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Bansod H, Wanjari A, Dumbhare O. A Review on Relationship Between Charcot Neuroarthropathy and Diabetic Patients. Cureus 2023; 15:e50988. [PMID: 38259415 PMCID: PMC10801819 DOI: 10.7759/cureus.50988] [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: 10/29/2023] [Accepted: 12/23/2023] [Indexed: 01/24/2024] Open
Abstract
Charcot Neuroarthropathy (CN) is a complex and incapacitating disorder characterized by neuropathy, progressive deformity, and joint destruction. It is of substantial interest within the diabetic population as this ailment chiefly affects individuals with diabetes. The pathophysiology of CN is multidimensional, connecting peripheral neuropathy, repetitive trauma, and autonomic dysfunction. The review analyses the mechanisms directing the development of CN, emphasizing the influence of diabetes in individuals who lean toward this condition. Clinical presentation and diagnosis of CN in diabetic patients present unique challenges. Complex clinical features have also been discussed, including joint deformities, insidious onset, and painless swelling, which mimic other musculoskeletal conditions. The diagnostic approaches, involving clinical examination and radiological imaging, are analyzed for early and accurate diagnosis. Risk factors and epidemiology emphasize the prevalence of CN within the diabetic population and draw attention to common risk factors contributing to its development. Significant factors such as glycemic control, duration of the disease, and type of diabetes are important in estimating an individual's risk for CN. Complications, such as foot ulcers and amputations, provide an understanding of the severe outcome of this condition on patients' quality of life. Management approaches and treatment involving conservative and surgical approaches are reviewed in depth. A multidisciplinary approach to patient care is emphasized, given the complex nature of CN and the comorbidities existing in diabetic individuals. Prognosis and prevention comprise approaches for mitigating the risk of CN in diabetic patients, such as glycemic control, regular foot examinations, and patient education. This thorough review aims to outline the intricate relationship between CN and diabetes, offering an understanding of pathophysiology, clinical complexities, diagnostic nuances, treatment modalities, and prevention strategies.
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Affiliation(s)
- Himani Bansod
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anil Wanjari
- Cardiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Omkar Dumbhare
- Genetics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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2
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Berli MC, Azaiez N, Götschi T, Pfirrmann CWA, Uçkay I, Sutter R, Waibel FWA, Rosskopf AB. Muscle atrophy in diabetic patients with Charcot foot: a case-control study. Skeletal Radiol 2023; 52:1661-1668. [PMID: 36997748 PMCID: PMC10348944 DOI: 10.1007/s00256-023-04328-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/19/2023] [Accepted: 03/19/2023] [Indexed: 04/01/2023]
Abstract
PURPOSE To evaluate the distribution and severity of muscle atrophy in diabetic patients with active Charcot foot (CF) compared to diabetic patients without CF. Furthermore, to correlate the muscle atrophy with severity of CF disease. MATERIAL/METHODS In this retrospective study, MR images of 35 diabetic patients (21 male, median:62.1 years ± 9.9SD) with active CF were compared with an age- and gender-matched control group of diabetic patients without CF. Two readers evaluated fatty muscle infiltration (Goutallier-classification) in the mid- and hindfoot. Furthermore, muscle trophic (cross-sectional muscle area (CSA)), intramuscular edema (none/mild versus moderate/severe), and the severity of CF disease (Balgrist Score) were assessed. RESULTS Interreader correlation for fatty infiltration was substantial to almost perfect (kappa-values:0.73-1.0). Frequency of fatty muscle infiltration was high in both groups (CF:97.1-100%; control:77.1-91.4%), but severe infiltration was significantly more frequent in CF patients (p-values: < 0.001-0.043). Muscle edema was also frequently seen in both groups, but significantly more often in the CF group (p-values: < 0.001-0.003). CSAs of hindfoot muscles were significantly smaller in the CF group. For the flexor digitorum brevis muscle, a cutoff value of 139 mm2 (sensitivity:62.9%; specificity:82.9%) in the hindfoot was found to differentiate between CF disease and the control group. No correlation was seen between fatty muscle infiltration and the Balgrist Score. CONCLUSION Muscle atrophy and muscle edema are significantly more severe in diabetic patients with CF disease. Muscle atrophy does not correlate with the severity of active CF disease. A CSA < 139 mm2 of the flexor digitorum brevis muscle in the hindfoot may indicate CF disease.
