The Charcot foot: pathophysiology, diagnosis and classification

Infectious Aspects of Chronic Wounds

The treatment, maintenance, and suppression of infection in chronic wounds remain a challenge to all practitioners. From an infectious disease standpoint, knowing when a chronic wound has progressed from colonized to infected, when to use systemic antimicrobial therapy and when and how to culture such wounds can be daunting. With few standardized clinical guidelines for infections in chronic wounds, caring for them is an art form. However, there have been notable advances in the diagnosis, treatment, and management of infected wounds. This article will discuss the pathophysiology of infection in older adults, including specific infections such as cutaneous candidiasis, necrotizing soft tissue infection, osteomyelitis, and infections involving hardware.

Charcot neuroarthropathy in diabetic patients in Texas

AIMS

Charcot neuroarthropathy (CN) is a complex disease of the bone and joints that can lead to serious and life-threatening complications. This study investigates epidemiologic trends in diabetic CN in Texas and the impact of age on these values.

METHODS

A retrospective analysis was conducted using the Texas Department of State Health Services Hospital Discharge Data Public Use Data File. Using International Classification of Diseases, Ninth (ICD-9) and Tenth (ICD-10) Revision codes, we identified patients with diabetes and Charcot ankle or foot. Data extracted included diagnoses, race, and gender. Population rates were estimated using census data, calculated per 1000 population and standardized by age.

RESULTS

Overall and age-standardized rates of CN increased each year from 2006 to 2016, except for a downward trend from 2014 to 2016. Poisson regression revealed significant increases in the incidence rate ratio compared to 2006 for each year from 2008 to 2016. When age group is included, all years except 2007 show a significant increase relative to 2006, and all age groups have increased rates relative to ages 18-44. Major and minor amputations in patients with CN have increased.

CONCLUSIONS

The increasing rates of CN and amputations highlight the need for further research and standardized strategies for diagnosis and management.

The Differentiation Between Infection and Acute Charcot

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.

Fabrication and In Vivo Assessment of Oxidatively Responsive PolyHIPE Scaffolds for Use in Diabetic Orthopedic Applications

Achieving surgical success in orthopedic patients with metabolic disease remains a substantial challenge. Diabetic patients exhibit a unique tissue microenvironment consisting of high levels of reactive oxygen species (ROS), which promotes osteoclastic activity and leads to decreased bone healing. Alternative solutions, such as synthetic grafts, incorporating progenitor cells or growth factors, can be costly and have processing constraints. Previously, the potential for thiol-methacrylate networks to sequester ROS while possessing tunable mechanical properties and degradation rates has been demonstrated. In this study, the ability to fabricate thiol-methacrylate interconnected porous scaffolds using emulsion templating to create monoliths with an average porosity of 97.0% is reported. The average pore sizes of the scaffolds range from 27 to 656 µm. The scaffolds can sequester pathologic levels of ROS via hydrogen peroxide consumption and are not impacted by sterilization. Subcutaneous implantation shows no signs of acute toxicity. Finally, in a 6-week bilateral calvarial defect model in Zucker diabetic fatty rats, ROS scaffolds increase new bone volume by 66% over sham defects. Histologic analysis identifies woven bone infiltration throughout the scaffold and neovascularization. Overall, this study suggests that porous thiol-methacrylate scaffolds may improve healing for bone grafting applications where high levels of ROS hinder bone growth.

Efficacy of Platelet-Rich Plasma in the Treatment of Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis

BACKGROUND

The probiological healing effect of platelet-rich plasma (PRP) during tissue repair has recently gathered much attention. This study aimed to conduct a systematic review and meta-analysis of patients with diabetic foot ulcer (DFU) receiving PRP or conventional treatment to evaluate their efficacy.

METHODS

PubMed, Excerpta Medica Database (EMBASE), Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases were comprehensively searched by 2 independent reviewers following PRISMA guidelines for the inclusion of randomized controlled trials (RCTs) comparing PRP with conventional treatments for DFUs. The primary measurements of healing rate and healing time, the methodological quality and extracted data were assessed using Review Manager 5.3. Statistical significance was set at P < 0.05.

RESULTS

A total of 10 RCTs involving 550 patients were included in this study, PRP was observed to significantly improve the healing rate (risk ratio [RR] = 1.38, 95% confidence interval [CI] 1.05-1.82, P = 0.02) and shorten the healing time (mean difference [MD] = -23.23, 95% CI -45.97 to -0.49, P = 0.05) of patients with DFU when compared to the conventional treatment.

