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Greco T, Mascio A, Comisi C, Polichetti C, Caravelli S, Mosca M, Mondanelli N, Troiano E, Maccauro G, Perisano C. RANKL-RANK-OPG Pathway in Charcot Diabetic Foot: Pathophysiology and Clinical-Therapeutic Implications. Int J Mol Sci 2023; 24:ijms24033014. [PMID: 36769345 PMCID: PMC9917950 DOI: 10.3390/ijms24033014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
Charcot Foot (CF), part of a broader condition known as Charcot Neuro-Osteoarthropathy (CNO), is characterized by neuropathic arthropathy with a progressive alteration of the foot. CNO is one of the most devastating complications in patients with diabetes mellitus and peripheral neuropathy but can also be caused by neurological or infectious diseases. The pathogenesis is multifactorial; many studies have demonstrated the central role of inflammation and the Receptor Activator of NF-κB ligand (RANKL)-Receptor Activator of NF-κB (RANK)-Osteoprotegerin (OPG) pathway in the acute phase of the disease, resulting in the serum overexpression of RANKL. This overexpression and activation of this signal lead to increased osteoclast activity and osteolysis, which is a prelude to bone destruction. The aim of this narrative review is to analyze this signaling pathway in bone remodeling, and in CF in particular, to highlight its clinical aspects and possible therapeutic implications of targeting drugs at different levels of the pathway. Drugs that act at different levels in this pathway are anti-RANKL monoclonal antibodies (Denosumab), bisphosphonates (BP), and calcitonin. The literature review showed encouraging data on treatment with Denosumab, although in a few studies and in small sample sizes. In contrast, BPs have been re-evaluated in recent years in relation to the high possibility of side effects, while calcitonin has shown little efficacy on CNO.
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Affiliation(s)
- Tommaso Greco
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-3807-582-118
| | - Antonio Mascio
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Comisi
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Polichetti
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Silvio Caravelli
- U.O.C. II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Massimiliano Mosca
- U.O.C. II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Giulio Maccauro
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Carlo Perisano
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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Chang MC, Choo YJ, Park IS, Park MW, Kim DH. Orthotic approach to prevention and management of diabetic foot: A narrative review. World J Diabetes 2022; 13:912-920. [PMID: 36437865 PMCID: PMC9693734 DOI: 10.4239/wjd.v13.i11.912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/24/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022] Open
Abstract
Diabetic foot is a common complication affecting more than one-fifth of patients with diabetes. If not treated in time, it may lead to diabetic foot ulcers or Charcot arthropathy. For the management of diabetic foot, shoe modifications and orthoses can be used to reduce pressure on the affected foot or provide the foot with increased stability. In addition, the shoe modifications and orthotic devices can relieve patient discomfort during walking. Appropriate shoe modifications include changing the insole material, modifying the heel height, adding a steel shank or rocker sole, and using in-depth shoes. Alternatively, a walking brace or ankle-foot orthosis can be used to reduce the pressure on the affected foot. The purpose of this narrative review was to provide a reference guide to support clinicians in prescribing shoe modifications and foot orthoses to treat diabetic foot ulcers and Charcot arthropathy.