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Affiliation(s)
- Martin C Berli
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicolas Azaiez
- Radiology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Tobias Götschi
- Unit for Clinical and Applied Research (UCAR), Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, Swiss Federal Institute of Technology, Zurich, Switzerland
| | | | - Ilker Uçkay
- Unit for Clinical and Applied Research (UCAR), Balgrist University Hospital, Zurich, Switzerland
| | - Reto Sutter
- Radiology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Felix W A Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andrea B Rosskopf
- Radiology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
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Mehlhorn AT, Illgner U, Lemperle S, Hoerterer H, Krenn V, Walther M. Histopathological assessment of a two-stage reconstructive procedure of the infected Charcot foot. Arch Orthop Trauma Surg 2023; 143:1223-1230. [PMID: 34743216 DOI: 10.1007/s00402-021-04238-8] [Citation(s) in RCA: 2] [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: 08/08/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Charcot neuropathic osteoarthropathy (CN) can be complicated by osteomyelitis (OM). Surgery is a standard procedure to treat OM including debridement and interposition of antibiotic-loaded cement (ABLC) spacer. The course of CN and OM was investigated on a histopathological level. MATERIALS AND METHODS Diabetic patients (n = 15) suffering from CN and midfoot OM underwent surgical debridement and interposition of ABLC was interposed. 6 weeks later, ABLC was removed and bone samples were taken again. Histopathological Charcot Score (HCS), Histopathological Osteomyelitis Evaluation Score (HOES) and microbiological assessment were used to evaluate osteomyelitic and neuroosteoarthropathic activity at both time points. RESULTS Interposition of ABLC leads to microbiological/histopathological eradication of OM in 73%/87% of patients. CN activity-measured by HCS-could be reduced from moderate to low activity by ABLC spacer and correlated with HOES. CONCLUSIONS CN activity could be reduced by surgery. It can be suggested that neuroosteoarthropathic activity measured by HCS is triggered by OM.
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Affiliation(s)
- Alexander T Mehlhorn
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany.
- Department of Orthopedics and Trauma Surgery, Medical Center, Albert-Ludwigs University of Freiburg, Freiburg, Germany.
| | - Ulrich Illgner
- Orthopädische Privatpraxis Seintsch Illgner, Koblenz, Germany
| | - Stefan Lemperle
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
| | - Hubert Hoerterer
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Veith Krenn
- MVZ-Zentrum Für Histologie, Zytologie Und Molekulare Diagnostik GmbH, Max-Planck-Str. 5, Trier, Germany
| | - Markus Walther
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
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Kidron A, Nguyen HH, Bayer J, Durkin M, Harris D, Dang H, Diehl M, Silver L. Salvage of Chronic Therapy-Resistant Bilateral Charcot Foot Osteoarthropathy with Signs of Osteomyelitis. Orthop Surg 2022; 14:1541-1544. [PMID: 35587533 PMCID: PMC9251323 DOI: 10.1111/os.13299] [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: 08/24/2021] [Revised: 03/26/2022] [Accepted: 04/10/2022] [Indexed: 11/30/2022] Open
Abstract
Charcot arthropathy is an insidious condition affecting the lower limbs of diabetic patients. It is a complication of diabetic neuropathy resulting from subsequent Wallerian degeneration of the nerves. This complication may eventually lead to limb amputation and a poor patient prognosis if not diagnosed and treated successfully. Herein, we report the case of a 73‐year‐old female who presented with rapidly progressive bilateral Charcot foot over a 5‐week period, necessitating an exostectomy on the mid foot, specifically on the cuboid bone and the navicular cuneiform joint. Her presentation with rapidly progressing foot ulcers on the plantar aspect prompted initial treatment based on osteomyelitis. The report will therefore serve as a useful guide on how to properly treat Charcot foot, which may present in an atypical manner.