CONCLUSIONS

Compared to conventional treatment, PRP effectively promoted the healing of patients with DFU by evidently improving the healing rate and healing time.

The pathophysiology of diabetic foot: a narrative review

An aging population and changes in dietary habits have increased the incidence of diabetes, resulting in complications such as diabetic foot ulcers (DFUs). DFUs can lead to serious disabilities, substantial reductions in patient quality of life, and high financial costs for society. By understanding the etiology and pathophysiology of DFUs, their occurrence can be prevented and managed more effectively. The pathophysiology of DFUs involves metabolic dysfunction, diabetic immunopathy, diabetic neuropathy, and angiopathy. The processes by which hyperglycemia causes peripheral nerve damage are related to adenosine triphosphate deficiency, the polyol pathway, oxidative stress, protein kinase C activity, and proinflammatory processes. In the context of hyperglycemia, the suppression of endothelial nitric oxide production leads to microcirculation atherosclerosis, heightened inflammation, and abnormal intimal growth. Diabetic neuropathy involves sensory, motor, and autonomic neuropathies. The interaction between these neuropathies forms a callus that leads to subcutaneous hemorrhage and skin ulcers. Hyperglycemia causes peripheral vascular changes that result in endothelial cell dysfunction and decreased vasodilator secretion, leading to ischemia. The interplay among these four preceding pathophysiological factors fosters the development and progression of infections in individuals with diabetes. Charcot neuroarthropathy is a chronic and progressive degenerative arthropathy characterized by heightened blood flow, increased calcium dissolution, and repeated minor trauma to insensate joints. Directly and comprehensively addressing the pathogenesis of DFUs could pave the way for the development of innovative treatment approaches with the potential to avoid the most serious complications, including major amputations.

Muscle atrophy in diabetic patients with Charcot foot: a case-control study

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.

Issues and challenges in diabetic neuropathy management: A narrative review

Diabetic neuropathy (DN) is a devastating disorder with an increasing prevalence globally. This epidemic can pose a critical burden on individuals and com-munities, subsequently affecting the productivity and economic output of a country. With more people living a sedentary lifestyle, the incidence of DN is escalating worldwide. Many researchers have relentlessly worked on ways to combat this devastating disease. Their efforts have given rise to a number of commercially available therapies that can alleviate the symptoms of DN. Unfortunately, most of these therapies are only partially effective. Worse still, some are associated with unfavorable side effects. This narrative review aims to highlight current issues and challenges in the management of DN, especially from the perspective of molecular mechanisms that lead to its progression, with the hope of providing future direction in the management of DN. To improve the approaches to diabetic management, the suggested resolutions in the literature are also discussed in this review. This review will provide an in-depth understanding of the causative mechanisms of DN, apart from the insights to improve the quality and strategic approaches to DN management.

Cartilage Damage Pathological Characteristics of Diabetic Neuropathic Osteoarthropathy

Background

Diabetic neuropathic osteoarthropathy (DNOAP) is a rare and easily missed complication for diabetes that leads to increased morbidity and mortality. DNOAP is characterized by progressive destruction of bone and joint, but its pathogenesis remains elusive. We herein aimed to investigate the pathological features and pathogenesis of the cartilages damage in DNOAP patients.

Methods

The articular cartilages of eight patients with DNOAP and eight normal controls were included. Masson staining and safranine O/fixed green staining (S-O) were used to observe the histopathological characteristics of cartilage. The ultrastructure and morphology of chondrocytes were detected by electron microscopy and toluidine blue staining. Chondrocytes were isolated from DNOAP group and control group. The expression of receptor activator of nuclear factor kappaB ligand (RANKL), osteoprotegerin (OPG), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and Aggrecan protein was evaluated by western blot. Reactive oxygen species (ROS) levels were measured using a 2',7'-dichlorofluorescin diacetate (DCFH-DA) probe. The percentage of apoptotic cells was determined by flow cytometry (FCM). The chondrocytes were cultured with different glucose concentrations to observe the expression of RANKL and OPG.

Results

Compared with the control group, the DNOAP group showed fewer chondrocytes, subchondral bone hyperplasia, and structural disorder, and a large number of osteoclasts formed in the subchondral bone area. Moreover, mitochondrial and endoplasmic reticulum swellings were observed in the DNOAP chondrocytes. The chromatin was partially broken and concentrated at the edge of nuclear membrane. The ROS fluorescence intensity of chondrocyte in DNOAP group was higher than that in normal control group (28.1 ± 2.3 vs. 11.9 ± 0.7; P < 0.05). The expression of RANKL, TNF-α, IL-1β, and IL-6 protein in DNOAP group was higher than that in normal control group, whereas OPG and Aggrecan protein were lower than that in normal control group (both P < 0.05). FCM showed that the apoptotic rate of chondrocyte in DNOAP group was higher than that in normal control group (P < 0.05). The RANKL/OPG ratio showed significant upward trend when the concentration of glucose was over than 15 mM.

