Surgically induced Charcot neuroarthropathy following partial forefoot amputation in diabetes

Surgical management of Charcot neuroarthropathy

BACKGROUND

Charcot neuroarthropathy is one of the more devastating complications of diabetes. It is a progressive, destructive condition that is characterized by acute fracture, dislocation, and joint destruction in weight-bearing neuropathic foot. In its acute phase, it is often misdiagnosed and can lead to several deformities such as ulcerations and amputation. Early diagnosis and management is, therefore, imperative to avoid rapid progression.

OBJECTIVES

Review current literature on the diagnosis and management of diabetic patients with Charcot neuroarthropathy.

STUDY DESIGN

Narrative review.

METHODS

Particular attention is directed to the role of surgical management in achieving long term osseous stability and alignment so that appropriate footwear and bracing are possible.

CONCLUSION

Charcot neuroarthropathy is a serious and potentially limb-threatening lower extremity late complication of diabetes. Correct timing, adequate fixation and a long post-operative weightbearing period are key to optimizing reconstructive surgery.

CLINICAL RELEVANCE

Primary care providers who treat diabetic patients should be cognizant of the possible complication among patients with diabetic neuropathy of which includes Charcot neuroarthropathy. In this paper, discussion is provided on a rational approach to functional limb salvage with various surgical techniques when non-operative management fails.

Diabetic charcot neuroarthropathy of the foot and ankle with osteomyelitis

One of the most devastating foot and/or ankle complications in the diabetic population with peripheral neuropathy is the presence of Charcot neuroarthropathy (CN). In recent years, diabetic limb salvage has been attempted more frequently as opposed to major lower extremity amputation for CN of the foot and ankle with ulceration and/or deep infection. Treatment strategies for osteomyelitis in the diabetic population have evolved. This article reviews some of the most common surgical strategies recommended for the diabetic patient with CN of the foot and/or ankle and concomitant osteomyelitis.

Negative-pressure wound therapy in the management of diabetic Charcot foot and ankle wounds

As the prevalence of diabetes mellitus continues to rise, innovative medical and surgical treatment options have increased dramatically to address diabetic-related foot and ankle complications. Among the most challenging clinical case scenarios is Charcot neuroarthropathy associated with soft tissue loss and/or osteomyelitis. In this review article, the authors present a review of the most common utilizations of negative-pressure wound therapy as an adjunctive therapy or combined with plastic surgery as it relates to the surgical management of diabetic Charcot foot and ankle wounds.

Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review

BACKGROUND

Charcot Neuro-Arthropathy (CN) is one of the more devastating complications of diabetes. To the best of the authors' knowledge, it appears that no clinical tools based on a systematic review of existing literature have been developed to manage acute CN. Thus, the aim of this paper was to systematically review existing literature and develop an evidence-based clinical pathway for the assessment, diagnosis and management of acute CN in patients with diabetes.

METHODS

Electronic databases (Medline, PubMed, CINAHL, Embase and Cochrane Library), reference lists, and relevant key websites were systematically searched for literature discussing the assessment, diagnosis and/or management of acute CN published between 2002-2012. At least two independent investigators then quality rated and graded the evidence of each included paper. Consistent recommendations emanating from the included papers were then fashioned in a clinical pathway.

RESULTS

The systematic search identified 267 manuscripts, of which 117 (44%) met the inclusion criteria for this study. Most manuscripts discussing the assessment, diagnosis and/or management of acute CN constituted level IV (case series) or EO (expert opinion) evidence. The included literature was used to develop an evidence-based clinical pathway for the assessment, investigations, diagnosis and management of acute CN.

CONCLUSIONS

This research has assisted in developing a comprehensive, evidence-based clinical pathway to promote consistent and optimal practice in the assessment, diagnosis and management of acute CN. The pathway aims to support health professionals in making early diagnosis and providing appropriate immediate management of acute CN, ultimately reducing its associated complications such as amputations and hospitalisations.

HIV neuropathy induced Charcot neuroarthropathy: a case discussion

Charcot neuroarthropathy is a devastating joint condition that affects persons with neuropathy. With HIV/AIDS treatments prolonging the lives of these persons, it is likely that long-term sequelae of the disease will become more evident in the near future. Patients with this disease frequently develop peripheral neuropathy. A high index of suspicion must be raised in any patient with peripheral neuropathy of any cause and a red, hot, swollen, painful foot for Charcot neuroarthropathy to give these patients proper treatment to help prevent the devastating effects of Charcot neuropathy with its potential consequences including foot ulceration and amputation. We present a case of an individual with HIV peripheral neuropathy and Charcot neuroarthropathy.

Triggering mechanisms of neuroarthropathy following conservative surgery for osteomyelitis

BACKGROUND

The purpose of this study was to raise awareness and stimulate discussion of the possible triggering factors of Charcot neuroarthropathy by presenting the case of one patient who had both undergone surgery and was suffering from osteomyelitis.

