1
|
Luo Z, Ding X, Yuan Y, Hou L. Rare complication of rheumatoid arthritis: Charcot Neuro-osteoarthropathy. BMC Musculoskelet Disord 2024; 25:340. [PMID: 38685038 PMCID: PMC11057095 DOI: 10.1186/s12891-024-07424-y] [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: 10/24/2023] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is an autoimmune disease.However, there are few cases of Charcot Neuro-osteoarthropathy (CN) caused by rheumatoid diseases in clinical reports. It is not easy to pay attention to the diagnosis of CN in the complications of rheumatoid disease, which greatly increases the probability of misdiagnosis and missed diagnosis. This case reported a rare complication of rheumatoid arthritis, Charcot arthritis, and the molecular mechanism and diagnosis and treatment of CN caused by RA were systematically discussed. CASE PRESENTATION The patient, a 79-year-old woman, was hospitalized due to bilateral shoulder pain, limited activity for half a year, aggravated for 4 months to the hospital. During this period, the symptoms did not improve after treatment with acupuncture and Chinese medicine. The patient was previously diagnosed with rheumatoid arthritis for more than 3 years and intermittent irregular use of methylprednisolone and methotrexate for 2 years. She had a history of osteoporosis. PHYSICAL EXAMINATION symmetrical malformed swelling of the finger joints of both hands; Bilateral supraspinatus and deltoid muscle atrophy, tenderness at the acromion, and attachment of the long head tendon of the biceps brachii were observed. The left Dugas test and the right Dugas test were positive.Blood test: anti-cyclic citrullinated peptide antibody (A-CCP) 33.10U/ml (normal range: 0-5RU/ml); antinuclear antibody quantification (ANA) 47.40AU/ml (normal range: Negative or < 32); anti-double stranded DNA IgG antibody quantification (dsDNA) 31.00 IU/ml (normal range: 0-100 IU/ml); D-Dimer 6.43 µg/ml (normal range: 0-0.5 mg/L); erythrocyte sedimentation rate (ESR) was 27 mm/h (normal range: < 20 mm/60 min). C-reactive protein (CRP) 39.06 mg/L(0.068-8 mg/L).MRI 3.0 T enhancement of bilateral shoulder joints, cervical spine and thoracic spine showed: 1.Large bone destruction, cartilage injury, multiple effusion, synovitis, obvious on the right side. 2.Intervertebral disc degeneration, cervical 3/4, 4/5, 5/6, 6/7 disc herniation, with cervical 3/4 obvious, posterior central herniation; CONCLUSIONS: Rheumatoid arthritis complicated with Charcot's joint is rare. Clinically, patients with rheumatoid diseases should not ignore Charcot's joint complications because of rareness. Early blood inflammatory markers, neuro electrophysiology, and imaging MRI of rheumatoid CN are of great significance for the diagnosis of this mild or early neurovascular inflammation. Early diagnosis and treatment are helpful to prevent further joint injury. The clinical diagnosis, treatment, and molecular mechanism of osteolysis in RA and peripheral sensory nerve injury remain to be further revealed.
Collapse
Affiliation(s)
- Zhiyuan Luo
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Xinxiang Ding
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Yu Yuan
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Lei Hou
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China.
- Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, China.
| |
Collapse
|
2
|
Novel Biomarkers Predictive of Diabetic Charcot Foot-An Overview of the Literature. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111944. [PMID: 36431079 PMCID: PMC9698200 DOI: 10.3390/life12111944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/05/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
Background: Although Charcot diabetic foot (CDF) is a frequent complication of diabetic neuropathy, less is known about the possibility of its early prevention. Methods: A review of the original articles published in English, using the "biomarkers AND Charcot's foot" criterion, resulted in 33 articles from the PubMed database and seven articles from the Web of Science database. The five duplicates were eliminated, and two independent reviewers selected the most relevant articles, leaving a total of 21 articles. Results: The biomarkers identified are exhaustively described, related to the system of advanced glycation end products (AGEs) and their soluble receptors (sRAGE), inflammatory cascade, osteoclastogenesis, and, respectively, osteoblastic activity. Conclusions: This article highlights the importance of potential early identifiable biomarkers that can lead to microstructural changes in the affected bones.
Collapse
|
3
|
Abstract
Bone metabolism in the healthy, young adult is identified as a relatively stable process. Normal bone turnover is a dynamic state, which is conferred through intracellular signaling and complex cellular pathways. It has been well described in the literature that Charcot neuro-osteoarthropathy is a disease state, which is marked by intense bone turnover leading to structural collapse and dissolution of skeletal features of the foot and ankle. Within the last two decades, extensive interest has been placed in characterizing the metabolic pathogenesis of Charcot bone metabolism. Despite this work, there remains an incomplete understanding of this devastating disorder. In this article, we review bone histology, physiologic bone metabolism, biomarkers of bone metabolism, pathologic bone metabolism in Charcot diabetics, and potential avenues for intervention.
Collapse
Affiliation(s)
- Lisa Grant-McDonald
- Tidewater Foot and Ankle, 760 Independence Boulevard, Virginia Beach, VA 23455, USA.
| | - William Grant
- Tidewater Foot and Ankle, 760 Independence Boulevard, Virginia Beach, VA 23455, USA
| |
Collapse
|
4
|
Jeffcoate W, Game F. The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm. Diabetes Care 2022; 45:1691-1697. [PMID: 35796768 DOI: 10.2337/dc21-2508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.
