need for studies into its causes as well as comparative audit and trials designed to determine the best treatment for this difficult condition. Such work can probably only be effectively carried out through the establishment of multicentre networks. Nevertheless, improved understanding in recent years of the likely role of inflammatory pathways has raised awareness of the multiple ways in which the effects of neuropathy may be manifest in the development of the Charcot foot. This awareness is also leading to the realization that similar processes may conceivably contribute to the refractoriness of other foot diseases in diabetes, including both chronic unhealing ulcers and osteomyelitis.
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Affiliation(s)
- W J Jeffcoate
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, UK
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27
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Hess S, Hansson SH, Pedersen KT, Basu S, Høilund-Carlsen PF. FDG-PET/CT in Infectious and Inflammatory Diseases. PET Clin 2014; 9:497-519, vi-vii. [DOI: 10.1016/j.cpet.2014.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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28
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Blume PA, Sumpio B, Schmidt B, Donegan R. Charcot neuroarthropathy of the foot and ankle: diagnosis and management strategies. Clin Podiatr Med Surg 2014; 31:151-72. [PMID: 24296023 DOI: 10.1016/j.cpm.2013.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This article reviews current literature discussing the etiology, pathophysiology, diagnosis and imaging, and conservative and surgical treatment of Charcot osteoarthropathy. The treatment of Charcot osteoarthropathy with concurrent osteomyelitis is also discussed.
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Affiliation(s)
- Peter A Blume
- Orthopedics and Rehabilitation, and Anesthesia, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA.
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