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Diacogiorgis D, Perrin BM, Kingsley MIC. Assessment, diagnosis and management characteristics of people with acute Charcot neuro-osteoarthropathy in a regional Australian health service: A 3-year retrospective audit. Aust J Rural Health 2024; 32:987-995. [PMID: 39044431 DOI: 10.1111/ajr.13168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/25/2024] [Accepted: 07/08/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVE Acute Charcot neuro-osteoarthropathy (CN) is highly destructive, causing bone and joint damage that can result in devastating structural changes to the foot. The objective of this study was to determine the characteristics of assessment, diagnosis and management of people with acute CN attending a large regional Australian health service. DESIGN Three-year retrospective medical record audit. SETTING Large regional health service with catchment area of >250 000 people in regional Australia. PARTICIPANTS People with acute CN who attended emergency, orthopaedic clinics or High Risk Foot Clinic (HRFC). MAIN OUTCOME MEASURES Participant characteristics and acute CN assessment, diagnosis and management characteristics. Trends in characteristics were investigated according to rurality as measured by the Modified Monash Model (MMM) scale. RESULTS Seventeen participants (20 presentations) of acute CN were identified. Mean age was 57.1 ± 10.8 years, with 11 female participants. Median duration to seek help was 31 (IQR 14-47) days. Total Contact Casting was undertaken for 85% of cases, with those who resided in MMM1-2 regions experienced significantly shorter time to TCC therapy compared to those residing in MMM3-7 regions (U = 3.0, p < 0.01). Resolution of acute CN with or without deformity occurred in 70% of cases. CONCLUSIONS Those who lived in smaller regional and rural communities were more likely to experience delayed access to gold standard treatment for acute CN. Regional models of care for acute CN should include activities to improve the knowledge of people at risk of acute CN about the condition and upskill regional health professionals for timely and local TCC therapy.
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Affiliation(s)
- Dimitri Diacogiorgis
- Department of Podiatry and Allied Health Assistants, Ballarat Health Services, Grampians Health, Ballarat, Victoria, Australia
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Byron Matthew Perrin
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Holsworth Research Initiative, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Michael Ian Charles Kingsley
- Holsworth Research Initiative, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Department of Exercise Sciences, Faculty of Science, University of Auckland, Auckland, New Zealand
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2
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Tsatsaris G, Rajamand Ekberg N, Fall T, Catrina SB. Risk factors for Charcot foot development in individuals with diabetes mellitus. Diabetologia 2024:10.1007/s00125-024-06271-9. [PMID: 39271519 DOI: 10.1007/s00125-024-06271-9] [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: 06/12/2024] [Accepted: 07/23/2024] [Indexed: 09/15/2024]
Abstract
AIMS/HYPOTHESIS Charcot foot is a complication of diabetes mellitus that has potentially disastrous consequences. Although it was first described in 1868 and found to be associated with diabetes in 1936, there is still uncertainty about the risk factors affecting the development of the condition. Here, we aim to identify risk factors for Charcot foot in a nationwide cohort study. METHODS A retrospective register-based cohort study was performed for the period 2001-2016, using nationwide registries. Individuals with diabetes and Charcot foot were identified and matched by diabetes type and with similar diabetes duration with individuals with diabetes but not Charcot foot. Logistic regression analyses were used to identify risk factors. RESULTS A total of 3397 participants with diabetes mellitus and Charcot foot and 27,662 control participants with diabetes but without Charcot foot were included. HbA1c, duration of diabetes, micro- and macroalbuminuria, retinopathy and atherosclerosis (general and peripheral) were identified as risk factors for Charcot foot in participants with type 1 diabetes and participants with type 2 diabetes. CONCLUSIONS/INTERPRETATION In the most extensive study on Charcot foot to date, we identified distinctive and common risk factors associated with the development of Charcot foot in individuals with type 1 diabetes and type 2 diabetes.
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Affiliation(s)
- Georgios Tsatsaris
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Neda Rajamand Ekberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Centre for Diabetes, Academic Specialist Centrum, Stockholm, Sweden
- Department of Endocrinology and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Tove Fall
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
- Centre for Diabetes, Academic Specialist Centrum, Stockholm, Sweden.
- Department of Endocrinology and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
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Tsatlidou M, Vasiliadis AV, Metaxiotis D. What the Physician Needs to Know about Charcot Arthropathy and Ankle Fracture Treatment Dilemma: A Case Report and a Possible Medical Approach and Treatment Algorithm. J Orthop Case Rep 2024; 14:45-51. [PMID: 38910990 PMCID: PMC11189088 DOI: 10.13107/jocr.2024.v14.i06.4498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/22/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Charcot arthropathy consists of a rapid and destructive complication of the joints following the loss of innervation caused by many complicated etiologies. Diabetic neuropathy has become the most common etiological factor. Case Report We present a case of a 64-year-old female patient with a history of chronic renal failure on hemodialysis, hypertension, hypothyroidism, and Type 2 diabetes, complicated with neuropathy and Charcot disease, who referred to our department. Initially, the patient was managed with a restraint orthotic device due to a bimalleolar ankle fracture. An unsuccessful treatment and the presence of a pressure ulcer with pus-like drainage on the lateral malleolus 2 months later led to the decision for a below-knee amputation. Conclusion High clinical suspicion by the attending physician may reduce the risk of complications and lead to proper treatment with better outcomes.
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Affiliation(s)
- Maria Tsatlidou
- nd Orthopaedic Department, General Hospital of Thessaloniki “Papageorgiou”, 56429 Thessaloniki, Greece
| | - Angelo V Vasiliadis
- nd Orthopaedic Department, General Hospital of Thessaloniki “Papageorgiou”, 56429 Thessaloniki, Greece
- Department of Orthopaedic Surgery and Sports Medicine, Croix-Rousse Hospital, 69002 Lyon, France
| | - Dimitrios Metaxiotis
- nd Orthopaedic Department, General Hospital of Thessaloniki “Papageorgiou”, 56429 Thessaloniki, Greece
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Duarte EG, Lopes CF, Gaio DRF, Mariúba JVDO, Cerqueira LDO, Manhanelli MAB, Navarro TP, Castro AA, de Araujo WJB, Pedrosa H, Galli J, de Luccia N, de Paula C, Reis F, Bohatch MS, de Oliveira TF, da Silva AFV, de Oliveira JCP, Joviliano EÉ. Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot. J Vasc Bras 2024; 23:e20230087. [PMID: 38803655 PMCID: PMC11129855 DOI: 10.1590/1677-5449.202300872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/12/2023] [Indexed: 05/29/2024] Open
Abstract
The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.
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Affiliation(s)
- Eliud Garcia Duarte
- Hospital Estadual de Urgência e Emergência do Estado do Espírito Santo – HEUE, Departamento de Cirurgia Vascular, Vitória, ES, Brasil.
| | - Cicero Fidelis Lopes
- Universidade Federal da Bahia – UFBA, Departamento de Cirurgia Vascular, Salvador, BA, Brasil.
| | | | | | | | | | - Tulio Pinho Navarro
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
| | - Aldemar Araújo Castro
- Universidade Estadual de Ciências da Saúde de Alagoas – UNCISAL, Departamento de Cirurgia Vascular, Maceió, AL, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Hermelinda Pedrosa
- Hospital Regional de Taguatinga – HRT, Departamento de Cirurgia Vascular, Brasília, DF, Brasil.
| | - Júnio Galli
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Nelson de Luccia
- Universidade de São Paulo – USP, Faculdade de Medicina, Hospital das Clínicas – HC, São Paulo, SP, Brasil.
| | - Clayton de Paula
- Rede D’or São Luiz, Departamento de Cirurgia Vascular, São Paulo, SP, Brasil.
| | - Fernando Reis
- Faculdade de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | - Milton Sérgio Bohatch
- Faculdade de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | | | | | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia Vascular, Rio de Janeiro, RJ, Brasil.
| | - Edwaldo Édner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Departamento de Cirurgia Vascular, Ribeirão Preto, SP, Brasil.
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Rogero RG, Swamy S, Bettin CC. The Differentiation Between Infection and Acute Charcot. Orthop Clin North Am 2024; 55:299-309. [PMID: 38403375 DOI: 10.1016/j.ocl.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.
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Affiliation(s)
- Ryan G Rogero
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA
| | - Samhita Swamy
- University of Tennessee Health Science Center College of Medicine, 847 E Parkway S, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA.