Collapse
Affiliation(s)
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, U.K
| |
Collapse
|
5
|
Ceprian N, Valera G, Caro J, Yuste C, Serroukh N, González de Pablos I, Oliva C, Figuer A, Praga M, Alique M, Ramirez R, Morales E, Carracedo J. Effect of Kidney Transplantation on Accelerated Immunosenescence and Vascular Changes Induced by Chronic Kidney Disease. Front Med (Lausanne) 2021; 8:705159. [PMID: 34646838 PMCID: PMC8502880 DOI: 10.3389/fmed.2021.705159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Kidney transplantation is the best option for patients with end-stage renal disease. Despite the improvement in cardiovascular burden (leading cause of mortality among patients with chronic kidney disease), cardiovascular adverse outcomes related to the inflammatory process remain a problem. Thus, the aim of the present study was to characterize the immune profile and microvesicles of patients who underwent transplantation. We investigated the lymphocyte phenotype (CD3, CD4, CD8, CD19, and CD56) and monocyte phenotype (CD14, CD16, CD86, and CD54) in peripheral blood, and endothelium-derived microvesicles (annexin V+CD31+CD41–) in plasma of patients with advanced chronic kidney disease (n = 40), patients with transplantation (n = 40), and healthy subjects (n = 18) recruited from the University Hospital “12 de Octubre” (Madrid, Spain). Patients with kidney transplantation had B-cell lymphopenia, an impairment in co-stimulatory (CD86) and adhesion (CD54) molecules in monocytes, and a reduction in endothelium-derived microvesicles in plasma. The correlations between those parameters explained the modifications in the expression of co-stimulatory and adhesion molecules in monocytes caused by changes in lymphocyte populations, as well as the increase in the levels of endothelial-derived microvesicles in plasma caused by changes in lymphocyte and monocytes populations. Immunosuppressive treatment could directly or indirectly induce those changes. Nevertheless, the particular characteristics of these cells may partly explain the persistence of cardiovascular and renal alterations in patients who underwent transplantation, along with the decrease in arteriosclerotic events compared with advanced chronic kidney disease. In conclusion, the expression of adhesion molecules by monocytes and endothelial-derived microvesicles is related to lymphocyte alterations in patients with kidney transplantation.
Collapse
Affiliation(s)
- Noemi Ceprian
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Instituto de Investigacin Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Gemma Valera
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Jara Caro
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Claudia Yuste
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Nadia Serroukh
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Instituto de Investigacin Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Carlos Oliva
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Madrid, Spain
| | - Andrea Figuer
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Manuel Praga
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Matilde Alique
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Rafael Ramirez
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Enrique Morales
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Julia Carracedo
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Instituto de Investigacin Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| |
Collapse
|
6
|
Dardari D. An overview of Charcot's neuroarthropathy. J Clin Transl Endocrinol 2020; 22:100239. [PMID: 33251117 PMCID: PMC7677697 DOI: 10.1016/j.jcte.2020.100239] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 12/30/2022] Open
Abstract
Charcot's neuroarthropathy is a destructive complication of the joints, which is often found in people with diabetes with peripheral neuropathy. Despite the fact that its description was published almost 130 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be described. Thanks to the use of bone remodelling, new therapeutic classes have emerged, we hope that this review will shed light on the pathology from its discovery through to the current state of knowledge on its classification, diagnosis and treatment methods.
Collapse
Affiliation(s)
- Dured Dardari
- Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil Essonnes, France
- LBEPS, Univ Evry, IRBA, Université Paris Saclay, 91025 Evry, France
| |
Collapse
|
7
|
Kloska A, Korzon-Burakowska A, Malinowska M, Bruhn-Olszewska B, Gabig-Cimińska M, Jakóbkiewicz-Banecka J. The role of genetic factors and monocyte-to-osteoclast differentiation in the pathogenesis of Charcot neuroarthropathy. Diabetes Res Clin Pract 2020; 166:108337. [PMID: 32707214 DOI: 10.1016/j.diabres.2020.108337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/07/2020] [Accepted: 07/16/2020] [Indexed: 12/29/2022]
Abstract
Charcot neuroarthropathy is a chronic, progressive condition of the skeletal system that affects some patients with diabetic neuropathy. It results in progressive destruction of bones of the foot and disorganisation of pedal joints and ligaments. Effective prevention and treatment for Charcot neuroarthropathy remain a challenge. Currently, there are no reliable repeatable markers to identify patients with diabetes who are at higher risk of developing Charcot neuroarthropathy. The pathogenesis underlying the development of Charcot neuroarthropathy also remains unclear. In this review, we provide an overview of the history, prevalence, symptoms, risk factors, diagnostics and treatment of Charcot neuroarthropathy. We also discuss the potential for OPG and RANKL gene variants to act as predictive markers for the development of Charcot neuroarthropathy. Finally, we summarise the latest research on the role of monocyte-to-osteoclast differentiation in the development of acute Charcot neuroarthropathy.