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Affiliation(s)
- Ariel Kidron
- Orthopaedic Surgery, Nova Southeastern University Osteopathic Medicine College of Medicine, Ft. Lauderdale, Florida, USA
| | - Hiep H Nguyen
- Orthopaedic Surgery, Nova Southeastern University Osteopathic Medicine College of Medicine, Ft. Lauderdale, Florida, USA
| | - Jack Bayer
- Orthopaedic Surgery, Dr. Kiran C. Patel College of Allopathic Medicine, Ft. Lauderdale, Florida, USA
| | - Michael Durkin
- Orthopaedic Surgery, Dr. Kiran C. Patel College of Allopathic Medicine, Ft. Lauderdale, Florida, USA
| | - Daniel Harris
- Orthopaedic Surgery, Case Western Reserve University College of Medicine, Cleveland, Ohio, USA
| | - Helen Dang
- Orthopaedic Surgery, Nova Southeastern University Osteopathic Medicine College of Medicine, Ft. Lauderdale, Florida, USA
| | - Matt Diehl
- Orthopedic Surgery, Robert Wood Johnson Medical School - Rutgers University, Newark, New Jersey, USA
| | - Larry Silver
- Orthopaedic Surgery, Nova Southeastern University Osteopathic Medicine College of Medicine, Ft. Lauderdale, Florida, USA
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Gratwohl V, Jentzsch T, Schöni M, Kaiser D, Berli MC, Böni T, Waibel FWA. Long-term follow-up of conservative treatment of Charcot feet. Arch Orthop Trauma Surg 2022; 142:2553-2566. [PMID: 33829302 PMCID: PMC9474498 DOI: 10.1007/s00402-021-03881-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 03/24/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN. METHODS A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development. RESULTS Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations. CONCLUSIONS With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking. LEVEL OF EVIDENCE III, long-term retrospective cohort study.
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Affiliation(s)
- Viviane Gratwohl
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Thorsten Jentzsch
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Madlaina Schöni
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Dominik Kaiser
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Martin C. Berli
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Thomas Böni
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Felix W. A. Waibel
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
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Kavarthapu V, Budair B. Two-stage reconstruction of infected Charcot foot using internal fixation : a promising functional limb salvage technique. Bone Joint J 2021; 103-B:1611-1618. [PMID: 34587806 DOI: 10.1302/0301-620x.103b10.bjj-2021-0339.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. METHODS We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months' follow-up. RESULTS We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. CONCLUSION Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of 'long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion' is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611-1618.
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Affiliation(s)
- Venu Kavarthapu
- Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, UK.,University of Southern Denmark, Odense, Denmark
| | - Basil Budair
- Trauma & Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Aston University School of Engineering and Applied Science, Birmingham, UK
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Berli MC, Higashigaito K, Götschi T, Pfirrmann CWA, Sutter R, Rosskopf AB. The "Balgrist Score" for evaluation of Charcot foot: a predictive value for duration of off-loading treatment. Skeletal Radiol 2021; 50:311-320. [PMID: 32699954 PMCID: PMC7736011 DOI: 10.1007/s00256-020-03541-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a new magnetic resonance imaging(MRI) scoring system for evaluation of active Charcot foot and to correlate the score with a duration of off-loading treatment ≥ 90 days. METHODS An outpatient clinic database was searched retrospectively for MRIs of patients with active Charcot foot who completed off-loading treatment. Images were assessed by two radiologists (readers 1 and 2) and an orthopedic surgeon (reader 3). Sanders/Frykberg regions I-V were evaluated for soft tissue edema, bone marrow edema, erosions, subchondral cysts, joint destruction, fractures, and overall regional manifestation using a score according to degree of severity (0-3 points). Intraclass correlations (ICC) for interreader agreement and receiver operating characteristic analysis between MR findings and duration of off-loading-treatment were calculated. RESULTS Sixty-five feet in 56 patients (34 men) with a mean age of 62.4 years (range: 44.5-85.5) were included. Region III (reader 1/reader 2: 93.6/90.8%) and region II (92.3/90.8%) were most affected. The most common findings in all regions were soft tissue edema and bone marrow edema. Mean time between MRI and cessation of off-loading-treatment was 150 days (range: 21-405). The Balgrist Score was defined in regions II and III using soft tissue edema, bone marrow edema, joint destruction, and fracture. Interreader agreement for Balgrist Score was excellent: readers 1/2: ICC 0.968 (95% CI: 0.948, 0.980); readers 1/2/3: ICC 0.856 (0.742, 0.917). A cutoff of ≥ 9.0 points in Balgrist Score (specificity 72%, sensitivity 66%) indicated a duration of off-loading treatment ≥ 90 days. CONCLUSION The Balgrist Score is a new MR scoring system for assessment of active Charcot foot with excellent interreader agreement. The Balgrist Score can help to identify patients with off-loading treatment ≥ 90 days.