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Schoug J, Katzman P, Fagher K, Löndahl M. Charcot Foot Offloading in Stage 0 Is Associated With Shorter Total Contact Cast Treatment and Lower Risk of Recurrence and Reconstructive Surgery: A Pilot Study. Diabetes Care 2024; 47:252-258. [PMID: 38032793 DOI: 10.2337/dc23-1063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Charcot foot (CF) requires prolonged offloading of the affected foot to decrease the risk of deformity. The earliest phase in active CF (stage 0) is characterized by inflammatory signs without established fractures or skeletal deformity. We investigated whether offloading in stage 0 influences duration of total contact casting (TCC), risk of recurrence, and future need for surgery. RESEARCH DESIGN AND METHODS All patients treated for active CF at Skåne University Hospital (Lund, Sweden) between 2006 and 2019 were screened for participation in a retrospective cohort study. CF events of included patients were classified as stage 0 or 1 according to X-ray and MRI reports. RESULTS A total of 183 individuals (median age 61 [interquartile range (IQR) 52-68] years, 37% type 1 diabetes, 62% men) were followed for a median of 7.0 (IQR 3.9-11) years. In 198 analyzed CF events, 74 were treated with offloading in stage 0 and 124 in stage 1. Individuals offloading in stage 0 had significantly shorter TCC duration (median 75 [IQR 51-136] vs. 111.5 [72-158] days; P = 0.001). The difference was sustained when including only MRI-confirmed CF. The risk of developing new ipsilateral CF events >1 year after introduced definitive footwear was lower in those treated with offloading in stage 0 (2.7% vs. 9.7%; P < 0.05). No individual treated with offloading in stage 0 underwent reconstructive surgery, compared with 11 (8.9%) treated with offloading in stage 1 (P < 0.01). Amputation rates were similar. CONCLUSIONS Offloading in stage 0 CF was associated with shorter TCC treatment, lower risk of a new CF event, and diminished need for reconstructive surgery. Future amputation risk was not affected.
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Affiliation(s)
- Johan Schoug
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
- Institution for Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Katzman
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
- Institution for Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Katarina Fagher
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
- Institution for Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Magnus Löndahl
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
- Institution for Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
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7
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Julien CA, Ha Van G, M'Bemba J, Bourgeon M, Dardari D, Lepeut M, Dumont I, Zemmache MZ, Serrand C, Bouillet B, Sultan A, Schuldiner S. Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic foot expert centers (The EPiChar Study). Acta Diabetol 2023; 60:1209-1218. [PMID: 37184671 DOI: 10.1007/s00592-023-02101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/09/2023] [Indexed: 05/16/2023]
Abstract
AIM To evaluate the real-life diagnosis and therapeutic means of Charcot Neuroosteoarthropathy (CN) in French-Belgian diabetic foot expert centers. METHODS We collected clinical characteristics, results of exams and therapeutic pathways of consecutive adult patients with diabetic osteoarthropathy seen in consultation or hospitalization from January 1 to December 31, 2019 in 31 diabetic foot expert centers. The primary outcome was to describe the diagnostic and management methods for CN according to patient clinical characteristics, the clinical-radiological characteristics of acute and chronic CN and discharge means. RESULTS 467 patients were included: 364 with chronic CN and 103 in the acute phase. 101 patients had bilateral chronic CN. Most patients were male (73.4%), treated with insulin (73.3%), and with multicomplicated diabetes. In the acute phase, edema and increased foot temperature were present in 75% and 58.3% of cases, respectively. Diagnosis confirmation was usually by MRI and the mode of discharge was variable. In the chronic phase, orthopedic shoes were prescribed in 81.5% of cases. CONCLUSIONS This observational study highlights the diagnostic and therapeutic practices in 31 diabetic foot centers. Our results highlight that the use of MRI and the modalities of offloading, an essential treatment in the acute phase, need to be better standardized. Centers were highly encouraging about creating a patient registry.
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Affiliation(s)
- Carole-Anne Julien
- Service des Maladies métaboliques et Endocriniennes, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Georges Ha Van
- Service de Diabétologie, AP-HP La Pitié Salpétrière, Paris, France
| | | | - Muriel Bourgeon
- Service Endocrinologie, AP-HP Kremlin Bicêtre, Kremlin Bicêtre, France
| | - Dured Dardari
- Service de Diabétologie, CH Sud Francilien, Corbeil-Essonnes, France
| | - Marc Lepeut
- Service de Diabétologie, CH Roubaix, Roubaix, France
| | | | - Mohammed Zakarya Zemmache
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Chris Serrand
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Benjamin Bouillet
- Service d'Endocrinologie, Diabétologie, Maladies Métaboliques, CHU Dijon, Dijon, France
| | - Ariane Sultan
- 10PhyMedExp, INSERM U1046, UMR 9214, Univ Montpellier, Service Des Maladies Métaboliques, CHU Montpellier, Montpellier, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service Des Maladies Métaboliques Et Endocriniennes, CHU Nîmes, Clinique du Pied Gard Occitanie, Route de Carnon, 30240, Le Grau du Roi, France.
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Greco T, Mascio A, Comisi C, Polichetti C, Caravelli S, Mosca M, Mondanelli N, Troiano E, Maccauro G, Perisano C. RANKL-RANK-OPG Pathway in Charcot Diabetic Foot: Pathophysiology and Clinical-Therapeutic Implications. Int J Mol Sci 2023; 24:ijms24033014. [PMID: 36769345 PMCID: PMC9917950 DOI: 10.3390/ijms24033014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
Charcot Foot (CF), part of a broader condition known as Charcot Neuro-Osteoarthropathy (CNO), is characterized by neuropathic arthropathy with a progressive alteration of the foot. CNO is one of the most devastating complications in patients with diabetes mellitus and peripheral neuropathy but can also be caused by neurological or infectious diseases. The pathogenesis is multifactorial; many studies have demonstrated the central role of inflammation and the Receptor Activator of NF-κB ligand (RANKL)-Receptor Activator of NF-κB (RANK)-Osteoprotegerin (OPG) pathway in the acute phase of the disease, resulting in the serum overexpression of RANKL. This overexpression and activation of this signal lead to increased osteoclast activity and osteolysis, which is a prelude to bone destruction. The aim of this narrative review is to analyze this signaling pathway in bone remodeling, and in CF in particular, to highlight its clinical aspects and possible therapeutic implications of targeting drugs at different levels of the pathway. Drugs that act at different levels in this pathway are anti-RANKL monoclonal antibodies (Denosumab), bisphosphonates (BP), and calcitonin. The literature review showed encouraging data on treatment with Denosumab, although in a few studies and in small sample sizes. In contrast, BPs have been re-evaluated in recent years in relation to the high possibility of side effects, while calcitonin has shown little efficacy on CNO.
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Affiliation(s)
- Tommaso Greco
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-3807-582-118
| | - Antonio Mascio
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Comisi
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Polichetti
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Silvio Caravelli
- U.O.C. II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Massimiliano Mosca
- U.O.C. II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Giulio Maccauro
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Carlo Perisano
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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Gooday C, Game F, Woodburn J, Poland F, Sims E, Dhatariya K, Shepstone L, Barton G, Hardeman W. A randomised feasibility study of serial magnetic resonance imaging to reduce treatment times in Charcot neuroarthropathy in people with diabetes (CADOM). J Foot Ankle Res 2023; 16:2. [PMID: 36703174 PMCID: PMC9878485 DOI: 10.1186/s13047-023-00601-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/04/2023] [Indexed: 01/27/2023] Open
Abstract
AIM This study aims to explore the feasibility of using serial MRI without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot, in order to decide whether a large-scale trial is warranted. METHODS A multicentre, randomised, prospective, two arm, open, feasibility study (CADOM) of people with diabetes with a suspected or confirmed diagnosis of Charcot neuroarthropathy. Participants were randomised (1:1) to 'standard care plus', including repeated foot temperature measurements and X-rays, or the intervention arm, with additional three-monthly MRI, until remission of Charcot neuroarthropathy or a maximum 12 months (active phase). Participants were then followed-up for a further 6 months, post remission to monitor for relapse of the Charcot neuroarthropathy (follow-up phase). Feasibility outcomes were recruitment, retention, data completeness, adherence to study procedures and safety of the intervention MRI. We also collected clinical efficacy outcomes, this included time in cast/off-loading device which will be the primary outcome of a future definitive trial. Finally, we collected patient reported outcomes, and data on health and social care usage. RESULTS One-hundred and five people were assessed for eligibility at five sites. 64/105 potential participants meet the eligibility criteria to participate in the study. Forty-three participants were randomised: 20 to standard care plus and 23 to MRI intervention. The main reason for ineligibility was a previous episode of Charcot neuroarthropathy. Thirteen participants were withdrawn post-randomisation due to an alternative diagnosis being made. Of the remaining 30 participants, 19 achieved remission, 6 had not gone into remission at the end of the 12 month active phase so exited the study. Five participants were lost to follow-up. Of the MRIs that were not disrupted by COVID-19 pandemic 26/31 (84%) were completed. For the visits that were conducted face-to-face, completion rates of patient-reported outcome measures were between 71 and 100%. There were no safety incidents associated with the intervention MRI. As this was a feasibility study it was not designed to test the effectiveness of serial MRI in diagnosing remission. The time in cast/off-loading device was 235 (±108.3) days for the standard care plus arm compared to 292 (±177.4) days for the intervention arm. There was no statistical difference in the time in cast/off-loading device between the two arms of the study: Hazard Ratio (HR) 0.405 (95% CI 0.140-1.172), p = 0.096. DISCUSSION The findings support a definitive randomised controlled trial to evaluate the effectiveness of MRI in diagnosing remission in Charcot neuroarthropathy. The rates of recruitment, retention, data, and MRI completeness show that a definitive study is feasible. STUDY REGISTRATION ISRCTN, 74101606 . Registered on 6 November 2017.