Collapse
Affiliation(s)
- Anna Kloska
- University of Gdańsk, Faculty of Biology, Department of Medical Biology and Genetics, Wita Stwosza 59, 80-308 Gdańsk, Poland
| | - Anna Korzon-Burakowska
- Medical University of Gdańsk, Faculty of Medicine, Department of Hypertension and Diabetology, Dębinki 7, 80-211 Gdańsk, Poland
| | - Marcelina Malinowska
- University of Gdańsk, Faculty of Biology, Department of Medical Biology and Genetics, Wita Stwosza 59, 80-308 Gdańsk, Poland
| | - Bożena Bruhn-Olszewska
- University of Gdańsk, Faculty of Biology, Department of Bacterial Molecular Genetics, Wita Stwosza 59, 80-308 Gdańsk, Poland
| | - Magdalena Gabig-Cimińska
- University of Gdańsk, Faculty of Biology, Department of Medical Biology and Genetics, Wita Stwosza 59, 80-308 Gdańsk, Poland; Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Laboratory of Molecular Biology, Kładki 24, 80-822 Gdańsk, Poland
| | - Joanna Jakóbkiewicz-Banecka
- University of Gdańsk, Faculty of Biology, Department of Medical Biology and Genetics, Wita Stwosza 59, 80-308 Gdańsk, Poland.
| |
Collapse
|
8
|
Yates TH, Cooperman SR, Shofler D, Agrawal DK. Current concepts underlying the pathophysiology of acute Charcot neuroarthropathy in the diabetic foot and ankle. Expert Rev Clin Immunol 2020; 16:839-845. [PMID: 32735458 DOI: 10.1080/1744666x.2020.1804869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION With a complex and often misunderstood etiology, acute Charcot neuroarthropathy (ACN) is a devastating complication of peripheral neuropathy. In patients with diabetes, timely diagnosis of ACN in the foot and ankle is essential to prevent loss of both limb and life. AREAS COVERED Herein, the authors evaluate the growing body of evidence in identifying targeted pathways for future therapeutic interventions. A literature search was conducted through the PubMed research database. Searched terms included 'Charcot,' 'foot and ankle,' 'neuroarthropathy,' 'pathophysiology,' 'arthropathy,' 'diabetic foot,' and 'Charcot foot.' EXPERT OPINION The interplay between the acute inflammatory response, cytokine signaling, and bone metabolism equilibrium can now be better understood with the aid of several novel immunobiologic mechanisms. The more recently elucidated roles of advanced glycation end-products, neuropeptides, monocyte differentiation, and genomics combine with classical Charcot pathophysiology to aid researchers and clinicians alike in combatting this often puzzling consequence of peripheral neuropathy.
Collapse
Affiliation(s)
- Thomas H Yates
- Western University of Health Sciences, College of Podiatric Medicine , Pomona, California, USA
| | - Steven R Cooperman
- Western University of Health Sciences, College of Podiatric Medicine , Pomona, California, USA
| | - David Shofler
- Western University of Health Sciences, College of Podiatric Medicine , Pomona, California, USA
| | - Devendra K Agrawal
- Western University of Health Sciences, College of Podiatric Medicine , Pomona, California, USA
| |
Collapse
|
9
|
Abstract
Charcot neuropathic arthropathy (CN) is a devastating condition resulting in non-reducible foot deformity that places patients with distal peripheral neuropathy at risk for the development of chronic neuropathic foot ulcers, major lower extremity amputation, and even death. The condition is often misdiagnosed early in its presentation because of a lack of knowledge among members of the medical community. Consequently, initial therapies for the condition are fewer and patients who present in more advanced stages of the condition are more difficult to manage. We now understand that CN is a multifactorial process resulting in unregulated osteoclastogenesis and bony destruction. Classically, the patient will present with an edematous, erythematous foot with increased temperature. These non-specific findings lead to a multitude of differential diagnoses. However, there are no diagnostic biomarkers or pathognomonic clinical signs to distinguish this condition from other common foot ailments seen in the context of peripheral neuropathy. Advancing our understanding of this condition, while educating the medical community about its devastating impact, is needed to advance and improve outcomes for patients affected by CN.
Collapse
Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48106, USA.
| |
Collapse
|
10
|
Kwaadu KY. Charcot Reconstruction: Understanding and Treating the Deformed Charcot Neuropathic Arthropathic Foot. Clin Podiatr Med Surg 2020; 37:247-261. [PMID: 32146981 DOI: 10.1016/j.cpm.2019.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
With worsening diet and increasing prevalence of diabetes, patient encounters with Charcot neuropathic arthropathy (CNA) are expected to increase. Without intervention, the pathology progresses with further subluxation/dislocation and fracture, placing soft tissues at risk of preulceration or formal ulceration, infection, and potentially major amputation. The need to avoid amputation is of paramount importance. Although a formal single eradicating tool for CNA is lacking, there is capacity to intervene in ways that may curtail the pace of destruction. This article reviews understanding of the disease process and provides guidance to surgical reconstruction of the deformity.
Collapse
Affiliation(s)
- Kwasi Y Kwaadu
- Department of Surgery, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA.
| |
Collapse
|
11
|
Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management. Clin Podiatr Med Surg 2019; 36:663-684. [PMID: 31466574 DOI: 10.1016/j.cpm.2019.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.
Collapse
|
12
|
Vopat ML, Nentwig MJ, Chong AC, Agan JL, Shields NN, Yang SY. Initial Diagnosis and Management for Acute Charcot Neuroarthropathy. Kans J Med 2018; 11:114-119. [PMID: 30937152 PMCID: PMC6276967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Matthew L. Vopat
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS
| | - Michelle J. Nentwig
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS
| | - Alexander C.M. Chong
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS,Via Christi Health, Wichita, KS
| | | | - Naomi N. Shields
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS,Advanced Orthopaedics Associates, Wichita, KS
| | - Shang-You Yang
- University of Kansas School of Medicine-Wichita, Department of Orthopaedics, Wichita, KS
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Diabetes mellitus affects approximately 30.8 million people currently living in the USA. Chronic diabetes complications, including diabetic foot complications, remain prevalent and challenging to treat. We review clinical diagnosis and challenges providers may encounter when managing diabetic foot ulcers and Charcot neuroarthropathy. RECENT FINDINGS Mechanisms controlling these diseases are being elucidated and not fully understood. Offloading is paramount to heal and manage diabetic foot ulcers and Charcot neuroarthropathy. Diabetic foot ulcers recur and the importance of routine surveillance and multidisciplinary approach is essential. Several predictors of failure in Charcot foot include a related diabetic foot ulcer, midfoot or rearfoot location of the Charcot event, and progressive bony changes on interval radiographs. Patients with diabetic foot ulcer and/or Charcot neuroarthropathy are in need of consistent and regular special multidisciplinary care. If not diagnosed early and managed effectively, morbidity and mortality significantly increase.