Conclusions

DNOAP patients tend to have severe destruction of articular cartilage and collapse of organelle structure including mitochondrion and endoplasm reticulum. Indicators of bone metabolism (RANKL and OPG) and inflammatory cytokines (IL-1β, IL-6, and TNF-α) play an important role in promoting the pathogenesis of DNOAP. The glucose concentration higher than 15 mM made the RANKL/OPG ratio change rapidly.

Therapeutics of Charcot neuroarthropathy and pharmacological mechanisms: A bone metabolism perspective

Charcot neuroarthropathy (CN) is a chronic, destructive, and painless damage of the skeletal system that affects the life quality of patients. CN, with an unclear mechanism, is characterized with invasive destruction of bones and a serious abnormality of bone metabolism. Unfortunately, development of an effective prevention and treatment strategy for CN is still a great challenge. Of note, recent studies providing an insight into the molecular mechanisms of bone metabolism and homeostasis have propelled development of novel CN therapeutic strategies. Therefore, this review aims to shed light on the pathogenesis, diagnosis, and treatment of CN. In particular, we highlight the eminent role of the osteoprotegerin (OPG)-receptor activator of nuclear factor-κB (RANK)-RANK ligand (RANKL) system in the development of CN. Furthermore, we summarize and discuss the diagnostic biomarkers of CN as well as the potential pharmacological mechanisms of current treatment regimens from the perspective of bone metabolism. We believe that this review will enhance the current state of knowledge on the diagnosis, prevention, and therapeutic efficacy of CN.

Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.

Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot

Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.

Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy

Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.

False aneurysm in a Charcot foot: A case report

Charcot foot or neurogenic osteoarthropathy is a serious complication of diabetic peripheral neuropathy. The association between false aneurysm and Charcot foot is yet uncommon and has not been reported through the literature. We describe a case of false aneurysm in a Charcot foot in a 55-year-old female patient.

Different approach to charcot neuroarthropathy: A case report

Introduction and importance

Charcot neuroarthropathy (CN) is a degenerative, progressive disease affecting the ankle and foot and it is usually a disabling factor in diabetic patients. Surgical management of CN aims to obtain a painless stable plantigrade foot which can be achieved through fusion. Achieving joint arthrodesis in CN usually carries a high failure rate.

Cases presentation

We presented two patients with late-stage CN foot deformity. The first case is a 52-year-old female with CN on her left ankle and presented without any infection or prior correction. The second case reported a 47-year-old man with complaints of deformity on his right ankle, he had undergone surgical treatment with an external fixator before, and now presented with infection in the surgical site.

Clinical discussion

Ankle arthrodesis has been considered by many as the treatment of choice for severe and late-stage CN foot. This treatment aims to give a rigid enough fixation which will maintain the stability of the ankle joint and prevents further destruction of surrounding tissue. Multiple modalities of treatment are available and must be chosen accordingly to each clinical case. Minimal implants and the use of multiple bone grafts could be considered as a plan of treatment. Both patients have promising and positive results from the two procedures.

Conclusion

Treatment of CN Foot with internal plate fixation combined with fibular strut graft seemed to give promising results, both radiographically and functionally. Furthermore, a slight modification of treatment with a minimal implant or iliac graft may be considered.

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We present case reports consist of 2 patients with CN and diabetes mellitus condition.

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The management for this varied condition has not described in many published literatures.

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We performed minimal implant and multiple bone grafts technique surgery in different kind of patient's condition, both in non-infected and infected patient.

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The follow up of clinical and radiograph imaging shows satisfiying outcome, and both patients now progresses to a partially weight bearing and continue to give promising results.

Superconstructs in reconstruction surgery of Charcot foot Brodsky 1: A case report

Introduction

Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive condition of joints, soft tissues, and bones. CN causes considerable high mortality and morbidity. A common issue is early diagnosis and appropriate treatment. Thus, the operative treatment is indicated when patients have progressive deformities, infection and ulceration. The superconstructs method for Charcot foot (CF) is considered giving better clinical outcome than other methods.