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Affiliation(s)
- Catherine Gooday
- grid.8273.e0000 0001 1092 7967School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK ,grid.240367.40000 0004 0445 7876Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Frances Game
- grid.508499.9Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE UK
| | - Jim Woodburn
- grid.1022.10000 0004 0437 5432School of Health Sciences and Social Work, Griffith University, Southport, QLD 4222 Australia
| | - Fiona Poland
- grid.8273.e0000 0001 1092 7967Institute for Volunteering Research, Faculty of Medicine and Health Science, University of East Anglia, Norwich, NR4 7TJ UK
| | - Erika Sims
- grid.8273.e0000 0001 1092 7967Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Ketan Dhatariya
- grid.240367.40000 0004 0445 7876Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK ,grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Lee Shepstone
- grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Garry Barton
- grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Wendy Hardeman
- grid.8273.e0000 0001 1092 7967School of Health Sciences - Behavioural and Implementation Science Group, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
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10
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Gooday C, Hardeman W, Poland F, Woodburn J, Dhatariya K. Controversies in the management of active Charcot neuroarthropathy. Ther Adv Endocrinol Metab 2023; 14:20420188231160406. [PMID: 37101723 PMCID: PMC10123890 DOI: 10.1177/20420188231160406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 02/11/2023] [Indexed: 04/28/2023] Open
Abstract
Charcot neuroarthropathy (CN) was first described over 150 years ago. Despite this there remains uncertanity around the factors that contribute to its development, and progression. This article will discuss the current controversies around the pathogenesis, epidemiology, diagnosis, assessment and management of the condition. The exact pathogenesis of CN is not fully understood, and it is likely to be multifactorial, with perhaps currently unknown mechanisms contributing to its development. Further studies are needed to examine opportunities to help screen for and diagnose CN. As a result of many of these factors, the true prevalence of CN is still largely unknown. Almost all of the recommendations for the assessment and treatment of CN are based on low-quality level III and IV evidence. Despite recommendations to offer people with CN nonremovable devices, currently only 40-50% people are treated with this type of device. Evidence is also lacking about the optimal duration of treatment; reported outcomes range from 3 months to more than a year. The reason for this variation is not entirely clear. A lack of standardised definitions for diagnosis, remission and relapse, heterogeneity of populations, different management approaches, monitoring techniques with unknown diagnostic precision and variation in follow-up times prevent meaningful comparison of outcome data. If people can be better supported to manage the emotional and physical consequences of CN, then this could improve people's quality of life and well-being. Finally, we highlight the need for an internationally coordinated approach to research in CN.
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Affiliation(s)
| | - Wendy Hardeman
- Behavioural and Implementation Science Group, School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Fiona Poland
- Institute for Volunteering Research, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Jim Woodburn
- School of Health Sciences and Social Work, Griffith University, Southport, QLD, Australia
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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11
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Abstract
Charcot can be a difficult clinical entity to diagnose in the acute phase, and clinicians should have a high clinical suspicion in neuropathic patients who present with erythema, edema, and warmth of the foot or ankle. Immobilization and nonweight-bearing should be immediately initiated when the diagnosis of Charcot has been made and patients should remain nonweight-bearing until the affected bones/joints have coalesced. Educating patients and managing expectations is crucial to improve compliance with the conservative treatment of Charcot and avoid the long-term sequelae including severe deformity, ulceration and infection, and amputation.
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Affiliation(s)
- Mallory Schweitzer
- Multicare Podiatry Associates, 315 M.L.K Jr. Way, Tacoma, WA 98405, USA.
| | - Stephen Rockhill
- Franciscan Foot and Ankle Institute, 34509 9th Avenue South, Federal Way, WA 98003, USA
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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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Shazadeh Safavi K, Janney C, Shazadeh Safavi P, Kunzler D, Jupiter D, Panchbhavi V. Inappropriate antibiotic administration in the setting of Charcot arthropathy: A case series and literature review. Prim Care Diabetes 2022; 16:202-206. [PMID: 34893452 DOI: 10.1016/j.pcd.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/15/2021] [Accepted: 11/28/2021] [Indexed: 11/20/2022]
Abstract
AIMS Differentiating Charcot neuropathic osteoarthropathy (CN) from infection is challenging. The diagnosis of CN is often missed or delayed, resulting in inappropriate and delayed treatment. We hypothesized that the misdiagnosis of CN results in inappropriate antibiotic prescriptions and explore the sequelae of unnecessary antibiotic use. METHODS A retrospective review of patient electronic medical records from January 2010 to December 2017 was conducted for those diagnosed with CN after being referred to an orthopaedic foot and ankle specialist. RESULTS Our review showed 58 of 103 (56%) patients received antibiotics on the date, or within the next 7 days, of referral to foot and ankle orthopaedic specialist. The antibiotic of choice given on referral were as follows: Sulfamethoxazole/Trimethoprim 18 of 58 (31%), doxycycline 13 of 58 (22%), clindamycin 13 of 58 (22%), cephalexin 9 of 58 (16%), minocycline 5 of 58 (9%). CONCLUSION Missed diagnoses for CN are common and result in complications stemming from inappropriate treatment, delays in appropriate therapy, and may accelerate antibiotic resistance. Misdiagnosis of CN contributes to the inappropriate use of prescription antibiotics.
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Affiliation(s)
- Kiya Shazadeh Safavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States.
| | - Cory Janney
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States; Naval Medical Center San Diego, San Diego, CA 91941, United States
| | | | - Daniel Kunzler
- Department of Orthopaedic Surgery Baylor Scott & White, Temple, TX 76502, United States
| | - Daniel Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Vinod Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States
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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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15
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Diacogiorgis D, Perrin BM, Kingsley MIC. Factors impacting the evidence-based assessment, diagnosis and management of Acute Charcot Neuroarthropathy: a systematic review. J Foot Ankle Res 2021; 14:26. [PMID: 33827640 PMCID: PMC8025319 DOI: 10.1186/s13047-021-00469-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 03/22/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Acute Charcot Neuroarthropathy (CN) is a destructive condition that is characterised by acute fractures, dislocations and joint destruction in the weight-bearing foot. The acute phase is often misdiagnosed and can rapidly lead to devastating health outcomes. Early diagnosis and management of CN is imperative to attenuate progression of this condition. Consequently, timely evidence-based assessment, diagnosis and management of acute CN is imperative. OBJECTIVE To identify the factors that impact the delivery of evidence-based care in assessment, diagnosis and management of people with acute CN. METHOD Systematic searches were conducted in four databases to identify studies in English that included factors that impact the delivery of evidence-based care in the assessment, diagnosis and management of people with acute CN. Articles and consensus/guideline documents were assessed for inclusion by the researchers and disagreements were resolved through consensus. Additionally backward citation searching was used to source other potentially relevant documents. Information relevant to the research question was extracted and thematic analyses were performed using qualitative synthesis. RESULTS Thirty-two articles and four additional consensus/guideline documents were included for data extraction and analyses. Information related to the research question was of expert opinion using the National Health and Medical Research Council (NHMRC) Levels of Evidence guidelines. Themes explaining practices that deviated from evidence-based care in assessment, diagnosis and management of acute CN centred around patient, health professional and health organisation/environmental. Delay to diagnosis is particularly influenced by the patient's knowledge of when to seek help, practitioner knowledge in knowing how to recognise and refer for appropriate immediate care, confusion in imaging and offloading and geographical and local health service resources to appropriately manage the condition. CONCLUSION Individual and health professional awareness and geographical barriers are key challenges to the effective delivery of evidence-based assessment, diagnosis and management of people with acute CN. Acute CN represents a medical emergency warranting the need for expedited assessment, diagnosis and management by appropriately trained health professionals in the appropriate.
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Affiliation(s)
- D Diacogiorgis
- Department of Podiatry and Allied Health Assistants, Ballarat Health Services, Ballarat, Australia
- La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Australia
| | - B M Perrin
- La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Australia.