Collapse
Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
| | - Crystal M Holmes
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA
| |
Collapse
|
14
|
Doria M, Viadé J, Palomera E, Pérez R, Lladó M, Costa E, Huguet T, Reverter JL, Serra-Prat M, Franch-Nadal J, Mauricio D. Short-term foot complications in Charcot neuroarthropathy: A retrospective study in tertiary care centres in Spain. ACTA ACUST UNITED AC 2018; 65:479-485. [PMID: 30108031 DOI: 10.1016/j.endinu.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Montserrat Doria
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain; Diabetic Foot Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Jordi Viadé
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain
| | | | - Ricard Pérez
- Department of Radiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Melcior Lladó
- Diabetic Foot Unit, University Hospital Son Espases, Palma de Mallorca, Spain
| | - Elisabet Costa
- Department of Endocrinology and Nutrition, University Hospital Josep Trueta, Girona, Spain
| | - Teresa Huguet
- Diabetic Foot Unit, University Hospital Mutua, Terrassa, Spain
| | - Jordi Lluís Reverter
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain
| | | | - Josep Franch-Nadal
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Spain; Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain; Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Spain; Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
| |
Collapse
|
15
|
Jansen RB, Svendsen OL. A review of bone metabolism and developments in medical treatment of the diabetic Charcot foot. J Diabetes Complications 2018; 32:708-712. [PMID: 29857955 DOI: 10.1016/j.jdiacomp.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
Charcot foot is a rare but severe, and possibly limb-threatening, complication to neuropathy and diabetes mellitus. The current treatment consists of long-term off-loading, and has a large negative impact on the patient's life. Much research has gone into understanding the condition and its biochemical mechanisms, however, the underlying pathogenesis of a Charcot foot is not yet fully understood. In the recent decades several key advances in our understanding of the Charcot foot have been made, both in regards to the changes in bone metabolism and structure an acute Charcot foot can cause, and to the molecular pathways involved in this. This review summerizes the available research into the bone metabolism around a Charcot foot, with an emphasis on the biochemical profile. The existing data regarding attempts at medical treatment is also reviewed, including novel trials targetting specific inflammatory pathways upregulated in the acute diabetic Charcot foot.
Collapse
Affiliation(s)
- Rasmus Bo Jansen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark.
| | - Ole Lander Svendsen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark; Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| |
Collapse
|
16
|
Takheaw N, Laopajon W, Surinkaew S, Khummuang S, Pata S, Kasinrerk W. Ligation of Na, K ATPase β3 subunit on monocytes by a specific monoclonal antibody mediates T cell hypofunction. PLoS One 2018; 13:e0199717. [PMID: 29940031 PMCID: PMC6016913 DOI: 10.1371/journal.pone.0199717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/12/2018] [Indexed: 12/20/2022] Open
Abstract
T cells play a crucial role in orchestrating body immune responses. T cell hyperfunction, however, leads to inflammation and induction of autoimmune diseases. Understanding of T cell regulation mechanisms and successful modulation of T cell responses is beneficial in treatment of disease associated to T cell hyperresponsiveness. Our previous study indicated that monoclonal antibody (mAb) P-3E10, a mAb to Na, K ATPase β3 subunit, inhibited anti-CD3-induced PBMC proliferation. In the current study, we further investigated the mechanism of mAb P-3E10 in the induction of T cell hypofunction. We demonstrated that mAb P-3E10 decreased T cell proliferation and Th1, Th2 and Th17 cytokine production. Monocytes were the cells playing a key role in mediation of mAb P-3E10 induced T cell hypofunction. The inhibition of T cell activation by mAb P-3E10 required cell contact between monocytes and T cells. The mAb P-3E10 induced the down-expression level of MHC class II and CD86 and increased IL-6, IL-10 and TNF-α production of monocytes. We concluded that ligation of the Na, K ATPase β3 subunit on monocytes by mAb P-3E10 arbitrated T cell hypofunction. This mAb might be a promising novel immunotherapeutic antibody for the treatment of hyperresponsive T cell associated diseases.
Collapse
Affiliation(s)
- Nuchjira Takheaw
- Division of Clinical Immunology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Witida Laopajon
- Division of Clinical Immunology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Biomedical Technology Research Center, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency at the Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sirirat Surinkaew
- Biomedical Technology Research Center, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency at the Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Saichit Khummuang
- Biomedical Technology Research Center, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency at the Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Supansa Pata
- Division of Clinical Immunology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Biomedical Technology Research Center, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency at the Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Watchara Kasinrerk
- Division of Clinical Immunology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Biomedical Technology Research Center, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency at the Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
17
|
Abstract
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.