Presentation of case

A 61-year-old male admitted to an outpatient clinic with chief complaint of swelling and pain on a left foot with history of diabetes mellitus type 2. From the physical examination, left foot revealed a swelling with rocker bottom deformity and limited range of motion. The radiological examination showed sclerotic appearance of bone deformity metatarsal joint of midfoot of toe. The patients were diagnosed with left Charcot foot Brodsky Type 1, Eichenholtz grade III with diabetes mellitus type 2.

Discussion

We made superconstructs rather than standard fixation which is frequently inadequate due to changes accompanying the Charcot process. Thus, we performed an adequate reduction of deformity, reduce soft tissue tension, fixation extension beyond a zone of injury, then use of strongest fixation devices that are applied to maximize mechanical function.

Conclusion

This study showed that superconstructs provide satisfactory clinical and outcomes. This method is useful for achieving construct and stable fixation especially for Charcot foot.

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Limited studies reported the outcome of the method of “superconstruct” surgery for Charcot's foot.

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Anatomical position and stable fixation are achieved with superconstruct surgery.

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Satisfactory clinical outcome was concluded after superconstruct surgery.

Charcot neuroarthropathy in patients with Charcot Marie Tooth Disease

Charcot Marie Tooth disease (CMT) is the most common inherited neuropathy and is also called Hereditary Motor Sensory Neuropathy (HMSN). Whilst both motor and sensory deficits are present, motor deficits tend to predominate over sensory deficits. Charcot neuroarthropathic joints occur in conditions, most commonly diabetes nowadays, where joints are destroyed in association with reduced protective sensation, pain in particular. Three cases of development of Charcot joint disorders in patients with CMT are discussed and the literature is reviewed. Orthopaedic surgeons should be aware that Charcot joints can occur in CMT and surgery can be complicated by Charcot joints.

Case Report: Mutant SCN9A Susceptible to Charcot Neuroarthropathy in a Patient With Congenital Insensitivity to Pain

Charcot neuroarthropathy is a systemic disease with pathological changes in the musculoskeletal system, which leads to fractures, dislocations, and deformities involving multiple bones and joints, particularly those of the feet. While the common underlying cause of Charcot neuroarthropathy is diabetes mellitus, it is also associated with congenital insensitivity to pain (CIP). CIP is a rare disorder caused by loss-of-function mutations in SCN9A encoding Nav1.7. In this study, we report a patient with CIP from a consanguineous family susceptible to Charcot neuroarthropathy with a novel SCN9A mutation. This report involves the case of a middle-aged man who suffered from CIP, had repeated painless fractures, and developed bone and joint destruction. The physical and radiological examinations revealed that multiple joints were swollen and deformed, and soft-tissue trauma was evident. We identified a novel homozygous SCN9A mutation (p.Cys1339Arg) by whole-exome sequencing (WES), which was verified using Sanger sequencing. In addition, the wild-type (WT) and mutated p. Cys1339Arg were assessed in HEK293 cells expressing Nav1.7, and the results showed that p. Cys1339Arg almost abolished the Nav1.7 sodium current. In conclusion, Charcot neuroarthropathy associated with CIP demonstrated a wider spectrum of Charcot neuroarthropathy than was previously recognized or documented. In addition, this finding is conducive to understanding the critical amino acids for maintaining the function of Nav1.7, thus contributing to the development of Nav1.7-targeted analgesics.

[The role of glycation end products in the development and progression of diabetic neuroarthropathy]

Diabetic neuroarthropathy (DNOAP, Charcot's foot) is a serious complication of diabetes mellitus, the genesis of which is not fully understood. In most cases, this pathology is diagnosed late, which leads to the development of severe deformities of the foot, up to the loss of support ability of the limb. There is no single hypothesis for the formation of Charcot's foot, but there are factors predisposing to its development, as well as a few likely provoking events. Excessive formation and accumulation of end products of glycation may play an important role in the pathogenesis of this complication of diabetes. End products of glycation (AGE) are a variety of compounds formed as a result of a non-enzymatic reaction between carbohydrates and free amino groups of proteins, lipids and nucleic acids. There are various factors that lead to the accumulation of AGE in the human body. Allocate endogenous and exogenous factors. The former include certain diseases, such as diabetes mellitus, renal failure, which accelerate glycation processes. Exogenous factors leading to the formation of lipo-oxidation and glyco-oxidation products include tobacco smoke and prolonged heat treatment of food.This review provides information on the role of glycation end products in the development and progression of complications in patients with diabetes mellitus.