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Affiliation(s)
- Martin C. Berli
- grid.412373.00000 0004 0518 9682Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Kai Higashigaito
- grid.7400.30000 0004 1937 0650Faculty of Medicine, University of Zurich, Zurich, Switzerland ,grid.412373.00000 0004 0518 9682Radiology, Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland
| | - Tobias Götschi
- grid.412373.00000 0004 0518 9682Unit for Clinical and Applied Research (UCAR), Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland ,grid.5801.c0000 0001 2156 2780Institute for Biomechanics, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Christian W. A. Pfirrmann
- grid.7400.30000 0004 1937 0650Faculty of Medicine, University of Zurich, Zurich, Switzerland ,grid.412373.00000 0004 0518 9682Radiology, Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland
| | - Reto Sutter
- grid.7400.30000 0004 1937 0650Faculty of Medicine, University of Zurich, Zurich, Switzerland ,grid.412373.00000 0004 0518 9682Radiology, Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland
| | - Andrea B. Rosskopf
- grid.7400.30000 0004 1937 0650Faculty of Medicine, University of Zurich, Zurich, Switzerland ,grid.412373.00000 0004 0518 9682Radiology, Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland
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Waibel FWA, Berli MC, Gratwohl V, Sairanen K, Kaiser D, Shin L, Armstrong DG, Schöni M. Midterm Fate of the Contralateral Foot in Charcot Arthropathy. Foot Ankle Int 2020; 41:1181-1189. [PMID: 32700577 PMCID: PMC8351021 DOI: 10.1177/1071100720937654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The contralateral foot in Charcot arthropathy or neuroarthropathy (CN) is subject to increased plantar pressure. To date, the clinical consequences of this pressure elevation are yet to be determined. The aim of this study was to evaluate ulcer and amputation rates of the contralateral foot in CN. METHODS We abstracted the medical records of 130 consecutive subjects with unilateral CN. Rates of contralateral CN development and recurrence, contralateral ulcer development, and contralateral amputations were recorded. Statistical analysis was performed to identify possible risk factors for contralateral CN and ulcer development, and contralateral amputation. Mean follow-up was 6.2 (SD 4) years. RESULTS After a mean of 2.5 years, 19.2% patients developed contralateral CN. Female gender was associated with contralateral CN development (odds ratio 3.13, 95% confidence interval 1.27, 7.7). Overall, 46.2% patients developed a contralateral ulcer. Among the patients who developed contralateral CN, 60% developed an ulcer. Sanders type 2 at the index foot (midfoot CN) was significantly associated with contralateral ulcer development. Ulcer-free survival (UFS) differed significantly between patients with diabetes type 1 (median UFS 5131 days) and patients with diabetes type 2 (median UFS 2158 days). A total of 25 amputations had to be performed in 22 (16.9%) patients. Three of those 22 patients (2.3%) needed major amputation. CONCLUSION Almost 20% of patients developed contralateral CN. Nearly half of people with CN developed a contralateral foot ulceration. Patients with type 2 diabetes had significantly shorter UFS than patients with diabetes type 1. Every sixth patient needed an amputation, with the majority being minor amputations. The contralateral foot should be monitored closely and included in the treatment in patients with CN. LEVEL OF EVIDENCE Level IV, retrospective study.
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Affiliation(s)
- Felix W. A. Waibel
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Martin C. Berli
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Viviane Gratwohl
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Kati Sairanen
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
| | - Dominik Kaiser
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Laura Shin
- Department of Surgery, The Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California (USC), Los Angeles, CA, USA
| | - David G. Armstrong
- Department of Surgery, The Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California (USC), Los Angeles, CA, USA
| | - Madlaina Schöni
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
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9
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Ramanujam CL, Stuto AC, Zgonis T. Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review. J Wound Care 2020; 29:S19-S28. [PMID: 32530758 DOI: 10.12968/jowc.2020.29.sup6.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes. METHOD A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded. RESULTS A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction. CONCLUSION Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C Stuto
- LVPG Orthopedics and Sports Medicine, Lehigh Valley Health Network, Bethlehem, PA, US
| | - Thomas Zgonis
- Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
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10
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Sun Y, Gao Y, Chen J, Sun H, Cai YT, Ge L, Li YN, Zhang J, Tian JH. Evidence mapping of recommendations on diagnosis and therapeutic strategies for diabetes foot: an international review of 22 guidelines. Metabolism 2019; 100:153956. [PMID: 31394109 DOI: 10.1016/j.metabol.2019.153956] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/18/2019] [Accepted: 08/01/2019] [Indexed: 12/14/2022]
Abstract
To systematically review clinical practice guidelines (CPGs) on diabetes foot and assess the consistency of recommendations, quality of CPGs and to present an evidence-map for explicating research trends and gaps. We performed a literature search on PubMed, Embase, and Web of Science, guideline databases and websites of diabetes society to include the diabetic CPGs. The basic information, recommendations for the diabetic foot, methodological quality and reporting quality of diabetic CPGs were exacted by the Excel. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE II instrument and RIGHT checklist. R3.5.1 software was used to create all bubble plots. A total of 22 diabetic CPGs were included, eight CPGs were from different professional diabetes societies. Recommendations on diabetic foot complications involve Diabetic foot ulcer (DFU), Charcot neuropathy (CN) and Osteomyelitis (OM). Eight DFU diagnostic systems presented in 22 CPGs. According to the recommendations of diabetic CPGs, the treatment of DFU can be summarized in four major items; six recommendations on CN diagnosis and six recommendations on treatment of CN were consistent among studies. However, there were inconsistencies in three OM diagnosis recommendations and four OM treatment recommendations. Some recommendations in CPGs were not very specific and clear, and hence they were not reliable for OM diagnosis and treatment. Once these inconsistencies are resolved, validated, accurate and effective diagnosis and treatment of diabetes foot will lead to reduced costs and adverse complications. The results of this review add to our knowledge and promote the development of trustworthy CPGs on diabetes.