Collapse
Affiliation(s)
- S E Johnson-Lynn
- Department of Trauma and Orthopaedics, Addenbrookes Hospital, Cambridge, UK
| | - A W McCaskie
- Department of Trauma and Orthopaedics, University of Cambridge, Cambridge, UK
| | - A P Coll
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - A H N Robinson
- Department of Trauma and Orthopaedics, Addenbrookes Hospital, Cambridge, UK
| |
Collapse
|
18
|
Pasquier J, Ramachandran V, Abu-Qaoud MR, Thomas B, Benurwar MJ, Chidiac O, Hoarau-Véchot J, Robay A, Fakhro K, Menzies RA, Jayyousi A, Zirie M, Al Suwaidi J, Malik RA, Talal TK, Najafi-Shoushtari SH, Rafii A, Abi Khalil C. Differentially expressed circulating microRNAs in the development of acute diabetic Charcot foot. Epigenomics 2018; 10:1267-1278. [PMID: 29869523 PMCID: PMC6240850 DOI: 10.2217/epi-2018-0052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aim: Charcot foot (CF) is a rare complication of Type 2 diabetes (T2D). Materials & methods: We assessed circulating miRNAs in 17 patients with T2D and acute CF (G1), 17 patients with T2D (G2) and equivalent neuropathy and 17 patients with T2D without neuropathy (G3) using the high-throughput miRNA expression profiling. Results: 51 significantly deregulated miRNAs were identified in G1 versus G2, 37 in G1 versus G3 and 64 in G2 versus G3. Furthermore, we demonstrated that 16 miRNAs differentially expressed between G1 versus G2 could be involved in osteoclastic differentiation. Among them, eight are key factors involved in CF pathophysiology. Conclusion: Our data reveal that CF patients exhibit an altered expression profile of circulating miRNAs.
Collapse
Affiliation(s)
- Jennifer Pasquier
- Stem Cell & Microenvironment Laboratory, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Department of Genetic Medicine, Weill Cornell Medicine, NY 10021, USA
| | - Vimal Ramachandran
- MicroRNA Core, Department of Research, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Moh'd Rasheed Abu-Qaoud
- Stem Cell & Microenvironment Laboratory, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Binitha Thomas
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Manasi J Benurwar
- MicroRNA Core, Department of Research, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Omar Chidiac
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Jessica Hoarau-Véchot
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Amal Robay
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Department of Genetic Medicine, Weill Cornell Medicine, NY 10021, USA
| | - Khalid Fakhro
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Department of Human Genetics, Sidra Medical & Research Centre, PO box 26999, Doha, Qatar
| | - Robert A Menzies
- Department of Medicine, Hamad Medical Corporation, PO box 2050, Doha, Qatar
| | - Amin Jayyousi
- Department of Medicine, Hamad Medical Corporation, PO box 2050, Doha, Qatar
| | - Mahmoud Zirie
- Department of Medicine, Hamad Medical Corporation, PO box 2050, Doha, Qatar
| | - Jassim Al Suwaidi
- Department of Medicine, Hamad Medical Corporation, PO box 2050, Doha, Qatar
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, PO box 3050, Doha, Qatar.,John & Sanford I, Weill Department of Medicine, Weill Cornell Medicine, NY 10021, USA
| | - Talal K Talal
- Department of Medicine, Hamad Medical Corporation, PO box 2050, Doha, Qatar
| | - Seyed Hani Najafi-Shoushtari
- MicroRNA Core, Department of Research, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Department of Cell & Developmental Biology, Weill Cornell Medicine, NY 10021, USA
| | - Arash Rafii
- Stem Cell & Microenvironment Laboratory, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar
| | - Charbel Abi Khalil
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, PO box 24144, Doha, Qatar.,Department of Genetic Medicine, Weill Cornell Medicine, NY 10021, USA.,Department of Medicine, Weill Cornell Medicine-Qatar, PO box 3050, Doha, Qatar.,John & Sanford I, Weill Department of Medicine, Weill Cornell Medicine, NY 10021, USA
| |
Collapse
|
19
|
Brocco E, Ninkovic S, Marin M, Whisstock C, Bruseghin M, Boschetti G, Viti R, Forlini W, Volpe A. Diabetic foot management: multidisciplinary approach for advanced lesion rescue. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:670-684. [PMID: 29808982 DOI: 10.23736/s0021-9509.18.10606-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The diabetic foot is a complication of diabetes affecting 15% of diabetics in their lives. It is associated to diabetic neuropathy and peripheral vascular disease and its incidence has increased. The ulceration is the initial cause of a dramatic process leading, if not correctly treated, to amputations. Both neuropathy, neuro-ischemia and infections have a role in determining healing or worsening of the lesions and 85% of all amputations in diabetic patients are preceded by a foot ulceration deteriorating to a severe gangrene or infection. The different causative agents and the different clinical presentations of diabetic foot ask a multidisciplinary approach in order to address treatments to the final goals, the prevention of the amputations and the maintenance of a functional foot able with weight-bearing ability. Many professional figures, diabetologists, surgeons (both general and vascular and orthopedics), interventional radiologists, infectious diseases specialists, specialized nurses, podiatrists, orthotic technicians, are called to apply their knowledges to the diabetic patients affected by diabetic foot in a virtuous circle leading to reach the goals, with the imperative action of the multidisciplinary team. The so organized center will allow both a correct and rapid diagnosis, the use in ambulatorial environments of modern tools, or the hospitalization in multitasking wards, in which all the complications and the necessary treatments are possible, both in emergencies or in elective way, considering both revascularizations and surgery.