Pedobarographic Statistical Parametric Mapping may identify specific plantar pressure patterns in patients with diabetes mellitus among different degrees of peripheral neuropathy: A pilot study

AIMS

Peripheral neuropathy (PN) in patients with diabetes can lead to changes in the distribution of plantar pressure during walking, which can be recorded with pedobarography. Compared to traditional spatial data reduction analysis, the pedobarographic Statistical Parametric Mapping (pSPM) allows comparison of the footprints with the advantage that sub-regions do not need to be defined a priori. Aim of the study was to test the potential of pSPM in identifying specific distribution of spatial pressure in different stages of PN.

METHODS

PN was defined according to usual tools (i.e., tendon reflexes and sensory tests). Four groups were compared: patients with diabetes without PN (n = 24; 239 steps); with signs of mild PN (n = 12; 117 steps); with signs of severe PN (n = 6; 52 steps) and a control group without diabetes (n = 12; 124 steps). Traditional spatial data reduction and pSPM were performed to compare plantar pressures in the different groups.

RESULTS

In patients with PN, traditional spatial data reduction analysis showed lower plantar pressures with PN severity. pSPM analysis is able to better define the initial changes: mild PN patients presents higher pressures on the anterior side of the metatarsal heads compared to patients without neuropathy. Patients with severe PN are characterised by higher pressures under the medial foot arch compared to other groups.

CONCLUSIONS

pSPM may identify specific features of plantar pressure distribution during walking in patients with mild PN and may become a useful screening tool for a timely identification of this complication.

Denosumab in active Charcot neuro-osteoarthropathy of the foot

OBJECTIVE

Active Charcot Neuro-osteoarthropathy (CN) is a rare and severe complication of peripheral neuropathy that leads to deformity and disability. No pharmacological treatment is available. Increased osteoclastic activity plays a central role in active CN, particularly via receptor activator of nuclear factor ligand (RANK-L). We aimed to describe clinical, morphological and metabolic imaging effects of denosumab, a fully human monoclonal anti- RANK-L antibody, in active CN.

METHODS

In this open-label study, we included all consecutive patients with active refractory CN treated with denosumab in our tertiary center. Baseline and follow-up assessment included clinical examination, biological and imaging procedures (morphological and metabolic) before and after treatment.

RESULTS

Seven patients were treated with denosumab between 2017 and 2020 and followed for a median of 16 months [6-39]. All patients clinically improved, 4 further relapsed after a median of 4 months [3-33]. Four patients were retreated with the same efficacy. Imaging follow-up available in 5 patients showed stability of structural damage (radiography) and a significant decrease of metabolic activity (FDG PET-CT) in 4 of them. No adverse event or hypocalcemia was observed.

CONCLUSION

In patients with refractory active CN, denosumab had a clinical effect, prevented bone and joint destruction, together with a metabolic effect, as assessed by FDG PET-CT. These results justify the conduction of a randomized controlled trial to assess the efficacy of denosumab in acute CN.

[Adult Acquired Flatfoot Deformity: Diagnosis and Surgical Treatment]

The adult acquired flatfoot is a deformity with slow progression, which may leads to pain and restrictions of activities of daily living if untreated. Various treatment strategies, depending on the clinical and radiological presentation, exist. Therefore, an individual therapy approach is necessary for optimal treatment. This article covers etiopathologic aspects, conservative and operative treatments as well as postoperative mobilization and rehabilitation.

Midterm Fate of the Contralateral Foot in Charcot Arthropathy

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.

Association between diabetic neuropathy and osteoporosis in patients: a systematic review and meta-analysis

OBJECTIVES

Many studies have explored the association between neuropathy and osteoporosis in patients with diabetes mellitus. However, the results still remain inconsistent and controversial. We aimed to estimate the association between diabetic neuropathy and osteoporosis.

METHODS

Databases, including PubMed, Embase, Web of Science, the Cochrane library, Chinese Biomedical Literature Database (CBM), and Wanfang, were screened from inception to 30 March 2020. Studies were selected and data were extracted by two independent reviewers. Study characteristics and quality sections were reviewed independently. Pooled ORs and 95% CIs were calculated using random effects model when evidence of heterogeneity was present; otherwise, fixed effects model was used. Meta-regression and subgroup analyses were performed to explore the source of heterogeneity. Sensitivity analysis and publication bias were also tested.

RESULTS

A total of 11 studies with 27,585 participants were included in this analysis which indicated that there was an increased odd between diabetic neuropathy and osteoporosis (overall OR 2.20, 95% CI 1.71-2.83). In the subgroup analyses and meta-regression, diabetic neuropathy has no significant difference in osteoporosis or fracture (p = 0.532). And osteoporosis also has no significant difference in type 1 or type 2 diabetic neuropathy (p = 0.668).

