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Abstract
There are many similarities between nondiabetic and diabetic Charcot neuroarthropathy (CN) but many of the underlying causes causing nondiabetic neuropathy and CN are associated with poor bone quality. Patient workup for nondiabetic CN should include the underlying cause of the neuropathy and optimization of bony healing, such as vitamin D supplementation and bisphosphonate or calcitonin administration. Surgical reconstruction should include the most robust fixation possible, as nondiabetic patients with CN are more prone to delayed union.
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Dardari D, Schuldiner S, Julien CA, Ha Van G, M'Bemba J, Bourgeon M, Sultan A, Lepeut M, Grandperret-Vauthier S, Baudoux F, François M, Clavel S, Martini J, Vouillarmet J, Michon P, Moret M, Monnier A, Chingan-Martino V, Rigalleau V, Dumont I, Kessler L, Stifii I, Bouillet B, Bonnin P, Lemoine A, Da Costa Correia E, Faraill MMB, Muller M, Cazaubiel M, Zemmache MZ, Hartemann A. Trends in the relation between hyperglycemia correction and active Charcot neuroarthropathy: results from the EPICHAR study. BMJ Open Diabetes Res Care 2022; 10:10/5/e002380. [PMID: 36215101 PMCID: PMC9462091 DOI: 10.1136/bmjdrc-2021-002380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The pathophysiology of Charcot neuroarthropathy (CN) remains unclear. There are a number of hypotheses but these are not exclusive. In its clinical presentation, this complication intersects with the semiology of diabetic-induced neuropathy, such as peripheral hypervascularization and the appearance of arteriovenous shunt. The EPICHAR study is as yet an unpublished cohort of people living with diabetes complicated by CN (in active or chronic phase). Based on the findings of the EPICHAR study, this study aimed to investigate whether a reduction in the rate of hyperglycemia accompanies the onset of an active phase of CN. RESEARCH DESIGN AND METHODS Hemoglobin A1c (HbA1c) levels were assessed 3 months (M3) and 6 months (M6) before the diagnosis of active CN (M0). RESULTS 103 patients living with diabetes and presenting active CN were included between January and December 2019 from the 31 centers participating in this study (30 in France and 1 in Belgium). The mean age of the participants was 60.2±12.2 years; the vast majority were men (71.8%) living with type 2 diabetes (75.5%). Mean HbA1c levels significantly declined between M6 (median 7.70; Q1, Q3: 7.00, 8.55) and M3 (median 7.65; Q1, Q3: 6.90, 8.50) (p=0.012), as well as between M6 and M0 (median 7.40; Q1, Q3: 6.50, 8.50) (p=0.014). No significant difference was found between M3 and M0 (p=0.072). CONCLUSIONS A significant reduction in HbA1c levels seems to accompany the onset of the active phase of CN. TRIAL REGISTRATION NUMBER NCM03744039.
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Affiliation(s)
- Dured Dardari
- Diabetology, Centre Hospitalier Sud Francilien, Corbeil Essonne, France
- LBEPS, Université d'Evry, Evry, France
| | - Sophie Schuldiner
- Department of Endocrinology, Diabetology and Nutrition, University Hospital Nîmes, Nimes, France
| | | | - Georges Ha Van
- Diabetology, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | - Muriel Bourgeon
- Department of Endocrinology-Diabetology University Hospital Kremlin-Bicêtre France + Department of Medecine University Hospital Antoine Béclère Clamart France, Kremlin-Bicêtre, France
| | - Ariane Sultan
- Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
- Endocrinology Diabetes Department, CHU Montpellier, Montpellier, France
| | - Marc Lepeut
- Department of Endocrinology and Diabetology, Roubaix Hospital, Roubaix, France
| | | | - Florence Baudoux
- Department of Endocrinology and Diabetology, Claude Huriez Regional University Hospital, Lille, France
| | - Maud François
- Department of Endocrinology and Diabetology, Nutrition Robert Debré Hospital, Reims, France
| | - Sylvaine Clavel
- Department of Endocrinology and Diabetology, Hôtel Dieu Hospital, Le Creusot, France
| | - Jacques Martini
- Department of Endocrinology and Diabetology, University Hospital Rangueil, Toulouse, France
| | - Julien Vouillarmet
- Department of Endocrinology and Diabetology, Lyon South Hospital, Lyon, France
| | - Paul Michon
- Department of Endocrinology and Diabetology, Lyon South Hospital, Lyon, France
| | - Myriam Moret
- Department of Endocrinology and Diabetology, Cardiology Hospital Louis Pradel, Bron, France
| | | | - Vaneva Chingan-Martino
- Department of Endocrinology and Diabetology, University Hospital, Pointe-à-Pitre, France
| | - Vincent Rigalleau
- Department of Endocrinology and Diabetology, Haut-Lévêque University Hospital, Pessac, France
- Bordeaux Medical School, Bordeaux, France
| | | | - Laurence Kessler