- Holsworth Research Initiative, La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Australia.
| | - M I C Kingsley
- Holsworth Research Initiative, La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Australia
- Department of Exercise Sciences, Faculty of Science, University of Auckland, Auckland, New Zealand
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16
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Rogers R, Dhatariya KK. Bilateral Charcot Neuroarthropathy in Pregnancy: A Case Report and Review of the Influence of Pregnancy Hormones on Ligament Laxity. AACE Clin Case Rep 2021; 7:57-60. [PMID: 33851021 PMCID: PMC7924155 DOI: 10.1016/j.aace.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To describe the case of a woman with long-standing poorly controlled type 1 diabetes mellitus who developed bilateral Charcot foot while pregnant. To the best of our knowledge, this is the first reported case of this condition in pregnancy. METHODS We performed a retrospective review of physical paper medical records; electronically held laboratory results, including glycated hemoglobin; and imaging reports, including plain radiographs and magnetic resonance imaging. RESULTS The Charcot feet were treated by standard offloading in total-contact casts or below-knee removable walking boots. As 1 side resolved, the patient was stepped down into normal footwear on one side and a below-knee walking boot on the other. A review of the literature suggests that the increase in ligamentous laxity associated with a rise in circulating hormones, such as relaxin, increases the risk of developing Charcot neuroarthropathy. CONCLUSION Bilateral concurrent Charcot neuroarthropathic foot is uncommon, and to our knowledge, this is the first reported case in pregnancy. We present a possible explanation for why there is an increased risk for the development of Charcot neuroarthropathy in pregnancy.
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Affiliation(s)
- Rebecca Rogers
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, United Kingdom
| | - Ketan K. Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, United Kingdom
- Norwich Medicine School, University of East Anglia, Norwich, Norfolk, United Kingdom
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Trindade M, Castro de Vasconcelos J, Ayub G, Grupenmacher AT, Gomes Huarachi DR, Viturino M, Correa-Giannella ML, Atala YB, Zantut-Wittmann DE, Parisi MC, Alves M. Ocular Manifestations and Neuropathy in Type 2 Diabetes Patients With Charcot Arthropathy. Front Endocrinol (Lausanne) 2021; 12:585823. [PMID: 33967949 PMCID: PMC8097086 DOI: 10.3389/fendo.2021.585823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/29/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Diabetes can affect the eye in many ways beyond retinopathy. This study sought to evaluate ocular disease and determine any associations with peripheral neuropathy (PN) or cardiac autonomic neuropathy (CAN) in type 2 diabetes (T2D) and Charcot arthropathy (CA) patients. DESIGN A total of 60 participants were included, 16 of whom were individuals with T2D/CA, 21 of whom were individuals with T2D who did not have CA, and 23 of whom were healthy controls. Ocular surface evaluations were performed, and cases of dry eye disease (DED) were determined using the Ocular Surface Disease Index (OSDI) questionnaire, ocular surface staining, Schirmer test, and Oculus Keratograph 5M exams. All variables were used to classify DED and ocular surface disorders such as aqueous deficiency, lipid deficiency, inflammation, and ocular surface damage. Pupillary and retinal nerve fiber measurements were added to the protocol in order to broaden the scope of the neurosensory ocular evaluation. PN and CAN were ascertained by clinical examinations involving the Neuropathy Disability Score (for PN) and Ewing's battery (for CAN). RESULTS Most ocular variables evaluated herein differed significantly between T2D patients and controls. When the controls were respectively compared to patients with T2D and to patients with both T2D and CA, they differed substantially in terms of visual acuity (0.92 ± 0.11, 0.73 ± 0.27, and 0.47 ± 0.26, p=0.001), retinal nerve fiber layer thickness (96.83 ± 6.91, 89.25 ± 10.44, and 80.37 ± 11.67 µm, p=0.03), pupillometry results (4.10 ± 0.61, 3.48 ± 0.88, and 2.75 ± 0.81 mm, p=0.0001), and dry eye symptoms (9.19 ± 11.71, 19.83 ± 19.08, and 24.82 ± 24.40, p=0.03). DED and ocular surface damage also differed between individuals with and without CA, and were associated with PN and CAN. CONCLUSION CA was found to be significantly associated with the severity of ocular findings. DED in cases of CA was also associated with PN and CAN. These findings suggest that intrinsic and complex neurosensory impairment in the eyes, peripheral sensory nerves, and the autonomic nervous system are somehow connected. Thus, a thorough ocular evaluation may be useful to highlight neurological complications and the impact of diabetes on ocular and systemic functions and structures.
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Affiliation(s)
- Marilia Trindade
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- *Correspondence: Marilia Trindade,
| | - Jessica Castro de Vasconcelos
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Gabriel Ayub
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Alex Treiger Grupenmacher
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Delma Regina Gomes Huarachi
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Marina Viturino
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Maria Lucia Correa-Giannella
- Programa de Pos-Graduação em Medicina, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
- Laboratório de Carboidratos e Radioimunoensaio (LIM-18), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Yeelen Ballesteros Atala
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Denise Engelbrecht Zantut-Wittmann
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Maria Candida Parisi
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Monica Alves
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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18
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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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19
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Dallimore SM, Puli N, Kim D, Kaminski MR. Infrared dermal thermometry is highly reliable in the assessment of patients with Charcot neuroarthropathy. J Foot Ankle Res 2020; 13:56. [PMID: 32928270 PMCID: PMC7489208 DOI: 10.1186/s13047-020-00421-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy (Charcot foot) is a serious limb-threatening complication most commonly seen in individuals with diabetic peripheral neuropathy. Although dermal thermometry is widely used by clinicians to assist in the diagnosis, monitoring, and management of the disease, there is limited high-quality evidence to support its reliability. Therefore, this study investigated the intra-rater and inter-rater reliability of infrared dermal thermometry in patients with Charcot neuroarthropathy. METHODS We collected clinical, demographic, health status, and foot examination information on 32 adults with Charcot neuroarthropathy from a metropolitan high-risk foot service in Melbourne, Australia. Infrared dermal thermometry assessments were conducted by two independent raters at 10 anatomical sites of the Charcot foot using both a (i) touch and (ii) non-touch technique. Intra-rater and inter-rater reliability of the two assessment techniques were evaluated using intra-class correlation coefficients (ICCs), limits of agreement, standard error of measurement, and minimal detectable change statistics. RESULTS Mean age was 59.9 (standard deviation [SD], 10.5) years, 68.8% were male, average duration of diabetes was 20.6 (SD, 15.1) years, 71.9% had type 2 diabetes, 93.8% had peripheral neuropathy, 43.8% had peripheral arterial disease, and 50% had previous foot ulceration. Charcot foot most commonly affected the tarsometatarsal joints (38.9%), had a median duration of 2.8 (interquartile range [IQR], 1.3 to 5.9) months, and a large proportion were being treated with total contact casting (69.4%). Overall, there was good to excellent intra-rater and inter-rater relative reliability for the 'touch' technique (ICC, 0.87 to 0.99; ICC, 0.83 to 0.98, respectively), and excellent intra-rater and inter-rater relative reliability for the 'non-touch' technique (ICC, 0.93 to 0.99; ICC, 0.91 to 0.99, respectively). In addition, measurement error was found to be relatively low across the 10 anatomical sites. CONCLUSIONS Infrared dermal thermometry can now be used with confidence in clinical and research settings to provide a reliable assessment of skin temperature in patients with Charcot neuroarthropathy, using either a touch or non-touch technique at 10 commonly used testing sites. A non-touch technique, however, was observed to have slightly higher reliability indicating it may be associated with less measurement error than the touch technique.
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Affiliation(s)
- Sarah M Dallimore
- Department of Podiatry, Eastern Health, Melbourne, Victoria, 3128, Australia
| | - Nicholas Puli
- Department of Podiatry, Eastern Health, Melbourne, Victoria, 3128, Australia.,Department of Podiatry, Alfred Health, Melbourne, Victoria, 3004, Australia.,Department of Quality Planning and Innovation, Eastern Health, Melbourne, Victoria, 3128, Australia
| | - Daniel Kim
- Department of Quality Planning and Innovation, Eastern Health, Melbourne, Victoria, 3128, Australia
| | - 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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20
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Gooday C, Game F, Woodburn J, Poland F, Sims E, Dhatariya K, Shepstone L, Hardeman W. A randomised feasibility study of serial magnetic resonance imaging to reduce treatment times in Charcot neuroarthropathy in people with diabetes (CADOM): a protocol. Pilot Feasibility Stud 2020; 6:85. [PMID: 32549996 PMCID: PMC7296621 DOI: 10.1186/s40814-020-00611-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/27/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complication of peripheral neuropathy associated with diabetes which most frequently affects the lower limb. It can cause fractures and dislocations within the foot, which may progress to deformity and ulceration. Recommended treatment is immobilisation and offloading, with a below knee non-removable cast or boot. Duration of treatment varies from six months to more than 1 year. Small observational studies suggest that repeated assessment with magnetic resonance imaging improves decision-making about when to stop treatment, but this has not been tested in clinical trials. This study aims to explore the feasibility of using serial magnetic resonance imaging without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot. A nested qualitative study aims to explore participants' lived experience of Charcot neuroarthropathy and of taking part in the feasibility study. METHODS We will undertake a two-arm, open study and randomise 60 people with a suspected or confirmed diagnosis of Charcot neuroarthropathy from five NHS, secondary care multidisciplinary Diabetic Foot Clinics across England. Participants will be randomised 1:1 to receive magnetic resonance imaging at baseline and remission up to 12 months, with repeated foot temperature measurements and X-rays (standard care plus), or standard care plus with additional three-monthly magnetic resonance imaging until remission up to 12 months (intervention). Time to confirmed remission of Charcot neuroarthropathy with off-loading treatment (days) and its variance will be used to inform sample size in a full-scale trial. We will look for opportunities to improve the protocols for monitoring techniques and the clinical, patient-centred and health economic measures used in a future study. For the nested qualitative study, we will invite a purposive sample of 10-14 people able to offer maximally varying experiences from the feasibility study to take part in semi-structured interviews to be analysed using thematic analysis. DISCUSSION The study will inform the decision whether to proceed to a full-scale trial. It will also allow deeper understanding of the lived experience of Charcot neuroarthropathy, and factors that contribute to engagement in management and contribute to the development of more effective patient-centred strategies. TRIAL REGISTRATION ISRCTN, ISRCTN74101606. Registered on 6 November 2017.