CONCLUSIONS

This meta-analysis suggests that patients with diabetic neuropathy have a significantly increased chance of developing osteoporosis, even fragility fracture. The clinicians should pay more attention to the patients with diabetic neuropathy. Further studies were still needed to explore the confounding factors among studies and to elucidate the underlying biological mechanisms.

Bone Mineral Density in Diabetes Mellitus Foot Patients for Prediction of Diabetic Neuropathic Osteoarthropathic Fracture

BACKGROUND

Diabetic neuropathic osteoarthropathy (DNOAP) is known as debilitating diabetes complications. The aim of study is to compare bone mineral density (BMD) among diabetic foot and DNOAP, and investigate the impact of BMD proceeded from diabetic foot to DNOAP.

METHODS

A DNOAP group (subgroup A and subgroup B) and control group were examined for this study. Subgroup A (n=21) were patients diagnosed with DNOAP with the development of new foot and ankle fractures, whereas subgroup B (n=4) were patients being managed with the diabetic foot before a diagnosis of DNOAP. BMD was also evaluated before the diagnosis. Control group (n=30) was diabetic foot patients without DNOAP. The demographic data, clinical and radiologic data, comorbidities, and BMD were compared for each group. And optimal BMD score was reviewed to predict fractures in neuropathic arthropathy.

RESULTS

BMD was significantly lower in DNOAP group (group A and B) compared with control group. Also neuropathic arthropathy group showed poor radiological results. After comparisons of 2 group lumbar and femur BMD was significantly different, but logistic regression analysis revealed that low femur T-score could be risk predictors of the condition. Base on the data of group B and control group, the cut-off point for predicting foot and ankle fracture-related with DNOAP was -1.65 of femur BMD.

CONCLUSIONS

Low BMD shows greater incidence in foot and ankle fracture patients associated with neuropathic arthropathy. A femur T score can be a risk predictor of diabetic neuropathic arthropathy for diabetic foot patients.

Rapid glycemic regulation in poorly controlled patients living with diabetes, a new associated factor in the pathophysiology of Charcot's acute neuroarthropathy

Objective

Aggressive antidiabetic therapy and rapid glycemic control are associated with diabetic neuropathy. Here we investigated if this is also the case for Charcot neuroarthropathy.

Research design and methods

HbA1c levels and other relevant data were extracted from medical databases of 44 cases of acute Charcot neuroarthropathy.

Results

HbA1c levels significantly declined from 8.25% (67mmol/mol) [7.1%–9.4%](54-79mmol/mol), at -6 months (M-6), to 7.40%(54mmol/mol) [6.70%–8.03%] (50–64 mmol/mol) during the six months preceding the diagnosis of Charcot neuroarthropathy (P <0.001).

Conclusions

HbA1c levels significantly declined during the six months preceding the onset of Charcot neuroarthropathy. This decline seems to be a associated factor with the appearance of an active phase of Charcot neuroarthropathy in poorly controlled patients with diabetic sensitive neuropathy.

Union of Brodsky type 1/Eichenholtz stage III Charcot neuroarthropathy after forefoot arthrodesis

INTRODUCTION

One of the surgical intervention options for Charcot neuroarthropathy (CN) is arthrodesis. The arthrodesis procedure for the foot and ankle joint have been widely used in previous studies. This study aimed to evaluate the functional and radiological outcomes after arthrodesis procedure for the CN patient with Brodsky type 1/Eichenholtz stage III.

PRESENTATION OF CASE

A 49-years-old diabetic woman presented with alteration of her right foot's shape and a cracking sensation while walking in the last six months. Rocker-bottom deformity and a decreased sensation on the right foot were found, and the initial American Orthopaedic Foot & Ankle Society (AOFAS) score was 45. Subsequently, forefoot arthrodesis of the right foot was performed.

DISCUSSION

Several studies state that arthrodesis procedure is often used for CN management in order to achieve a plantigrade and stable foot. This study presents an improvement of the foot arch, AOFAS score, and union of the talus six months after surgery.

CONCLUSION

The arthrodesis procedure by using screws and Kirschner wire (K-wire) fixation is an effective method in CN management if the patient is compliant. This study showed a good result, anatomically restored the foot arch, and excellent radiological union, but different tools to analyze foot functional status and longer follow up period are needed for a better analysis.

New Concepts in the Management of Charcot Neuroarthropathy in Diabetes

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.