- Internal Medicine Rheumatology Nutrition Endocrinology Diabetes Pole, Strasbourg University Hospitals, Strasbourg, France
- Medicine School Strasbourg, Strasbourg, France
| | - Ionela Stifii
- Internal Medicine Rheumatology Nutrition Endocrinology Diabetes Pole, Strasbourg University Hospitals, Strasbourg, France
| | - Benjamin Bouillet
- Department of Endocrinology, Diabetology and Nutrition, Dijon University Hospital, Dijon, France
- INSERM Unit, LNC-UMR 1231, University of Burgundy, DIJON, France
| | - Pierre Bonnin
- Department of Infectiology, Annecy Genevois Hospital, Metz-Tessy, France
| | - Amal Lemoine
- Vienne Hospital Centre Indoor Use Pharmacy, Vienne, France
| | | | | | - Marie Muller
- Department of Endocrinology and Diabetology, CHU MICHALLON, Grenoble, France
| | - Marie Cazaubiel
- Anesthesia Department, Tourcoing Hospital Center, Tourcoing, France
| | | | - Agnes Hartemann
- Department of Diabetes, Pitié Salpêtrière Hospital, Paris, France
- Sorbonne University Médicine, PARIS, FRANCE
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Jeffcoate W, Game F. The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm. Diabetes Care 2022; 45:1691-1697. [PMID: 35796768 DOI: 10.2337/dc21-2508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, U.K
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Cates NK, Wagler EC, Bunka TJ, Elmarsafi T, Tefera E, Kim PJ, Liu GT, Evans KK, Steinberg JS, Attinger CE. Charcot Reconstruction: Outcomes in Patients With and Without Diabetes. J Foot Ankle Surg 2021; 59:1229-1233. [PMID: 32921562 DOI: 10.1053/j.jfas.2020.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/12/2020] [Accepted: 05/21/2020] [Indexed: 02/03/2023]
Abstract
The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.
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Affiliation(s)
- Nicole K Cates
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Emily C Wagler
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Taylor J Bunka
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Tammer Elmarsafi
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington DC
| | - Paul J Kim
- Attending Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - George T Liu
- Attending Physician, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Karen K Evans
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - John S Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC.
| | - Christopher E Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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Dardari D, Dardari R. Why the Risk of Developing Neuroarthropathy Is Higher After Simultaneous Kidney and Pancreatic Transplantation Compared to Kidney Transplantation Only: The Role of Euglycemia. Ann Transplant 2021; 26:e928449. [PMID: 33526764 PMCID: PMC7866488 DOI: 10.12659/aot.928449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Dured Dardari
- Department of Diabetes, Sud Francilien Hospital Center 40 Avenue Serge Dassault, Corbeil-Essonnes, France.,LEBPS, Univ Evry, IRBA, Université de Paris-Saclay, Evry, France
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Dardari D. An overview of Charcot's neuroarthropathy. J Clin Transl Endocrinol 2020; 22:100239. [PMID: 33251117 PMCID: PMC7677697 DOI: 10.1016/j.jcte.2020.100239] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Dured Dardari
- Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil Essonnes, France
- LBEPS, Univ Evry, IRBA, Université Paris Saclay, 91025 Evry, France
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Ho S, Giddie J, Dhatariya KK. BILATERAL NEUROARTHROPATHY 11 YEARS AFTER SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT FOR TYPE 1 DIABETES MELLITUS. AACE Clin Case Rep 2020; 5:e259-e262. [PMID: 31967048 DOI: 10.4158/accr-2018-0408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/23/2018] [Indexed: 11/15/2022] Open
Abstract
Objective To report a case of a man who developed bilateral Charcot arthropathic feet 11 years after a simultaneous pancreas-kidney transplant (SPKT) for type 1 diabetes mellitus (DM). The patient had remained normoglycemic after surgery. Methods We present a retrospective review of the case notes and serial imaging. Results The patient developed dense peripheral diabetic neuropathy due to poor glycemic control. His biochemical markers of DM all normalized following SPKT, and he was discharged by his primary and secondary care diabetes services. Eleven years later, he developed Charcot arthropathy in one foot and, within a month, the other foot as well. Conclusion Individuals with DM who had preoperative end organ diabetes-related damage who went into biochemical remission after SPKT may be at risk for future complications. They should not be discharged from specialist diabetes services, and they need continued education about foot care.