Collapse
Affiliation(s)
- Enrico Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy -
| | - Sasa Ninkovic
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Mariagrazia Marin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Christine Whisstock
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Marino Bruseghin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Giovanni Boschetti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Raffaella Viti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | | | - Antonio Volpe
- Department of Orthopedic Surgery, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| |
Collapse
|
20
|
Jansen RB, Christensen TM, Bülow J, Rørdam L, Holstein PE, Jørgensen NR, Svendsen OL. Bone mineral density and markers of bone turnover and inflammation in diabetes patients with or without a Charcot foot: An 8.5-year prospective case-control study. J Diabetes Complications 2018; 32:164-170. [PMID: 29196119 DOI: 10.1016/j.jdiacomp.2017.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIMS Charcot foot is a rare but severe complication to diabetes and peripheral neuropathy. It is still unclear if an acute Charcot foot has long-term effects on the bone metabolism. To investigate this, we conducted a follow-up study to examine if a previously acute Charcot foot has any long-term effects on bone mineral density (BMD) or local or systemic bone metabolism. METHODS An 8.5-year follow-up case-control study of 44 individuals with diabetes mellitus, 24 of whom also had acute or chronic Charcot foot at the baseline visit in 2005-2007, who were followed up in 2015 with DXA scans and blood samples. RESULTS 21 of the 44 baseline participants participated in the follow-up. There were no difference in the change in total hip BMD from baseline to follow-up in either the Charcot or the control group (p = 0.402 and 0.517), and no increased risk of osteoporosis in the previous Charcot feet either. From baseline to follow-up, there was a significant difference in the change in levels of fsRANK-L in the Charcot group, but not in the control group (p = 0.002 and 0.232, respectively). At follow-up, there were no differences in fsRANK-L between the groups. The fsRANK-L/OPG ratio also significantly decreased from baseline to follow-up in the Charcot group (3.4 versus 0.5) (p = 0.009), but not in the control group (1.3 versus 1.1) (p = 0.302). CONCLUSION We found that diabetes patients with an acute Charcot foot have an elevated fsRANK-L/OPG ratio, and that the level decreased from baseline to follow-up to be comparable to the level in diabetes patients without previous or current Charcot foot. We found no permanent effect of an acute Charcot foot on hip or foot BMD.
Collapse
Affiliation(s)
- Rasmus Bo Jansen
- Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark; Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark.
| | - Tomas Møller Christensen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Jens Bülow
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Lene Rørdam
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Per E Holstein
- Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, DK-2600 Glostrup, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ole Lander Svendsen
- Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark; Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, NV, Denmark
| |
Collapse
|
21
|
Jansen RB, Christensen TM, Bülow J, Rørdam L, Jørgensen NR, Svendsen OL. Markers of Local Inflammation and Bone Resorption in the Acute Diabetic Charcot Foot. J Diabetes Res 2018; 2018:5647981. [PMID: 30155488 PMCID: PMC6098852 DOI: 10.1155/2018/5647981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Due to the localized nature of Charcot foot, systemically altered levels of inflammation markers can be difficult to measure. The aim of this study was to investigate whether it is possible to detect an arteriovenous (A-V) flux in any locally produced inflammatory biomarkers from an acute Charcot foot by comparing local and systemic measurements. METHODS We included patients with acute diabetic Charcot foot. Blood was sampled from the vena saphena magna on the distal part of the crus bilaterally as well as from the arteria radialis. To minimize the A-V shunting effect, the feet were externally cooled with ice water prior to resampling. RESULTS Both before and after cooling, the A-V flux of interleukin-6 (IL-6) between the Charcot feet and the arterial level was significantly higher than the flux between the healthy feet and the arterial level (Δvaluebefore: 7.25 versus 0.41 pg/mL, resp., p = 0.008; Δvalueafter: 10.04 versus 1.68 pg/mL, resp., p = 0.032). There were no differences in the fluxes for other markers of inflammation. CONCLUSION We have found an increased A-V flux of IL-6 in the acute diabetic Charcot foot compared to the healthy foot in the same patients.
Collapse
Affiliation(s)
- Rasmus Bo Jansen
- Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
| | - Tomas Møller Christensen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
| | - Jens Bülow
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
| | - Lene Rørdam
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark
- Odense Patient data Explorative Network (OPEN), Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ole Lander Svendsen
- Copenhagen Diabetes Foot Center (CODIF), Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen NV, Denmark
| |
Collapse
|
22
|
Alam U, Riley DR, Jugdey RS, Azmi S, Rajbhandari S, D'Août K, Malik RA. Diabetic Neuropathy and Gait: A Review. Diabetes Ther 2017; 8:1253-1264. [PMID: 28864841 PMCID: PMC5688977 DOI: 10.1007/s13300-017-0295-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Indexed: 01/08/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is a major sequela of diabetes mellitus and may have a detrimental effect on the gait of people with this complication. DPN causes a disruption in the body's sensorimotor system and is believed to affect up to 50% of patients with diabetes mellitus, dependent on the duration of diabetes. It has a major effect on morbidity and mortality. The peripheral nervous system controls the complex series of events in gait through somatic and autonomic functions, careful balancing of eccentric and concentric muscle contractions and a reliance on the sensory information received from the plantar surface. In this literature review focussing on kinetics, kinematics and posture during gait in DPN patients, we have identified an intimate link between DPN and abnormalities in gait and demonstrated an increased risk in falls for older patients with diabetes. As such, we have identified a need for further research on the role of gait abnormalities in the development of diabetic foot ulceration and subsequent amputations.