Short-term foot complications in Charcot neuroarthropathy: A retrospective study in tertiary care centres in Spain

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.

Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy

Charcot neuroarthropathy is a rare but serious complication of diabetes, causing progressive destruction of the bones and joints of the foot leading to deformity, altered biomechanics and an increased risk of ulceration.

Management is complicated by a lack of consensus on diagnostic criteria and an incomplete understanding of the pathogenesis. In this review, we consider recent insights into the development of Charcot neuroarthropathy.

It is likely to be dependent on several interrelated factors which may include a genetic pre-disposition in combination with diabetic neuropathy. This leads to decreased neuropeptides (nitric oxide and calcitonin gene-related peptide), which may affect the normal coupling of bone formation and resorption, and increased levels of Receptor activator of nuclear factor kappa-B ligand, potentiating osteoclastogenesis.

Repetitive unrecognized trauma due to neuropathy increases levels of pro-inflammatory cytokines (interleukin-1β, interleukin-6, tumour necrosis factor α) which could also contribute to increased bone resorption, in combination with a pre-inflammatory state, with increased autoimmune reactivity and a profile of monocytes primed to transform into osteoclasts - cluster of differentiation 14 (CD14).

Increased blood glucose and loss of circulating Receptor for Advanced Glycation End-Products (AGLEPs), leading to increased non-enzymatic glycation of collagen and accumulation of AGLEPs in the tissues of the foot, may also contribute to the pathological process.

An understanding of the relative contributions of each of these mechanisms and a final common pathway for the development of Charcot neuroarthropathy are still lacking.

Cite this article: S. E. Johnson-Lynn, A. W. McCaskie, A. P. Coll, A. H. N. Robinson. Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy. Bone Joint Res 2018;7:373–378. DOI: 10.1302/2046-3758.75.BJR-2017-0334.R1.

New trends in the orthopaedic management of diabetic foot

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.

Exosomes from adipose-derived stem cells overexpressing Nrf2 accelerate cutaneous wound healing by promoting vascularization in a diabetic foot ulcer rat model

Diabetic foot ulcers (DFU) increase the risks of infection and amputation in patients with diabetes mellitus (DM). The impaired function and senescence of endothelial progenitor cells (EPCs) and high glucose-induced ROS likely exacerbate DFUs. We assessed EPCs in 60 patients with DM in a hospital or primary care setting. We also evaluated the therapeutic effects of exosomes secreted from adipose-derived stem cells (ADSCs) on stress-mediated senescence of EPCs induced by high glucose. Additionally, the effects of exosomes and Nrf2 overexpression in ADSCs were investigated in vitro and in vivo in a diabetic rat model. We found that ADSCs that secreted exosomes promoted proliferation and angiopoiesis in EPCs in a high glucose environment and that overexpression of Nrf2 increased this protective effect. Wounds in the feet of diabetic rats had a significantly reduced ulcerated area when treated with exosomes from ADSCs overexpressing Nrf2. Increased granulation tissue formation, angiogenesis, and levels of growth factor expression as well as reduced levels of inflammation and oxidative stress-related proteins were detected in wound beds. Our data suggest that exosomes from ADSCs can potentially promote wound healing, particularly when overexpressing Nrf2 and therefore that the transplantation of exosomes may be suitable for clinical application in the treatment of DFUs.

Tiny membrane-bound sacs released by some stem cells carry chemicals that can heal the foot ulcers that are a major complication of diabetes. The sacs, called exosomes, are released by many cells for signaling between cells and other functions. Xue Li of Tongji University in Shanghai and co-workers focused on the effects of exosomes from stem cells derived from body fat cells. They found that the exosomes could encourage the healing of diabetic foot ulcers in rats. The research also uncovered useful information about the molecular interactions involved in the accelerated healing. It revealed the significance of one particular protein in the formation of new blood vessels, which is central to the healing. The authors suggest that collecting and transplanting suitable exosomes could offer a new approach for treating diabetic foot ulcers.

Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot

Aims

Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up.

Patients and Methods

We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70).

Results

The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) – Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS).

Conclusion

The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190–6.

Diabetic Neuropathic Arthropathy of the Knee: Two Case Reports and a Review of the Literature

Diabetic neuroarthropathy of the knee or Charcot knee (CK) is a lesser-known complication of diabetes mellitus, with a limited number of case reports and small case series published in the literature. The majority of these reports describe the complexities and challenges that arise in these patients undergoing knee arthroplasty procedures. We present two cases of CK, including a rare case of concurrent bilateral disease, and also a review of the current literature.

Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus

Background

Calcaneal insufficiency avulsion (CIA) fractures often present with neuropathic etiology, such as Charcot neuroarthropathy (CN). Under the same surgical procedures, the outcomes of CIA fractures are less desirable, compared to the outcomes of the traumatic calcaneal avulsion fractures. Here, the study suggests Achilles tenodesis technique using suture anchor after resection of the CIA fracture fragments could provide satisfactory clinical results in the cases of surgically indicated CIA fractures.

Materials and methods

This retrospective study included seven patients of calcaneal avulsion fracture who had underlying diabetes mellitus (DM) and no specific traumatic event. The patients were treated with Achilles tenodesis techniques for their CIA fractures. Achilles tenodesis was performed using suture anchor with removal of the fracture fragments. The patients were evaluated with the Foot and Ankle Outcome Score (FAOS), visual analogue scale (VAS), single-heel rise test, and X-ray images on their final follow-ups.

Results

Initially, three of the CIA fracture cases treated with traditional open reduction and internal fixation reported pullout failure. Consequently, all patients received Achilles tenodesis using suture anchor after bone fragment resection and had good clinical outcomes. Only one subject with low compliance reported poor outcome.

The FAOS of each patient were obtained at a mean of 16.3 months after surgery. The results are as follows: pain 80.6 (SD = 6.2), symptom 83.8 (SD = 4.9), activities of daily living 80.5 (SD = 8.0), sport and recreation function 75.6 (SD = 11.93), and foot- and ankle-related quality of life 77.9 (SD = 6.7). On their final follow-ups, the average VAS was 2.6 (range, 1 to 4).

Conclusion

Achilles tenodesis using suture anchor after bone fragment resection achieved competent clinical results in the patients with CIA fractures. The study proposes that this surgical procedure could be an appropriate treatment option for patients with CIA fractures.

Trial registration

The study was approved by the institutional review board (IRB) of our medical center (IRB File No. 2016-07-043), retrospectively registered.

[Charcot foot masked by erysipelas and peripheral arterial disease]

Charcot foot is also known as Charcot disease or Charcot arthropathy. The associated aseptic destruction of the bones and joints of the foot results due to peripheral neuropathy accompanied by impaired pain perception, impaired vasomotricity with increased vasodilation, and an unequal weight distribution. Because it is frequently diagnosed late and, thus, incorrectly treated, serious complications often result. An 86-year-old man in poor health was diagnosed with erysipelas of the right foot. The foot was glossy and edematously swollen, showing necrosis of the distal phalanx of the third toe. The patient experienced pain after a walking distance of approximately 20 m. In addition to erysipelas, confirmed neuropathic arthropathy and radiological indicators for Charcot foot established peripheral artery disease (PAD) as a third diagnosis. Despite multiple systemic antibiotic therapies, there was a progressive disease pattern marked by increasing inflammation parameters with an increasing decline of the patient's overall health. The patient suffered severe deterioration in spite of vascular surgical measures, ultimately leading to his death. In the present case, the indicators and respective confirmation of the three overlapping diagnoses erysipelas, Charcot foot and PAD are elaborated.

Pathogenesis and potential relative risk factors of diabetic neuropathic osteoarthropathy

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.

Cutaneous Manifestations of Diabetes Mellitus: A Review

Diabetes mellitus is a widespread endocrine disease with severe impact on health systems worldwide. Increased serum glucose causes damage to a wide range of cell types, including endothelial cells, neurons, and renal cells, but also keratinocytes and fibroblasts. Skin disorders can be found in about one third of all people with diabetes and frequently occur before the diagnosis, thus playing an important role in the initial recognition of underlying disease. Noninfectious as well as infectious diseases have been described as dermatologic manifestations of diabetes mellitus. Moreover, diabetic neuropathy and angiopathy may also affect the skin. Pruritus, necrobiosis lipoidica, scleredema adultorum of Buschke, and granuloma annulare are examples of frequent noninfectious skin diseases. Bacterial and fungal skin infections are more frequent in people with diabetes. Diabetic neuropathy and angiopathy are responsible for diabetic foot syndrome and diabetic dermopathy. Furthermore, antidiabetic therapies may provoke dermatologic adverse events. Treatment with insulin may evoke local reactions like lipohypertrophy, lipoatrophy and both instant and delayed type allergy. Erythema multiforme, leukocytoclastic vasculitis, drug eruptions, and photosensitivity have been described as adverse reactions to oral antidiabetics. The identification of lesions may be crucial for the first diagnosis and for proper therapy of diabetes.