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Anthony ML, Cravey KS, Atway SA. Development of Charcot Neuroarthropathy in Diabetic Patients who Received Kidney or Kidney-Pancreas Transplants. J Foot Ankle Surg 2019; 58:475-479. [PMID: 30765253 DOI: 10.1053/j.jfas.2018.09.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 02/03/2023]
Abstract
Only a small percentage of the general diabetic population develops Charcot neuroarthropathy. Charcot arthropathy greatly increases the risk of foot complications. At our academic institution, there appeared to be an increased incidence of Charcot arthropathy in transplant patients. We hypothesized that Charcot neuroarthropathy incidence is higher in the diabetic patients who had received kidney or kidney-pancreas transplants. The charts of 1000 patients were reviewed from January 2000 to January 2011. Four hundred and eighty-seven patients were included in the study. Of these diabetic patients, 249 had received a kidney transplant and 238 a kidney-pancreas transplant. The data were analyzed for the incidence of Charcot in each group. Other risk factors and sequelae were also evaluated and analyzed. The incidence of Charcot development in the diabetic patients who had a kidney-pancreas transplant was 18.4%, 44 of 238 patients. This was significantly higher than the incidence in kidney transplant patients, which was 11.2%, 28 of 249 patients (p < .05). Peripheral arterial disease was a statistically significant independent risk factor for developing ulceration, osteomyelitis, and subsequent amputation. Type 1 diabetic patients developed Charcot at a higher rate that was also statistically significant compared with type 2 diabetic patients. In our study, diabetic patients who had undergone kidney-pancreas transplants were associated with higher risk for development of Charcot neuroarthropathy than kidney transplants alone. The incidence of Charcot development in both these transplant groups was also much higher than in the general diabetic population. This is of particular interest to clinicians and surgeons as both transplant groups were found to be high risk for subsequent foot ulceration, infection, and amputation.
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Affiliation(s)
- Michael L Anthony
- Assistant Professor, Podiatric Medicine and Surgery Residency Program, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kimberly S Cravey
- Resident, Podiatric Medicine and Surgery Residency Program, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Said A Atway
- Assistant Professor, Podiatric Medicine and Surgery Residency Program, The Ohio State University Wexner Medical Center, Columbus, OH
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De Lucena DD, Rangel ÉB. Glucocorticoids use in kidney transplant setting. Expert Opin Drug Metab Toxicol 2018; 14:1023-1041. [DOI: 10.1080/17425255.2018.1530214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Débora Dias De Lucena
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
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DiDomenico L, Flynn Z, Reed M. Treating Charcot Arthropathy Is a Challenge: Explaining Why My Treatment Algorithm Has Changed. Clin Podiatr Med Surg 2018; 35:105-121. [PMID: 29156160 DOI: 10.1016/j.cpm.2017.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Charcot deformity is a challenge that foot and ankle surgeons struggle to manage successfully. Despite the advances in knowledge, technology, and treatment modalities, limb loss is still greater than 10%. This article discusses the efficacy of conservative measures and traditional surgical approaches. It proposes a multidisciplinary team approach, medical optimization, and lifestyle modification to put the patient in the best position to heal. Also discussed is the authors' staged surgical treatment protocol to enhance outcomes and decrease the rate of limb loss.
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Affiliation(s)
- Lawrence DiDomenico
- St. Elizabeth Medical Center, 8175 Market Street, Youngstown, OH 44512, USA.