Collapse
Affiliation(s)
- Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, UK.
| | | | | | - Shazli Azmi
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, UK
| | | | - Kristiaan D'Août
- Evolutionary Morphology and Biomechanics Group, Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, UK
- Weill Cornell Medicine-Qatar, Doha, Qatar
| |
Collapse
|
23
|
Pasquier J, Thomas B, Hoarau-Véchot J, Odeh T, Robay A, Chidiac O, Dargham SR, Turjoman R, Halama A, Fakhro K, Menzies R, Jayyousi A, Zirie M, Al Suwaidi J, Rafii A, Malik RA, Talal T, Abi Khalil C. Circulating microparticles in acute diabetic Charcot foot exhibit a high content of inflammatory cytokines, and support monocyte-to-osteoclast cell induction. Sci Rep 2017; 7:16450. [PMID: 29180664 PMCID: PMC5703953 DOI: 10.1038/s41598-017-16365-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 11/10/2017] [Indexed: 01/18/2023] Open
Abstract
Circulating microparticles (MPs) are major mediators in cardiovascular complications of type 2 diabetes (T2D); however, their contribution to Charcot foot (CF) disease is not known. Here, we purified and assessed the origin, concentration and content of circulating MPs from 33 individuals: 11 with T2D and acute CF, 11 T2D patients with equivalent neuropathy and 11 non-diabetic controls. First, we demonstrated that there were no differences in the distribution of MPs of endothelial, platelet origin among the 3 groups. However, MPs from leukocytes and monocytes origin were increased in CF patients. Moreover, we demonstrated that monocytes-derived MPs originated more frequently from intermediate and non-classical monocytes in CF patients. Five cytokines (G-CSF, GM-CSF, IL-1-ra, IL-2 and IL-16) were significantly increased in MPs from acute CF patients. Applying ingenuity pathways analysis, we found that those cytokines interacted well and induced the activation of pathways that are involved in osteoclast formation. Further, we treated THP-1 monocytes and monocytes sorted from healthy patients with CF-derived MPs during their differentiation into osteoclasts, which increased their differentiation into multinucleated osteoclast-like cells. Altogether, our study suggests that circulating MPs in CF disease have a high content of inflammatory cytokines and could increase osteoclast differentiation in vitro.
Collapse
Affiliation(s)
- Jennifer Pasquier
- Stem Cell and Microenvironment Laboratory, Weill Cornell Medicine-Qatar, Doha, Qatar.,Department of Genetic Medicine, Weill Cornell Medicine, New York, USA
| | - Binitha Thomas
- Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Tala Odeh
- Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Amal Robay
- Department of Genetic Medicine, Weill Cornell Medicine, New York, USA.,Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Omar Chidiac
- Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Soha R Dargham
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Rebal Turjoman
- Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Anna Halama
- Department of Physiology and Biophysics, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Khalid Fakhro
- Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.,Sidra Medical and Research center, Doha, Qatar
| | - Robert Menzies
- Department of Podiatry, Hamad Medical Corporation, Doha, Qatar
| | - Amin Jayyousi
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Mahmoud Zirie
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | | | - Arash Rafii
- Stem Cell and Microenvironment Laboratory, Weill Cornell Medicine-Qatar, Doha, Qatar.,Department of Genetic Medicine, Weill Cornell Medicine, New York, USA
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine, New York, USA
| | - Talal Talal
- Department of Podiatry, Hamad Medical Corporation, Doha, Qatar
| | - Charbel Abi Khalil
- Department of Genetic Medicine, Weill Cornell Medicine, New York, USA. .,Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar. .,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar. .,Department of Medicine, Weill Cornell Medicine, New York, USA.
| |
Collapse
|
24
|
Zhao HM, Diao JY, Liang XJ, Zhang F, Hao DJ. Pathogenesis and potential relative risk factors of diabetic neuropathic osteoarthropathy. J Orthop Surg Res 2017; 12:142. [PMID: 28969714 PMCID: PMC5625723 DOI: 10.1186/s13018-017-0634-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/11/2017] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hong-Mou Zhao
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
| | - Jia-Yu Diao
- Cardiovascular Medicine Department, The Second Affiliated Hospital of Xi'an Jiaotong University College of Medicine, No. 157 West Fifth Road, Xi'an, 710004, People's Republic of China
| | - Xiao-Jun Liang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
| | - Feng Zhang
- School of Public Health, Health Science Center Xi'an Jiaotong University, No. 76 Yan Ta West Road, Xi'an, 710061, People's Republic of China.
| | - Ding-Jun Hao
- Spine Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China.
| |
Collapse
|
25
|
Schara K, Štukelj R, Krek J, Lakota K, Sodin-Šemrl S, Boulton A, Kralj-Iglič V. A study of extracellular vesicle concentration in active diabetic Charcot neuroarthropathy. Eur J Pharm Sci 2017; 98:58-63. [DOI: 10.1016/j.ejps.2016.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 09/06/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
|
26
|
Petrova NL, Edmonds ME. Conservative and Pharmacologic Treatments for the Diabetic Charcot Foot. Clin Podiatr Med Surg 2017; 34:15-24. [PMID: 27865311 DOI: 10.1016/j.cpm.2016.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Charcot neuroarthropathy is a disabling complication of diabetic neuropathy. Prolonged immobilization in a total contact cast (TCC) is among the main treatments. Education of health care professionals in the application of TCC together with well-conducted clinical trials are required to overcome its frequent underuse. There are no established pharmacologic therapies to treat this condition; however, there is an overwhelming need for a new therapeutic approach. Novel targeted drug delivery systems are required to prevent the pathologic bone and joint destruction of the Charcot neuroarthropathy and this may lead to an improved outcome in diabetic patients with this condition.
