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Kelechi TJ, Prentice M, Mueller M, Madisetti M. Infrared Thermometry and Thermography in Detecting Skin Temperature Variations to Predict Venous Leg Ulcer Reulceration: A Case Report. J Wound Ostomy Continence Nurs 2024; 51:405-414. [PMID: 39313976 DOI: 10.1097/won.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
BACKGROUND We aimed to determine whether monitoring skin temperature (Tsk) over recently healed venous leg ulcers (VLUs) can provide an objective approach to predicting reulceration. The cases presented in this article were part of a larger, multisite, 6-month randomized clinical trial of a cooling intervention to prevent ulcer recurrence among patients with chronic venous disease (CVD) and with recently healed VLUs. CASES We report a series of four patients with CVD, three experienced VLU reulceration, and one case remained free of recurrence. Assessments of recurrence likelihood is based on daily patient Tsk self-reports using a handheld infrared (IR) thermometer and clinic visits using a combination digital and long-wave IR camera. All three cases with reulceration demonstrate a persistent 2°C above baseline average Tsk increase and a "dip-and-spike" pattern from -3°C to +5°C for several days prior to reulceration. In contrast, the patient who remained free of VLU recurrence showed a stable pattern of Tsk with minimal daily fluctuations. Thermal images showed Tsk of the affected extremity is warmer compared with the contralateral limb and increased between visits when ulcers recurred. CONCLUSION Using IR devices to monitor Tsk among patients with CVD at risk of reulceration is an objective and reliable approach to detect changes over time. Consistent Tsk elevation over the affected area as compared to the contralateral limb and a "dip-and-spike" pattern may predict reulceration. Infrared devices showed effectiveness in detecting changes indicative of Tsk changes in recently healed leg skin over scar tissue after VLU healing.
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Affiliation(s)
- Teresa J Kelechi
- Teresa J. Kelechi, PhD, RN, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Margie Prentice, MBA, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Martina Mueller, PhD, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Mohan Madisetti, MSc, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Margie Prentice
- Teresa J. Kelechi, PhD, RN, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Margie Prentice, MBA, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Martina Mueller, PhD, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Mohan Madisetti, MSc, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Martina Mueller
- Teresa J. Kelechi, PhD, RN, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Margie Prentice, MBA, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Martina Mueller, PhD, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Mohan Madisetti, MSc, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Mohan Madisetti
- Teresa J. Kelechi, PhD, RN, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Margie Prentice, MBA, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Martina Mueller, PhD, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
- Mohan Madisetti, MSc, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
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Lasschuit JWJ, Center JR, Greenfield JR, Tonks KTT. Effect of denosumab on inflammation and bone health in active Charcot foot: A phase II randomised controlled trial. J Diabetes Complications 2024; 38:108718. [PMID: 38490126 DOI: 10.1016/j.jdiacomp.2024.108718] [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: 12/03/2023] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 03/17/2024]
Abstract
AIMS We aimed to investigate the effect of denosumab on pedal bone health and clinical resolution in active Charcot foot (CN). METHODS This multicentre open-label phase 2 randomised controlled trial recruited adults with diabetes mellitus and active CN within 3 months of onset. Participants were randomised to standard care alone, or with denosumab 60 mg subcutaneously. Denosumab was administered at baseline and again at 6 months, unless foot temperature had normalised (i.e. <2 °C compared to contralateral foot). Co-primary outcomes were change in calcaneal Stiffness Index and foot temperature normalisation over 18 months. RESULTS Twelve participants per group were analysed; mean age 58 ± 11 years, 83 % male and 92 % had type 2 diabetes. Active CN duration was median 8 (IQR 7-12) weeks. Ninety-two percent were Eichenholtz stage 1 and 96 % involved the midfoot. After 1-month, median decline in Stiffness Index was less in the denosumab verses standard care group (0.5 [IQR -1.0 to 3.9] vs -2.8 [-8.5 to -1.0], p = 0.008). At 18-months, 92 % of the denosumab group attained foot temperature normalisation versus 67 % of the standard care group (p = 0.13). CONCLUSIONS Denosumab ameliorated the early decline in calcaneal Stiffness Index associated with active CN. However, no difference in normalisation of foot temperature was observed.