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Affiliation(s)
- Catherine Gooday
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Frances Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE UK
| | - Jim Woodburn
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, G4 0BA UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
| | - Erika Sims
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
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21
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Galeazzi Rech AL, Stüve Y, Toepfer A, Schimke KE. Missing the boat: fatal ending to a missed case of Charcot arthropathy. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200013. [PMID: 32554824 PMCID: PMC7354711 DOI: 10.1530/edm-20-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 01/22/2023] Open
Abstract
SUMMARY Acute Charcot neuropathic osteoarthropathy (CN) is a clinical entity which can easily go unrecognized in its acute early stages due to lack of awareness and unspecific presentation. However, missing early diagnosis can lead to severe complications. We present the case of a 72-year-old male patient who went through the natural course of the disease unnoticed before the very eyes of his physicians leading to a tragic end. We aim to raise awareness for this rare diabetic complication, emphasizing the necessity of early diagnosis and adequate, interdisciplinary treatment. LEARNING POINTS Clinical signs and symptoms of acute Charcot neuropathic osteoarthropathy (CN). Red flags. Importance of early diagnosis and correct treatment. Diagnostic challenges of acute CN. Awareness of high morbidity and mortality.
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Affiliation(s)
- Anna Luiza Galeazzi Rech
- Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland
| | - Yvon Stüve
- Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland
| | - Andreas Toepfer
- Kantonsspital Sankt Gallen, Klinik für Orthopädische Chirurgie und Traumatologie des Bewegungsapparts, Sankt Gallen, Switzerland
| | - Katrin E Schimke
- Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland
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Al-Najjar A, Al Shakarchi J, Pereira M, Downing R. An unusual presentation of acute onset Charcot arthropathy. J Surg Case Rep 2020; 2020:rjaa128. [PMID: 32509268 PMCID: PMC7263751 DOI: 10.1093/jscr/rjaa128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 11/13/2022] Open
Abstract
Charcot arthropathy is a progressive condition primarily affecting the lower limbs in patients with diabetes mellitus. It is a rare complication of diabetic neuropathy and if left untreated can lead to severe limb destruction necessitating major amputation. Here, we report the case of a 41-year-old female who presented with rapidly progressive Charcot foot over a 10-day period, necessitating open reduction and internal fixation of Lisfranc-type fracture dislocations. Her presentation with a rapidly progressing red, swollen foot with a blister on the plantar aspect prompted initial treatment on the basis of a diabetic foot infection. The report will therefore serve as a useful reminder to maintain a high index of suspicion for Charcot foot, which may present in an atypical manner.
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Affiliation(s)
- Ammar Al-Najjar
- Vascular Surgery Unit, Worcestershire Royal Hospital, Worcester, UK
| | | | - Melwyn Pereira
- Department of Orthopaedic Surgery, Alexandra Hospital, Redditch, UK
| | - Richard Downing
- Vascular Surgery Unit, Worcestershire Royal Hospital, Worcester, UK
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Bergin S, Naidoo P, Williams CM. A radiological severity scale to measure the impact of Charcot's Neuroarthropathy: an observational study. J Foot Ankle Res 2020; 13:7. [PMID: 32046771 PMCID: PMC7014691 DOI: 10.1186/s13047-020-0375-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/03/2020] [Indexed: 08/30/2023] Open
Abstract
Background Charcot’s Neuroarthropathy (Charcot foot) is a debilitating and destructive disorder resulting from neurological changes in the foot. Whilst the majority of cases are painless, as a result of disruption to sensory function, a common outcome is severe deformity that impacts considerably on foot function. The purpose of this study was to develop and validate a radiological severity scale to quantify resultant damage from acute mid foot Charcot’s. This in turn can be used to evaluate clinical outcomes related to different degrees of offloading. Methods A four round Delphi process was used to develop five tool items. Level of consensus and agreement was set at 80%. Inter-rater and intra-rater reliability was evaluated using 3 raters and 24 plain x-rays of chronic mid-foot Charcot’s. Strength of agreement of individual items and overall scores was calculated using weighted Kappa coefficients (S.E). Cronbach’s α was used to determine internal consistency. Floor (> 15% score 0) and ceiling (> 15% score 11) effects were examined at each time point. Spearman’s correlation coefficient was used to assess construct validity using Mobility and Usual Activity scores taken from the EQ-5D-5 L. Results Twenty two patients participated. The five item severity scale demonstrated a Cronbach’s α of 0.91. Intra-rater Kappa coefficients (SE) for total scores ranged from 0.84 (0.20) to 0.86 (0.20). Inter rater coefficients (SE) ranged from 0.72 (0.14) to 0.83 (0.14). Distribution was normal and no floor or ceiling effects were identified. Conclusion/interpretation This study suggests it may be possible to quantify resultant damage from mid foot Charcot’s. Given the physical and emotional impacts from long periods of complete immobilisation defining a minimum standard would be an important development in the management of Charcot foot.
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Affiliation(s)
- Shan Bergin
- Monash Health, Department of Podiatry, David Street, Dandenong, VIC, 3175, Australia.
| | - Parm Naidoo
- Monash Health, Monash Imaging, David Street, Dandenong, VIC, 3175, Australia
| | - Cylie M Williams
- Monash Health, Allied Health Research Unit, Warrigal Rd, Cheltenham, VIC, 3192, Australia.,Department of Physiotherapy, Monash University, McMahon's Road, Frankston, VIC, 3199, Australia
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New Concepts in the Management of Charcot Neuroarthropathy in Diabetes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:391-415. [PMID: 32124412 DOI: 10.1007/5584_2020_498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Charcot Neuroarthropathy (CN) is an uncommon, debilitating and often underdiagnosed complication of chronic diabetes mellitus though, it can also occur in other medical conditions resulting from nerve injury. Till date, the etiology of CN remains unknown, but enhanced osteoclastogenesis is believed to play a central role in the pathogenesis of CN, in the presence of neuropathy. CN compromises the overall health and quality of life. Delayed diagnosis can result in a severe deformity that can act as a gateway to ulceration, infection and in the worst case, can lead to limb loss. In an early stage of CN, immobilization with offloading plays a key role to a successful treatment. Medical therapies seem to have limited role in the treatment of CN.In case of severe deformity, proper footwear or bracing may help prevent further deterioration and development of an ulcer. In individuals with a concomitant ulcer with osteomyelitis, soft tissue infection and severe deformity, where conservative measures fall short, surgical intervention becomes the only choice of treatment. Early diagnosis and proper management at an early stage can help prevent the occurrence of CN and amputation.
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Mitochondrial dysfunction is the cause of one of the earliest changes seen on magnetic resonance imaging in Charcot neuroarthopathy - Oedema of the small muscles in the foot. Med Hypotheses 2019; 134:109439. [PMID: 31644972 DOI: 10.1016/j.mehy.2019.109439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/17/2019] [Indexed: 12/20/2022]
Abstract
The hypothesis laid out in this thesis states that the early changes seen on an MR imaging in those with early Charcot neuroarthopathy may be due to mitochondrial dysfunction. In a Charcot foot, there is movement between bones. In an attempt to prevent this movement, the small muscles of the foot contract continuously when the foot is weight bearing. This contraction takes energy in the form of ATP. However, the reduction of glucose transport into the muscle cells due to insulin resistance / insufficiency, leads to reduction in the ATP producing capacity of the mitochondria. The ATP depletion affects the cell membrane gradient leading to mitochondrial and cellular swelling. These early cellular changes could then be picked up with MR imaging as muscle oedema.