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Affiliation(s)
- Yue Sun
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Ji Chen
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Hao Sun
- School of Information Engineering, Zhengzhou University, Henan Province, China
| | - Yi-Tong Cai
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Long Ge
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China; School of Public Health, Lanzhou University, Lanzhou City, Gansu Province, China
| | - Ya-Nan Li
- Binzhou Maternal and Child Health Care Hospital, Binzhou City, Shandong Province, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Jin-Hui Tian
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China.
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Yang QH, Hsu P, Gao YS, Zhang CQ. Charcot neuroarthropathy of the knee due to idiopathic sensory peripheral neuropathy. BMC Musculoskelet Disord 2019; 20:501. [PMID: 31666060 PMCID: PMC6822451 DOI: 10.1186/s12891-019-2873-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/09/2019] [Indexed: 12/18/2022] Open
Abstract
Background Charcot neuroarthropathy is a systemic disease that generates pathological changes in the musculoskeletal system, causing instability, dislocations, and deformities. Charcot neuroarthropathy of the knee, due to either diabetes mellitus or syringomyelia, is anecdotally reported with the epidemic of the diseases. However, idiopathic sensory peripheral neuropathy can inflict osteoarticular structures directly, inducing a dysfunctional Charcot neuroarthropathy. An early diagnosis and effective relief of the symptomatic deformity is essential for the treatment. Case presentation We report the case of a patient with idiopathic sensory peripheral neuropathy who presented with a swelling right knee, as well as distorted and painless gait disorder, diagnosed as Charcot neuroarthropathy of the knee. Partial weight bearing with a hinged knee brace was used to correct the abnormal alignment and gait posture, and bisphosphonates were prescribed to decrease pathological bone resorption. Although the alignment and Knee Society Score got a gradual deterioration, the combination of orthosis and pharmacy could alleviate the symptom to a certain extent. Conclusion The diagnosis of Charcot neuroarthropathy of the knee is rare that requiring early diagnosis. The presence of features, including painlessness, numbness, and deformed arthropathy following chronic-onset algesthesia loss should be taken carefully.
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Affiliation(s)
- Qian-Hao Yang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Peichun Hsu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - You-Shui Gao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China. .,Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, WA, 6009, Australia.
| | - Chang-Qing Zhang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Goldsmith L, Barlow M, Evans PJ, Srinivas-Shankar U. Acute hot foot: Charcot neuroarthropathy or osteomyelitis? Untangling a diagnostic web. BMJ Case Rep 2019; 12:12/5/e228597. [PMID: 31088814 DOI: 10.1136/bcr-2018-228597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 55-year-old man with poorly controlled type 1 diabetes with microvascular and macrovascular complications presented with a 1-week history of painful erythematous swelling on the dorsum of the left foot with two areas of foot ulceration. Inflammatory markers were raised. MRI of the left foot revealed a soft tissue swelling on the dorsum of the left foot, marrow oedema and destruction of several small joints of the foot, indicating osteomyelitis and Charcot neuroarthropathy (CN). The soft tissue swelling on the dorsum of the left foot was debrided; per-operatively bone destruction of base of the fifth metatarsal was found. The patient received intravenous antibiotics for 6 weeks. The clinical features of CN including erythema, oedema and elevated temperature of the left foot settled with off-loading the foot in an air cast walker after 6 months. Our case highlights the need to recognise CN in an acutely inflamed foot of diabetic patients with neuropathy, even when other conditions like soft tissue infection and osteomyelitis can explain the clinical features.
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Affiliation(s)
- Louise Goldsmith
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew Barlow
- Department of Diabetes and Endocinology, Arrowe Park Hospital, Wirral, UK
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