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Affiliation(s)
- Joel Willem Johan Lasschuit
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia; Clinical Diabetes, Appetite and Metabolism Lab, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, New South Wales 2010, Australia; St Vincent's Clinical Campus, School of Clinical Medicine, University of New South Wales, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia.
| | - Jacqueline Ruth Center
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia; Skeletal Diseases Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, New South Wales 2010, Australia; St Vincent's Clinical Campus, School of Clinical Medicine, University of New South Wales, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia.
| | - Jerry Richard Greenfield
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia; Clinical Diabetes, Appetite and Metabolism Lab, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, New South Wales 2010, Australia; St Vincent's Clinical Campus, School of Clinical Medicine, University of New South Wales, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia.
| | - Katherine Thuy Trang Tonks
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia; Clinical Diabetes, Appetite and Metabolism Lab, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, New South Wales 2010, Australia; St Vincent's Clinical Campus, School of Clinical Medicine, University of New South Wales, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia; School of Medicine, University of Notre Dame, 160 Oxford Street, Darlinghurst, New South Wales 2010, Australia.
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Bajaj G, Chhabra A. Bone Marrow Changes and Lesions of Diabetic Foot and Ankle Disease: Conventional and Advanced Magnetic Resonance Imaging. Semin Musculoskelet Radiol 2023; 27:73-90. [PMID: 36868246 DOI: 10.1055/s-0043-1761494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Diabetic foot and ankle complications contribute to substantial mortality and morbidity. Early detection and treatment can lead to better patient outcomes. The primary diagnostic challenge for radiologists is distinguishing Charcot's neuroarthropathy from osteomyelitis. Magnetic resonance imaging (MRI) is the preferred imaging modality for assessing diabetic bone marrow alterations and for identifying diabetic foot complications. Several recent technical advances in MRI, such as the Dixon technique, diffusion-weighted imaging, and dynamic contrast-enhanced imaging, have led to improved image quality and increased capability to add more functional and quantitative information.We discuss the bone marrow abnormalities encountered in daily radiologic assessment: osteopenia, reactive bone marrow edema-like signal, insufficiency fractures, Charcot's neuroarthropathy, osteomyelitis, serous marrow atrophy, digital ischemia, and bone infarcts, along with their pathophysiology and the conventional and advanced imaging techniques used for a comprehensive marrow evaluation.
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Affiliation(s)
- Gitanjali Bajaj
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Avneesh Chhabra
- Department Radiology and Orthopedic Surgery, UT Southwestern, Dallas, Texas.,Johns Hopkins University and Walton Centre for Neuroscience, Liverpool, United Kingdom.,University of Dallas, Irving, Texas
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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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Ahluwalia R, Armstrong DG, Petrova N, Papanas N, Edmonds M. Stage 0 Charcot Neuroarthropathy in the Diabetic Foot: An Emerging Narrow Window of Opportunity? INT J LOW EXTR WOUND 2022; 21:374-376. [PMID: 33960848 DOI: 10.1177/15347346211011844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In a world where popular culture and concepts can become the norm without all the rigors of normal scrutiny, our attention is focused on identifying Charcot neuroarthropathy (CN) at a stage before radiological bone destruction occurs. The rationale is that early recognition can prevent a destructive chain of events and thus potentially reduce the burden to patients and health care providers. In this article, we describe the evolution of stage 0 CN, and the use of modern imaging in characterizing the abnormalities recognized by these modalities and how they aid our understanding and supplement our knowledge. We review the potential of these imaging modalities, assessing how far we have come in characterizing stage 0 and if we have robust criteria for the identification of stage 0 in the natural history of CN.
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Affiliation(s)
| | | | - Nina Petrova
- 8948King's College Hospital, London, UK
- King's College, London, UK
| | | | - Michael Edmonds
- 8948King's College Hospital, London, UK
- King's College, London, UK
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Waibel FWA, Böni T. Nonoperative Treatment of Charcot Neuro-osteoarthropathy. Foot Ankle Clin 2022; 27:595-616. [PMID: 36096554 DOI: 10.1016/j.fcl.2022.05.002] [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] [Indexed: 02/02/2023]
Abstract
Conservative treatment of Charcot neuro-osteoarthropathy (CN) aims to retain a stable, plantigrade, and ulcer-free foot, or to prevent progression of an already existing deformity. CN is treated with offloading in a total contact cast as long as CN activity is present. Transition to inactive CN is monitored by the resolution of clinical activity signs and by resolution of bony edema in MRI. Fitting of orthopedic depth insoles, orthopedic shoes, or ankle-foot orthosis should follow immediately after offloading has ended to prevent CN reactivation or ulcer development.
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Affiliation(s)
- Felix W A Waibel
- Division of Technical and Neuroorthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland.
| | - Thomas Böni
- Division of Technical and Neuroorthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland
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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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