| | - Zachary Flynn
- St. Elizabeth Medical Center, 8175 Market Street, Youngstown, OH 44512, USA
| | - Michael Reed
- Northside Medical Center, 500 Gypsy Lane, Youngstown, OH 44512, USA
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Lauria MW, Ribeiro-Oliveira A. Diabetes and other endocrine-metabolic abnormalities in the long-term follow-up of pancreas transplantation. Clin Diabetes Endocrinol 2016; 2:14. [PMID: 28702248 PMCID: PMC5471933 DOI: 10.1186/s40842-016-0032-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/03/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreas transplantation (PTX) has been demonstrated to restore long-term glucose homeostasis beyond what can be achieved by intensive insulin therapy or islet transplants. Moreover, PTX has been shown to decrease the progression of the chronic complications of diabetes. However, PTX patients require chronic use of immunosuppressive drugs with potential side effects. The long-term follow-up of PTX patients demands special care regarding metabolic deviations, infectious complications, and chronic rejection. Diabetes and other endocrine metabolic abnormalities following transplantation are common and can increase morbidity and mortality. Previous recipient-related and donor-related factors, as well as other aspects inherent to the transplant, act together in the pathogenesis of those abnormalities. Early recognition of these disturbances is the key to timely treatment; however, adequate tools to achieve this goal are often lacking. In a way, the type of PTX procedure, whether simultaneous pancreas kidney or not, seems to differentially influence the evolution of endocrine and metabolic abnormalities. Further studies are needed to define the best approach for PTX patients. This review will focus on the most common endocrine metabolic disorders seen in the long-term management of PTX: diabetes mellitus, hyperlipidemia, and bone loss. The authors here cover each one of these endocrine topics by showing the evaluation as well as proper management in the follow-up after PTX.
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Affiliation(s)
- Marcio W Lauria
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
| | - Antonio Ribeiro-Oliveira
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
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12
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Wilson M. Charcot's Neuroarthropathy After Simultaneous Pancreas-Kidney TransplantA Case Report. J Am Podiatr Med Assoc 2016; 106:294-8. [PMID: 27489970 DOI: 10.7547/15-037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Simultaneous pancreas-kidney transplant (SPKT) is an accepted approach and the treatment of choice in patients with type 1 diabetes with accompanying end-stage renal disease. Charcot's neuroarthropathy of the foot (CN) is a fairly common and devastating complication found in patients with long-standing, mostly uncontrolled, diabetes. However, CN has also been identified as a posttransplant consequence of SPKT. Traditional postoperative immunosuppressive therapy, particularly the use of corticosteroids, is acknowledged as an additional risk factor for the development of de novo CN after SPKT. This article describes an unusual case of a patient who presented with full-blown CN deformity after SPKT.
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13
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García Barrado F, Kuypers DR, Matricali GA. Charcot neuroarthropathy after simultaneous pancreas-kidney transplantation: risk factors, prevalence, and outcome. Clin Transplant 2015; 29:712-9. [PMID: 26033225 DOI: 10.1111/ctr.12572] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 01/25/2023]
Abstract
We retrospectively analyzed outcome and risk factors of developing Charcot foot (CF) in 100 patients with type 1 diabetes mellitus who underwent a simultaneous pancreas-kidney (SPK) transplantation. Patients who developed CF after SPK transplantation had significantly higher mortality (56% vs. 18%) and more frequently graft failure (44% vs. 13%). Recipients with CF also experienced acute rejections more frequently (78% vs. 41%). They furthermore had higher pre-transplant values of HbA1c , received cyclosporine and azathioprine more often, and had significantly higher cumulative corticosteroid use. Patients transplanted in an earlier era (1992-1998) received cyclosporine and azathioprine more often and had a significantly higher cumulative corticosteroid use with the higher prevalence of CF. Conversely, patients with diabetes transplanted more recently (1999-2012) received lower doses of corticosteroids as part of their tacrolimus-based immunosuppressive therapy, resulting in fewer CF attacks. In conclusion, development of CF after SPK is associated with poor patient and graft outcome. Poor pre-transplant diabetic control and the use of high-dose corticosteroids are risk factors for the development of CF. We recommend reduction in or even total avoidance of corticosteroids after SPK transplantation. Given the importance of the diagnosis of CF on outcome, a systematic examination of SPK patients' feet is recommended.