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Wanzou JPV, Sekimpi P, Komagum JO, Nakwagala F, Mwaka ES. Charcot arthropathy of the diabetic foot in a sub-Saharan tertiary hospital: a cross-sectional study. J Foot Ankle Res 2019; 12:33. [PMID: 31210786 PMCID: PMC6567465 DOI: 10.1186/s13047-019-0343-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/29/2019] [Indexed: 01/14/2023] Open
Abstract
Background Charcot foot arthropathy is a potentially limb-threatening condition that leads to progressive destruction of the bones and joints in the neuropathic foot. One of its main causes is diabetes mellitus whose prevalence is steadily increasing. The acute phase is often misdiagnosed thus leading to foot deformity, ulceration and increased risk of amputation. There is a paucity of literature on this condition from sub-Saharan Africa. This study aimed at determining the extent of Charcot foot arthropathy, the radiological patterns of Charcot foot arthropathy and patient’s factors associated with Charcot foot arthropathy among adult patients with longstanding diabetes in an African setting. Methods This was a cross-sectional study that was carried at a national referral and university teaching hospital in Kampala, Uganda. One hundred patients with longstanding diabetes mellitus were consecutively recruited. Patients with a history of having diabetes mellitus for at least seven years since diagnosis were considered to have a longstanding disease. Clinical assessment of both feet was done. Weight-bearing radiographs of the selected foot were taken and evaluated using the Sanders and Frykberg and modified Eichenholtz classifications. A blood sample was taken for glycosylated haemoglobin (HbA1c). Data were summarized using descriptive statistics and student t-test. Results The proportion of Charcot foot arthropathy among patients with longstanding diabetes was 12% of which one-third (4 out of 12) were acute cases. Fifty percent of the lesions were in the forefoot and 50% in the midfoot. Seventeen percent of lesions were at the inflammatory stage of the modified Eichenholtz classification, 50% at the developmental stage, 25% at the healing stage, and 8% at the remodelling stage. An abnormal foot radiograph was significantly associated with Charcot foot arthropathy among patients with longstanding diabetes. Conclusion Charcot foot arthropathy is fairly common in patients with longstanding diabetes mellitus in these settings with one third of patients presenting in the early acute phase. An abnormal weight-bearing radiograph was an associated factor of Charcot foot arthropathy among this specific group of patients. To reduce on the morbidity and limb threatening sequelae of this condition, clinicians are therefore advised to routinely examine the feet of patients with diabetes and send those with suspicious signs and symptoms for radiographic assessment.
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Affiliation(s)
- Jean Paul Vwakya Wanzou
- 1Department of Orthopaedics, College of Health Sciences, Makerere University, P.O BOX 7072, Kampala, Uganda
| | - Patrick Sekimpi
- 1Department of Orthopaedics, College of Health Sciences, Makerere University, P.O BOX 7072, Kampala, Uganda
| | | | - Frederick Nakwagala
- 3Department of Internal medicine, Endocrinology Unit, Mulago Hospital, P.O BOX 7051, Kampala, Uganda
| | - Erisa Sabakaki Mwaka
- 4Department of Anatomy, College of Health Sciences, Makerere University, P.O BOX 7072, Kampala, Uganda
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Higgins A, Teixeira M, Szostek JH. 58-Year-Old Diabetic Man With a Warm, Erythematous Foot. Mayo Clin Proc 2019; 94:526-530. [PMID: 30832792 DOI: 10.1016/j.mayocp.2018.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/29/2018] [Accepted: 04/30/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Alexandra Higgins
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Miguel Teixeira
- Resident in Anesthesia, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Jason H Szostek
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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Jansen RB, Jørgensen B, Holstein PE, Møller KK, Svendsen OL. Mortality and complications after treatment of acute diabetic Charcot foot. J Diabetes Complications 2018; 32:1141-1147. [PMID: 30301593 DOI: 10.1016/j.jdiacomp.2018.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/13/2018] [Accepted: 09/20/2018] [Indexed: 11/22/2022]
Abstract
AIMS Charcot foot is a rare but disabling complication to diabetic neuropathy, and can cause permanent, limb-threatening deformities. The aim of this study was to investigate a population of patients a Charcot foot on a case-by-case basis, in order to assess the consequences of an acute Charcot foot and its complications. METHODS The study was conducted a retrospective study of patients admitted to the Copenhagen Wound Healing Center between 1996 and 2015 with the diagnosis of Charcot foot (DM14.6) and diabetes mellitus type 1 or 2 (DE10.X and DE11.X). Physical and electronic records were used, and compared to data from the Danish Diabetes Registry. RESULTS In total 392 patients were identified of which 173 were included. There were 26% with type 1 diabetes (initial HbA1c 81.7 ± 21.4 mmol/mol) and 74% with type 2 diabetes (initial HbA1c 66.5 ± 20.3 mmol/mol). Primary off-loading was with a removable walker in 95% of the cases (average off-loading time 8.3 months). The 5-year mortality was 14% with a mean survival time of 12.7 years. There was an association between lack of compliance and occurrence of foot complications, as well as between having a Charcot foot and leaving the workforce. CONCLUSION More patients had type 1 diabetes compared to the background population, and they had a higher HbA1c than the general population of diabetes patients. A total of 67% developed complications such as ulcers, while patients non-compliant to treatment did significantly worse than those being compliant. The 5-year mortality was low, 14%, and comparable to diabetes patients without Charcot foot.
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Affiliation(s)
- Rasmus Bo Jansen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark.
| | - Bo Jørgensen
- Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Per E Holstein
- Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Klaus Kirketerp Møller
- Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Ole Lander Svendsen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
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Vopat ML, Nentwig MJ, Chong AC, Agan JL, Shields NN, Yang SY. Initial Diagnosis and Management for Acute Charcot Neuroarthropathy. Kans J Med 2018; 11:114-119. [PMID: 30937152 PMCID: PMC6276967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Matthew L. Vopat
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS
| | - Michelle J. Nentwig
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS
| | - Alexander C.M. Chong
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS,Via Christi Health, Wichita, KS
| | | | - Naomi N. Shields
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS,Advanced Orthopaedics Associates, Wichita, KS
| | - Shang-You Yang
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS
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Abstract
PURPOSE OF REVIEW Diabetes mellitus affects approximately 30.8 million people currently living in the USA. Chronic diabetes complications, including diabetic foot complications, remain prevalent and challenging to treat. We review clinical diagnosis and challenges providers may encounter when managing diabetic foot ulcers and Charcot neuroarthropathy. RECENT FINDINGS Mechanisms controlling these diseases are being elucidated and not fully understood. Offloading is paramount to heal and manage diabetic foot ulcers and Charcot neuroarthropathy. Diabetic foot ulcers recur and the importance of routine surveillance and multidisciplinary approach is essential. Several predictors of failure in Charcot foot include a related diabetic foot ulcer, midfoot or rearfoot location of the Charcot event, and progressive bony changes on interval radiographs. Patients with diabetic foot ulcer and/or Charcot neuroarthropathy are in need of consistent and regular special multidisciplinary care. If not diagnosed early and managed effectively, morbidity and mortality significantly increase.
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Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
| | - Crystal M Holmes
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA
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Doria M, Viadé J, Palomera E, Pérez R, Lladó M, Costa E, Huguet T, Reverter JL, Serra-Prat M, Franch-Nadal J, Mauricio D. Short-term foot complications in Charcot neuroarthropathy: A retrospective study in tertiary care centres in Spain. ACTA ACUST UNITED AC 2018; 65:479-485. [PMID: 30108031 DOI: 10.1016/j.endinu.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the clinical characteristics of patients with Charcot neuroarthropathy (CN) in Spain and to identify predictors for CN-related complications. PATIENTS AND METHODS A retrospective study was conducted at five tertiary hospitals with diabetic foot care units in Spain. Data were collected from 83 patients, including demographic profiles, foot factors, diabetes characteristics, and presence of microvascular and macrovascular comorbidity, and a podiatric examination was also performed. Logistic regression analyses were used to determine significant predictors of the predefined clinical events. RESULTS Signs of diabetic neuropathy were found in almost all patients (98.9%) at the initial assessment, approximately half of them had diabetic retinopathy or nephropathy (61.5% and 51.8%, respectively), and peripheral artery disease was uncommon (8.6%). Thirty-eight patients (47.5%) experienced one or more relevant clinical events: 22 (27.5%) a new foot ulcer; 7 (8.7%) a major amputation; 20 (25%) were admitted to hospital; and 4 (5%) died. Only the presence of diabetic nephropathy was independently associated to development of any of the complications studied (p = 0.009; odds ratio = 3.37; 95% CI: 1.12-10.1). CONCLUSIONS Almost half the patients with CN attending specialised foot care units in tertiary hospitals experienced short-term CN-associated complications, and the risk was 3 times higher in those with a history of diabetic nephropathy.