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Affiliation(s)
- Min Cheol Chang
- Rehabilitation Medicine, Yeungnam University, Daegu 42415, South Korea
| | - Yoo Jin Choo
- Rehabilitation Medicine, Yeungnam University, Daegu 42415, South Korea
| | - In Sik Park
- Korean Podiatry and Pedorthics Institute, Goyang 10442, South Korea
| | - Myung Woo Park
- Physical Medicine and Rehabilitation, Chung-Ang University, Seoul 06973, South Korea
| | - Du Hwan Kim
- Physical Medicine and Rehabilitation, Chung-Ang University, Seoul 06973, South Korea
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Pitocco D, Scavone G, Di Leo M, Vitiello R, Rizzi A, Tartaglione L, Costantini F, Flex A, Galli M, Caputo S, Ghirlanda G, Pontecorvi A. Charcot Neuroarthropathy: From the Laboratory to the Bedside. Curr Diabetes Rev 2019; 16:62-72. [PMID: 31057120 DOI: 10.2174/1573399815666190502121945] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/26/2019] [Accepted: 04/17/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The diabetic Charcot foot syndrome is a serious and potentially limbthreatening lower-extremity complication of diabetes. INTRODUCTION The present review provides a concise account of the advances made over the last twentyfive years in understanding the pathogenesis and management of Charcot neuroarthropathy (CN). METHODS In this study, the widely known pathogenetic mechanisms underpinning CN are brought into focus, particularly the role of RANKL/RANK/OPG system and advanced glycation end production in the pathogenesis of CN. Furthermore, other potential triggering factors, namely nitric oxide, endothelial dysfunction, macro calcifications and body weight that influence CN have also been discussed. RESULTS The wide range of diagnostic tools available to clinicians for accurate staging of this pathology has been examined, particularly radiological and nuclear medicine imaging. Additionally, the difficult differential diagnosis between osteomyelitis and CN is also elucidated. CONCLUSION The review concludes with the comprehensive summary of the major promising therapeutic strategies, including conservative treatment involving orthopedic devices, pharmacological approach, and the most common surgical techniques currently employed in the diagnosis and treatment of this acute disease.
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Affiliation(s)
- Dario Pitocco
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Scavone
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Di Leo
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele Vitiello
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Rizzi
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Linda Tartaglione
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Federica Costantini
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Flex
- Institute of Internal Medicine, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Galli
- Institute of Orthopedic Surgery, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Caputo
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Ghirlanda
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Pontecorvi
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Ergen FB, Sanverdi SE, Oznur A. Charcot foot in diabetes and an update on imaging. Diabet Foot Ankle 2013; 4:21884. [PMID: 24273635 PMCID: PMC3837304 DOI: 10.3402/dfa.v4i0.21884] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 08/26/2013] [Accepted: 09/01/2013] [Indexed: 11/14/2022]
Abstract
Charcot neuroarthropathy (CN) is a serious complication of diabetes mellitus that can cause major morbidity including limb amputation. Since it was first described in 1883, and attributed to diabetes mellitus in 1936, the diagnosis of CN has been very challenging even for the experienced practitioners. Imaging plays a central role in the early and accurate diagnosis of CN, and in distinction of CN from osteomyelitis. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, and positron emission tomography are the imaging techniques currently in use for the evaluation of CN but modalities other than magnetic resonance imaging appeared to be complementary. This study focuses on imaging findings of acute and chronic neuropathic osteoarthropathy in diabetes and discrimination of infected vs. non-infected neuropathic osteoarthropathy.
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Affiliation(s)
- Fatma Bilge Ergen
- Department of Radiology, School of Medicine, Hacettepe University, Ankara, Turkey
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Role of the General Surgeon in the Early Diagnosis and Treatment of Charcot Foot. Cir Esp 2013; 93:320-5. [PMID: 24229811 DOI: 10.1016/j.ciresp.2013.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 04/09/2013] [Accepted: 04/10/2013] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The Charcot foot (CF) consists of a progressive deterioration of the bones and joints, most common in diabetic patients with advanced neuropathy. The great problem is that can be confused with other processes, delaying the diagnosis and specific treatment. The aim is to analyze the cases of CF diagnosed in our hospital and especially to highlight the role of the general surgeon. MATERIAL AND METHODS Retrospective study of all registered cases diagnosed of CF between the diabetic population of our Department of Health. A review of the literature was performed. RESULTS From 2008 to 2012, there 7 cases of CF were diagnosed (prevalence 1:710). Two of the patients were diagnosed erroneously of cellulitis. The average time of delay in the diagnosis was 10 weeks (minimum 1, maximum 24). The initial treatment was immobilization of the extremity. Once the edema was eliminated, an offload orthesis was placed according to Sanders's anatomical classification. Evolution was favorable in 5 patients, 1 patient needed amputation, and other one died of acute cardiac pathology. CONCLUSIONS The CF is a more frequent pathology than we believe. The general surgeon is the fundamental prop in the diagnosis and initial treatment. Before the presence of inflammation and edema of the foot in a patient with diabetes and severe neuropathy, once cellulitis, osteomyelitis, and TVP are ruled out, Charcot neuroarthropathy should be considered.
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