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Affiliation(s)
- Fernando García Barrado
- Department of Orthopaedics & Diabetic Foot Clinic, University Hospitals Leuven, Leuven, Belgium
| | - Dirk R Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Giovanni A Matricali
- Department of Orthopaedics & Diabetic Foot Clinic, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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14
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Zou RH, Wukich DK. Outcomes of Foot and Ankle Surgery in Diabetic Patients Who Have Undergone Solid Organ Transplantation. J Foot Ankle Surg 2015; 54:577-81. [PMID: 25488595 PMCID: PMC5664157 DOI: 10.1053/j.jfas.2014.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Indexed: 02/03/2023]
Abstract
Foot and ankle problems are highly prevalent in patients with diabetes mellitus (DM). Increased rates of surgical site infections and noninfectious complications, such as malunion, delayed union, nonunion, and hardware failure, have also been more commonly observed in diabetic patients who undergo foot and ankle surgery. DM is a substantial contributor of perioperative morbidity in patients with solid organ transplantation. To the best of our knowledge, postoperative foot and ankle complications have not been studied in a cohort of diabetic patients who previously underwent solid organ transplantation. The aim of the present study was to evaluate the outcomes of foot and ankle surgery in a cohort of diabetic transplant patients and to compare these outcomes with those of diabetic patients without a history of transplantation. We compared the rates of infectious and noninfectious complications after foot and ankle surgery in 28 diabetic transplant patients and 56 diabetic patients without previous transplantation and calculated the odds ratios (OR) for significant findings. The diabetic transplant patients who underwent foot and ankle surgery in the present cohort were not at an increased risk of overall complications (OR 0.83, 95% confidence interval [CI] 0.33 to 2.08, p = .67), infectious complications (OR 0.54, 95% CI 0.09 to 3.09, p = .49), or noninfectious complications (OR 1.14, 95% CI 0.41 to 3.15, p = .81). Four transplant patients (14.3%) died of non-orthopedic surgery-related events during the follow-up period; however, no deaths occurred in the control group. Diabetic patients with previous solid organ transplantation were not at an increased risk of developing postoperative complications after foot and ankle surgery, despite being immunocompromised. The transplant patients had a greater mortality rate, but their premature death was unrelated to their foot and ankle surgery. Surgeons treating transplant patients can recommend foot and ankle surgery when indicated. However, owing to the increased mortality rate and comorbidities associated with this high-risk group, we recommend preoperative clearance from the transplant team and medical consultations before performing surgery.
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Affiliation(s)
- Richard H. Zou
- Medical Student, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Dane K. Wukich
- Professor, Department of Orthopaedic Surgery; Chief, Division of Foot and Ankle Surgery; Professor, Rehabilitation Science and Technology; Medical Director, Mercy Center for Healing and Amputation Prevention; and Medical Director, Comprehensive Foot and Ankle Center, University of Pittsburgh Medical Center, Pittsburgh, PA
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15
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Del Vecchio JJ, Raimondi N, Rivarola H, Autorino C. Charcot neuroarthropathy in simultaneous kidney-pancreas transplantation: report of two cases. Diabet Foot Ankle 2013; 4:21819. [PMID: 24003361 PMCID: PMC3758518 DOI: 10.3402/dfa.v4i0.21819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 08/02/2013] [Accepted: 08/03/2013] [Indexed: 11/18/2022]
Abstract
Charcot neuroarthropathy (CN) is considered a major complication in diabetes mellitus (DM), and it is estimated that 1% of diabetic patients may develop this complication. Simultaneous kidney–pancreas transplantation (SKPT) is one of the most effective therapies for patients with type 1 DM and end-stage diabetic nephropathy. Some cases with a Charcot-modified clinical presentation during the postoperative convalescence period after SKPT have been described. The clinical presentation may condition severe destructive lesions, and good practices include systematic follow-up. Based on the cases described, SKPT is one more entity that might lead to CN ‘foot-at-risk’. The aim of this article is to describe two cases of neuropathic arthropathy with rapid progression in the short term after SKPT.
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Affiliation(s)
- Jorge Javier Del Vecchio
- Foot and Ankle Section, Department of Orthopaedic and Traumatology, Favaloro Foundation, CABA (Ciudad Autónoma de Buenos Aires), Argentina
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Kaynak G, Birsel O, Güven MF, Oğüt T. An overview of the Charcot foot pathophysiology. Diabet Foot Ankle 2013; 4:21117. [PMID: 23919113 PMCID: PMC3733015 DOI: 10.3402/dfa.v4i0.21117] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/09/2013] [Accepted: 07/01/2013] [Indexed: 01/15/2023]
Abstract
Charcot arthropathy of the foot is a rare but devastating complication of diabetes that remains to be a challenging issue for the foot and ankle surgeons. Charcot foot fails to be an obvious diagnostic option that comes to mind, even in a pathognomonic clinical appearance. The rarity of the disorder, more common pathologies that mimic the condition, and the self-limiting prognosis deviate the clinician from the right diagnosis. The clinical challenges in the diagnosis of Charcot foot require in-depth investigations of its enigmatic nature to establish useful guidelines. Yet, this goal seems to be beyond reach, without a holistic view of the immense literature concerning the pathophysiology of the disorder. The primary objective of this article is to put together and review the recent advancements about the etiology and intrinsic mechanisms of diabetic Charcot foot.
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Affiliation(s)
- Gökhan Kaynak
- Cerrahpasa Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, Istanbul, Turkey
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