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Affiliation(s)
- Montserrat Doria
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain; Diabetic Foot Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Jordi Viadé
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain
| | | | - Ricard Pérez
- Department of Radiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Melcior Lladó
- Diabetic Foot Unit, University Hospital Son Espases, Palma de Mallorca, Spain
| | - Elisabet Costa
- Department of Endocrinology and Nutrition, University Hospital Josep Trueta, Girona, Spain
| | - Teresa Huguet
- Diabetic Foot Unit, University Hospital Mutua, Terrassa, Spain
| | - Jordi Lluís Reverter
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain
| | | | - Josep Franch-Nadal
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Spain; Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain; Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Spain; Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
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Jansen RB, Svendsen OL. A review of bone metabolism and developments in medical treatment of the diabetic Charcot foot. J Diabetes Complications 2018; 32:708-712. [PMID: 29857955 DOI: 10.1016/j.jdiacomp.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
Charcot foot is a rare but severe, and possibly limb-threatening, complication to neuropathy and diabetes mellitus. The current treatment consists of long-term off-loading, and has a large negative impact on the patient's life. Much research has gone into understanding the condition and its biochemical mechanisms, however, the underlying pathogenesis of a Charcot foot is not yet fully understood. In the recent decades several key advances in our understanding of the Charcot foot have been made, both in regards to the changes in bone metabolism and structure an acute Charcot foot can cause, and to the molecular pathways involved in this. This review summerizes the available research into the bone metabolism around a Charcot foot, with an emphasis on the biochemical profile. The existing data regarding attempts at medical treatment is also reviewed, including novel trials targetting specific inflammatory pathways upregulated in the acute diabetic Charcot foot.
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Affiliation(s)
- Rasmus Bo Jansen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark.
| | - Ole Lander Svendsen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark; Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
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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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Jansen RB, Christensen TM, Bülow J, Rørdam L, Holstein PE, Jørgensen NR, Svendsen OL. Bone mineral density and markers of bone turnover and inflammation in diabetes patients with or without a Charcot foot: An 8.5-year prospective case-control study. J Diabetes Complications 2018; 32:164-170. [PMID: 29196119 DOI: 10.1016/j.jdiacomp.2017.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIMS Charcot foot is a rare but severe complication to diabetes and peripheral neuropathy. It is still unclear if an acute Charcot foot has long-term effects on the bone metabolism. To investigate this, we conducted a follow-up study to examine if a previously acute Charcot foot has any long-term effects on bone mineral density (BMD) or local or systemic bone metabolism. METHODS An 8.5-year follow-up case-control study of 44 individuals with diabetes mellitus, 24 of whom also had acute or chronic Charcot foot at the baseline visit in 2005-2007, who were followed up in 2015 with DXA scans and blood samples. RESULTS 21 of the 44 baseline participants participated in the follow-up. There were no difference in the change in total hip BMD from baseline to follow-up in either the Charcot or the control group (p = 0.402 and 0.517), and no increased risk of osteoporosis in the previous Charcot feet either. From baseline to follow-up, there was a significant difference in the change in levels of fsRANK-L in the Charcot group, but not in the control group (p = 0.002 and 0.232, respectively). At follow-up, there were no differences in fsRANK-L between the groups. The fsRANK-L/OPG ratio also significantly decreased from baseline to follow-up in the Charcot group (3.4 versus 0.5) (p = 0.009), but not in the control group (1.3 versus 1.1) (p = 0.302). CONCLUSION We found that diabetes patients with an acute Charcot foot have an elevated fsRANK-L/OPG ratio, and that the level decreased from baseline to follow-up to be comparable to the level in diabetes patients without previous or current Charcot foot. We found no permanent effect of an acute Charcot foot on hip or foot BMD.
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Affiliation(s)
- Rasmus Bo Jansen
- Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark; Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark.
| | - Tomas Møller Christensen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Jens Bülow
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Lene Rørdam
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Per E Holstein
- Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, DK-2600 Glostrup, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ole Lander Svendsen
- Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark; Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
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Wijlens AM, Holloway S, Bus SA, van Netten JJ. An explorative study on the validity of various definitions of a 2·2°C temperature threshold as warning signal for impending diabetic foot ulceration. Int Wound J 2017; 14:1346-1351. [PMID: 28990362 PMCID: PMC7949930 DOI: 10.1111/iwj.12811] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/27/2017] [Accepted: 08/04/2017] [Indexed: 12/30/2022] Open
Abstract
Home monitoring of skin temperature is effective to prevent diabetic foot ulceration. We explored the validity of various definitions for the >2·2°C left‐to‐right threshold used as a warning signal for impending ulceration. Twenty patients with diabetes and peripheral neuropathy monitored their skin temperature with an infrared thermometer at the plantar hallux, metatarsal heads, midfoot and heel four times a day for 6 consecutive days. Environmental temperature and walking activity were monitored and associated with foot temperature. The average temperature difference between feet was 0·65°C. At single locations, a left‐to‐right temperature difference of >2·2°C was found 245 times (8·5% of measurements). Confirmation of these above‐threshold readings on the following day was found seven times (0·3%). Corrected for individual left‐to‐right mean foot temperature differences, this reduced to four (0·2%). No ulcers developed in the week after monitoring. Left‐to‐right foot temperature differences were not significantly correlated with walking activity, environmental temperature or time of day. The >2·2°C left‐to‐right foot temperature threshold for impending ulceration is not valid as single measurement, but validity improves to acceptable levels when an above‐threshold temperature difference is confirmed the following day and further improves with individual correction. The threshold is independent of time of day, environmental temperature and walking activity.
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Affiliation(s)
- Anke M Wijlens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Podiatry, School of Health, Saxion University of Applied Sciences, Enschede, the Netherlands
| | - Samantha Holloway
- College of Biomedical & Life Sciences, Centre for Medical Education, School of Medicine, Cardiff University, Wales, UK
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Surgery, Diabetic Foot Unit, Ziekenhuisgroep Twente, Almelo and Hengelo, the Netherlands
| | - Jaap J van Netten
- Department of Surgery, Diabetic Foot Unit, Ziekenhuisgroep Twente, Almelo and Hengelo, the Netherlands.,School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
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Zhao HM, Diao JY, Liang XJ, Zhang F, Hao DJ. Pathogenesis and potential relative risk factors of diabetic neuropathic osteoarthropathy. J Orthop Surg Res 2017; 12:142. [PMID: 28969714 PMCID: PMC5625723 DOI: 10.1186/s13018-017-0634-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/11/2017] [Indexed: 12/18/2022] Open
Abstract
Diabetic neuropathic osteoarthropathy (DNOAP) is an uncommon, but with considerable morbidity and mortality rates, complication of diabetes. The real pathogenesis is still unclear. The two popular theories are the neuro-vascular theory and neuro-traumatic theory. Most theories and pathways focused on the uncontrolled inflammations that resulted in the final common pathway, receptor activator of nuclear factor κβ ligand (RANKL)/osteoprotegerin (OPG) axis, for the decreased bone density in DNOAP with an osteoclast and osteoblast imbalance. However, the RANKL/OPG pathway does not explain all the changes, other pathways and factors also play roles. A lot of DNOAP potential relative risk factors were evaluated and reported in the literature, including age, gender, weight, duration and type of diabetes, bone mineral density, peripheral neuropathy and arterial disease, trauma history, and some others. However, most of them are still in debates. Future studies focus on the pathogenesis of DNOAP are still needed, especially for the genetic factors. And, the relationship between DNOAP and those potential relative risk factors are still need to further clarify.
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Affiliation(s)
- Hong-Mou Zhao
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
| | - Jia-Yu Diao
- Cardiovascular Medicine Department, The Second Affiliated Hospital of Xi'an Jiaotong University College of Medicine, No. 157 West Fifth Road, Xi'an, 710004, People's Republic of China
| | - Xiao-Jun Liang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
| | - Feng Zhang
- School of Public Health, Health Science Center Xi'an Jiaotong University, No. 76 Yan Ta West Road, Xi'an, 710061, People's Republic of China.
| | - Ding-Jun Hao
- Spine Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China.
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Trieb K. The Charcot foot: pathophysiology, diagnosis and classification. Bone Joint J 2017; 98-B:1155-9. [PMID: 27587513 DOI: 10.1302/0301-620x.98b9.37038] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 04/12/2016] [Indexed: 12/15/2022]
Abstract
Neuropathic changes in the foot are common with a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy is often delayed in diabetic patients with harmful consequences including amputation. The appropriate diagnosis and treatment can avoid an extensive programme of treatment with significant morbidity for the patient, high costs and delayed surgery. The pathogenesis of a Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels. In most cases, changes are due to a combination of both pathophysiological factors. The Charcot foot is triggered by a combination of mechanical, vascular and biological factors which can lead to late diagnosis and incorrect treatment and eventually to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. The clinical diagnostic pathways based on different classifications are presented. Cite this article: Bone Joint J 2016;98-B:1155-9.