CASE REPORT

We have extracted one case from our data set for a patient who underwent conservative surgery for osteomyelitis and subsequently developed acute Charcot in the midfoot. We present the clinical findings, photographs and X-ray studies. Preoperative X-ray showed irregular severe bone destruction in the fourth metatarsal head and a fracture of the fourth metatarsal bone. No signs of midfoot Charcot neuroarthropathy were found in this preoperative X-ray. The third and fourth metatarsal bones were both removed and the surgical wound was left open to heal by second intention. Histopathological study confirmed osteomyelitis in the bone sample. Twenty-five days after surgery, the surgical wound showed no signs of infection and healing progressed in a satisfactory way. However, the foot was swollen, erythematous and warm. Skin temperature was two degrees higher than the contralateral foot. X-ray was taken and acute neuroarthropathy of the tarso-metatarsal joints was diagnosed.

CONCLUSIONS

Charcot neuroarthropathy appears to have been triggered by bone infection and/or surgery. We believe that the pivotal factor in the development of acute Charcot neuroarthropathy in this case was the weight bearing in the deformed foot so soon after the operation. Immobilization of the foot is critical as it serves to decrease the inflammation which has a key role in the development of Charcot neuroarthropathy.

Treatment of Diabetic Foot Osteomyelitis: A Surgical Critique

Osteomyelitis is one of the most frequent infections of the diabetic foot accounting for 10-15% of mild infections and almost 50% of severe infections. The definitive diagnosis of foot osteomyelitis requires obtaining bone samples for microbiological and histopathological studies. The treatment of osteomyelitis of the foot in diabetic patients continues to be debated. Until recently, most experts considered that the standard treatment for diabetic foot osteomyelitis should be the surgical removal of infected bone. Recent data suggest that antibiotic treatment can achieve an apparent remission of osteomyelitis though it is difficult to identify patients for this approach. One of the main arguments used to justify the solely antibiotic treatment of osteomyelitis is the alteration of foot biomechanics produced as a consequence of surgery. Conservative surgery combined with antibiotics is an attractive option in treating diabetic foot osteomyelitis because it may reduce the changes in the biomechanics of the foot and minimize the duration of antibiotic therapy. It is currently accepted that the combination of antibiotics with surgical removal of the infected bone may cure the majority of diabetic foot osteomyelitis. Recent literature emphasizes the role of antibiotics in the management of foot infections while little effort is dedicated to reviewing the surgical treatment of this challenging diabetic complication, apart from amputation. More research, including studies of adjunctive therapies in cases of bone infection in the feet of diabetic patients is required.

Charcot neuroarthropathy triggered by osteomyelitis and/or surgery

INTRODUCTION

Charcot neuroarthropathy (CN) is a rare but devastating complication of diabetic neuropathy. Osteomyelitis is also a complication of the diabetic foot and it may be difficult to differentiate from CN.

PATIENTS AND METHODS

A patient with Type 1 diabetes and peripheral neuropathy developed a foot ulcer complicated by osteomyelitis of the first proximal phalanx. He was successfully treated with antibiotics and surgical excision of the infected bone. Six months later, he developed a hot, swollen, red foot and X-ray showed destruction of the second and third metatarsal heads. At the second presentation, it was difficult to determine whether this was a recurrence of osteomyelitis or a new onset of CN. Thus, to obtain a definitive diagnosis, recourse was made to more sophisticated imaging techniques.

RESULTS

99mTc methylenediphosphonate (MDP) bone scans and magnetic resonance imaging proved inconclusive to differentiate between osteomyelitis and CN. Subsequently, an indium-labelled white cell scan confirmed the absence of osteomyelitis and the patient was successfully treated for CN.

DISCUSSION

Infection and/or surgery may be predisposing factors in the development of diabetic CN but the combination of the two could accelerate the onset of the Charcot process in people with diabetes and neuropathy.

The Charcot foot: medical and surgical therapy

Charcot neuro-osteoarthropathy (CN) is among the most devastating complications of neuropathy and now most commonly occurs in the feet of diabetic patients. Because it is relatively rare and because most patients and practitioners do not expect major bone pathology in the absence of significant pain, CN is often misdiagnosed as cellulitis, deep venous thrombosis, or gout. Also, radiographs early in the process are often relatively unremarkable. Although MRI findings are characteristic, treatment should not wait for the MRI result. The hot swollen erythematous neuropathic foot suspected to be CN should be emergently mechanically protected, usually in an irremovable total contact cast. Mechanical protection is the mainstay of conservative therapy, but surgical reconstruction of a deformed foot can usually also be successful. Unless diagnosed very early, significant decrements in quality of life result. Controlled studies are urgently needed to identify best practices.

Epidemiology of the Charcot foot

The Charcot foot (osteoarthropathy) is a significant lower extremity complication of diabetes mellitus that can result in significant deformity, ulceration, and subsequent limb loss. A result of even unrecognized trauma to an insensitive foot, continued weight bearing on the injured foot promotes the evolution of the disorder that is often diagnosed only after significant deformity has occurred. Although this entity is considered a rare complication of the diabetic population, it has profound implications for those persons affected. Greater awareness of the frequency, distribution, determinants, and natural history of Charcot foot can help clinicians establish an earlier diagnosis and institute effective treatment before the onset of limb-threatening deformity.