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Affiliation(s)
- K Trieb
- Klinikum Wels-Grieskirchen, Grieskirchnerstr. 42, Wels, 4600, Austria
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Hingsammer AM, Bauer D, Renner N, Borbas P, Boeni T, Berli M. Correlation of Systemic Inflammatory Markers With Radiographic Stages of Charcot Osteoarthropathy. Foot Ankle Int 2016; 37:924-8. [PMID: 27162224 DOI: 10.1177/1071100716649173] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Charcot osteoarthropathy (COA) is characterized by a progressive destruction of bone and joint associated with neuropathy and is most common in the foot and ankle. Clinical manifestation of COA is frequently indistinguishable from other causes of pain, swelling, and erythema of the affected extremity, in particular, infection. Diagnosis of COA can be challenging in particular in early stages where radiographic changes are sparse. The presence of elevated systemic inflammatory parameters in the context of suspected infection may delay early diagnosis and treatment of COA. The aim of this retrospective analysis was to assess whether elevated systemic inflammatory parameters may be present, in particular in early stages of COA and thus not be used as an exclusion criterion for the diagnosis of COA. METHODS Forty-two patients (mean age 48.2 ± 9.4 years, 36 male, 6 female) with a diagnosis of unilateral COA were the subject of this retrospective study. The diagnosis of COA was confirmed by plain radiographs, magnetic resonance imaging and clinical course. Systemic inflammatory parameters were recorded at the time of referral. Acute stages (stages 0 and 1) were treated with a total contact cast (TCC) and protected weight bearing for a minimum of 6 weeks. For chronic stages (stages 2 and 3) custom-made shoes were prescribed. The feet were stratified into "acute" (Eichenholz stages 0 and 1) and "subacute/chronic" (Eichenholz stages 2 and 3) groups. RESULTS Statistically significant differences were observed for all recorded systemic inflammatory parameters (C-reactive protein level, WBC count, erythrocyte sedimentation rate) between the acute and subacute/chronic groups. No statistical difference was observed considering the anatomic pattern of involvement. CONCLUSION The present study demonstrated that elevated systemic inflammatory parameters may be present in COA and can further be used to distinguish between acute and subacute stages of COA, based on the Eichenholtz classification. Thus, we suggest that elevated inflammatory markers should not be considered an exclusion criterion for the diagnosis of COA. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Andreas M Hingsammer
- Balgrist University Hospital Zurich, University of Zurich, Forchstrasse, Zurich, Switzerland
| | - David Bauer
- Balgrist University Hospital Zurich, University of Zurich, Forchstrasse, Zurich, Switzerland
| | - Niklas Renner
- Balgrist University Hospital Zurich, University of Zurich, Forchstrasse, Zurich, Switzerland
| | - Paul Borbas
- Balgrist University Hospital Zurich, University of Zurich, Forchstrasse, Zurich, Switzerland
| | - Thomas Boeni
- Balgrist University Hospital Zurich, University of Zurich, Forchstrasse, Zurich, Switzerland
| | - Martin Berli
- Balgrist University Hospital Zurich, University of Zurich, Forchstrasse, Zurich, Switzerland
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Stark C, Murray T, Gooday C, Nunney I, Hutchinson R, Loveday D, Dhatariya K. 5 year retrospective follow-up of new cases of Charcot neuroarthropathy-A single centre experience. Foot Ankle Surg 2016; 22:176-180. [PMID: 27502226 DOI: 10.1016/j.fas.2015.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/08/2015] [Accepted: 07/10/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few data describe the natural history of Charcot neuroarthropathy treated with a total contact plaster cast (TCC). METHODS A 5 year retrospective analysis of 50 patients presenting with an acute CN, Assessing time to clinical resolution into appropriate footwear and assessing if initial immobilisation device influenced resolution time. RESULTS During the study period 42 patients (84%) of patients went into remission, 2 died during their treatment, 4 had major amputations, in 2 patients treatment was ongoing. 36 patients were treated with combination offloading devices, 6 were treated with one modality only. Median time to resolution for patients initially treated with a TCC was not significantly shorter than for those treated with a removable below knee boot. 34.9% required re-casting due to clinical deterioration in the removable device. CONCLUSIONS More precise measures of resolution of CN are needed to assess the impact of initial treatment modality on time to resolution.
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Affiliation(s)
- C Stark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - T Murray
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - C Gooday
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - I Nunney
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - R Hutchinson
- Department of Orthopaedic Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - D Loveday
- Department of Orthopaedic Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - K Dhatariya
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.
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Kucera T, Shaikh HH, Sponer P. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. J Diabetes Res 2016; 2016:3207043. [PMID: 27656656 PMCID: PMC5021483 DOI: 10.1155/2016/3207043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022] Open
Abstract
Charcot neuropathic osteoarthropathy of the foot is a relatively common complication of diabetic neuropathy. Incorrect diagnosis and improper treatment often result in the extremity having to be amputated. This paper summarises the current view on the etiology, diagnostics, and treatment of diabetic Charcot neuropathic osteoarthropathy, with particular focus on preserving the extremity through surgical intervention from our own experiences.
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Affiliation(s)
- Tomas Kucera
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
| | - Haroun Hassan Shaikh
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Pavel Sponer
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
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Foley AM. Acute Charcot foot and diabetes: A primer for the vascular nurse. JOURNAL OF VASCULAR NURSING 2016; 34:27-30. [PMID: 26897350 DOI: 10.1016/j.jvn.2015.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The clinical findings of the acute Charcot process includes a swollen, warm, and erythematous foot; although pain may be present, it is often mild and out of proportion to the clinical examination. The diagnosis is confirmed by radiologic imaging, and the diagnosis must be considered in any patient with diabetic neuropathy and unilateral foot swelling. Initial treatment calls for immediate immobilization of the foot. Failure to do so can lead to further foot damage, destruction, and possibly amputation. The patient with acute CN requires referral to a multidisciplinary team experienced in the care of the diabetic patient with this devastating condition. Patient education is a crucial component of the treatment plan when caring for a client with CN.
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Affiliation(s)
- Anne M Foley
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Holmes C, Schmidt B, Munson M, Wrobel JS. Charcot stage 0: A review and consideratons for making the correct diagnosis early. Clin Diabetes Endocrinol 2015; 1:18. [PMID: 28702236 PMCID: PMC5471964 DOI: 10.1186/s40842-015-0018-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/19/2015] [Indexed: 01/28/2023] Open
Abstract
Charcot neuropathic osteoarthropathy (CN) is a rare disease (NIDDK, NIH Summary Report Charcot Workshop, 2008) that causes significant morbidity and mortality for affected patients. The disease can result in severe deformities of the foot and ankle that contribute to the development of ulcerations and amputations. Medical advances have failed to find ways to stop the progression of the disease. However, it is known that early detection of the CN has a substantial impact on patient outcomes. CN in the earliest stage is very difficult to recognize and differentiate from other similar presenting diseases. We intend to outline clinical considerations practitioners can use when evaluating a patient with early stage suspected CN.
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Affiliation(s)
- Crystal Holmes
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
| | - Brian Schmidt
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
| | - Michael Munson
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
| | - James S. Wrobel
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
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Jansen RB, Christensen TM, Bülow J, Rørdam L, Holstein PE, Svendsen OL. Sarcopenia and body composition in diabetic Charcot osteoarthropathy. J Diabetes Complications 2015; 29:937-42. [PMID: 26139557 DOI: 10.1016/j.jdiacomp.2015.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 05/26/2015] [Accepted: 05/28/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Treatment of Charcot osteoarthropathy (COA) requires restricted walking and offloading for several months, which lead to fat re-distribution and increased sarcopenia. OBJECTIVES/AIM To investigate whether subjects with COA have an altered body composition compared to controls. METHODS Cross-sectional case-control study of people with diabetes with acute or chronic Charcot osteoarthropathy, matched with otherwise healthy people with diabetes. A total of 49 subjects (distribution ~1:1) had a total body DXA-scanning, measuring appendicular lean mass, android/gynoid and truncal/total body fat distribution ratios. RESULTS Sarcopenia frequency was higher in the total population with diabetes overall (9-40%), compared to normal materials. Using two different models for correlating appendicular lean mass to sarcopenia, there were no differences in sarcopenia-rates between the groups (P=0.413 and 0.948 respectively). There was no significant difference in lean tissue mass between the affected and the unaffected leg in the immobilised subject group (P=0.830). The average fat percentage was (29.4-37.7%) in the population with diabetes, compared to a matching background population (24.5-31.9%), whereas there were no significant differences found between the groups (P=0.065). Neither truncal/total fat percent nor android/gynoid fat percent ratios showed differences between the groups. CONCLUSION To our knowledge, this is the first published dataset investigating body composition in subjects with Charcot osteoarthropathy. The study population of diabetics were more fat and sarcopenic than normal subjects, whereas no statistically significant impact of Charcot osteoarthropathy was found.
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Affiliation(s)
- Rasmus Bo Jansen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark.
| | - Tomas Møller Christensen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Jens Bülow
- Department of Clinical Physiology and Imaging, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Lene Rørdam
- Department of Clinical Physiology and Imaging, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Per E Holstein
- Copenhagen Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Ole Lander Svendsen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
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