Collapse
Affiliation(s)
- Nina L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.
| | - Michael E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| |
Collapse
|
27
|
Ghiassian SD, Menche J, Chasman DI, Giulianini F, Wang R, Ricchiuto P, Aikawa M, Iwata H, Müller C, Zeller T, Sharma A, Wild P, Lackner K, Singh S, Ridker PM, Blankenberg S, Barabási AL, Loscalzo J. Endophenotype Network Models: Common Core of Complex Diseases. Sci Rep 2016; 6:27414. [PMID: 27278246 PMCID: PMC4899691 DOI: 10.1038/srep27414] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 05/19/2016] [Indexed: 02/03/2023] Open
Abstract
Historically, human diseases have been differentiated and categorized based on the organ system in which they primarily manifest. Recently, an alternative view is emerging that emphasizes that different diseases often have common underlying mechanisms and shared intermediate pathophenotypes, or endo(pheno)types. Within this framework, a specific disease’s expression is a consequence of the interplay between the relevant endophenotypes and their local, organ-based environment. Important examples of such endophenotypes are inflammation, fibrosis, and thrombosis and their essential roles in many developing diseases. In this study, we construct endophenotype network models and explore their relation to different diseases in general and to cardiovascular diseases in particular. We identify the local neighborhoods (module) within the interconnected map of molecular components, i.e., the subnetworks of the human interactome that represent the inflammasome, thrombosome, and fibrosome. We find that these neighborhoods are highly overlapping and significantly enriched with disease-associated genes. In particular they are also enriched with differentially expressed genes linked to cardiovascular disease (risk). Finally, using proteomic data, we explore how macrophage activation contributes to our understanding of inflammatory processes and responses. The results of our analysis show that inflammatory responses initiate from within the cross-talk of the three identified endophenotypic modules.
Collapse
Affiliation(s)
- Susan Dina Ghiassian
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, USA.,Center for Cancer Systems Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jörg Menche
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, USA.,Center for Cancer Systems Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Theoretical Physics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Daniel I Chasman
- Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Ruisheng Wang
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Piero Ricchiuto
- Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Masanori Aikawa
- Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroshi Iwata
- Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Müller
- University Heart Center Hamburg, Clinic for General and Interventional Cardiology, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Tania Zeller
- University Heart Center Hamburg, Clinic for General and Interventional Cardiology, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Amitabh Sharma
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, USA.,Center for Cancer Systems Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philipp Wild
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, Hamburg, Germany.,Preventive Cardiology and Preventive Medicine, Dept. of Medicine 2, University Medical Center Mainz, Mainz, Germany.,Clinical Epidemiology, Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Karl Lackner
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, Hamburg, Germany.,Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| | - Sasha Singh
- Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul M Ridker
- Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stefan Blankenberg
- University Heart Center Hamburg, Clinic for General and Interventional Cardiology, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Albert-László Barabási
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, USA.,Center for Cancer Systems Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Theoretical Physics, Budapest University of Technology and Economics, Budapest, Hungary.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Network Science, Central European University, Budapest, Hungary
| | - Joseph Loscalzo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
28
|
Leone A, Cassar-Pullicino VN, Semprini A, Tonetti L, Magarelli N, Colosimo C. Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot. Skeletal Radiol 2016; 45:735-54. [PMID: 26883537 DOI: 10.1007/s00256-016-2339-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/10/2016] [Accepted: 01/17/2016] [Indexed: 02/02/2023]
Abstract
Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.
Collapse
Affiliation(s)
- Antonio Leone
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy.
| | - Victor N Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Alessia Semprini
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Laura Tonetti
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Nicola Magarelli
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| |
Collapse
|
29
|
Nóbrega MBDM, Aras R, Netto EM, Couto RD, Marinho AMDN, da Silva JL, Colares VNQ, Campelo PL, Nunes MAL. Risk factors for Charcot foot. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 59:226-30. [PMID: 26154090 DOI: 10.1590/2359-3997000000042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 04/08/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Diabetes mellitus is the main cause of Charcot neuroarthropathy and is clinically classified as follows: Charcot foot, acute Charcot foot (ACF) when there is inflammation, and inactive Charcot foot when inflammatory signs are absent. The aim of this study was to identify the risk factors for ACF in patients with type 2 diabetes mellitus. MATERIALS AND METHODS A matched case-control study was conducted to assess the factors associated with acute Charcot foot from February 2000 until September 2012. Four controls for each case were selected 47 cases of ACF and 188 controls without ACF were included. Cases and controls were matched by year of initialization of treatment. Conditional logistic regression was used to estimate matched odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS In multivariate analysis, patients having less than 55 years of age (adjusted OR = 4.10, 95% CI = 1.69 - 9.94), literate education age (adjusted OR = 3.73, 95% CI = 1.40 - 9.92), living alone (adjusted OR = 5.84, 95% CI = 1.49 - 22.86), previous ulceration (adjusted OR = 4.84, 95% CI = 1.62 - 14.51) were at increased risk of ACF. However, peripheral arterial disease (adjusted OR = 0.16, 95% CI = 0.05 - 0.52) of 6.25 (1.92 - 20.0) was a protective factor. DISCUSSION The results suggest that PCA in type 2 diabetes primarily affects patients under 55 who live alone, are literate, and have a prior history of ulcers, and that peripheral arterial disease is a protective factor.
Collapse
Affiliation(s)
| | - Roque Aras
- Federal University of Bahia, Salvador, BA, Brazil
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Bergamini A, Bolacchi F, Pesce CD, Veneziano G, Uccioli L, Girardi V, De Corato L, Mondillo MT, Squillaci E. Expression of the receptor activator of nuclear factor-kB ligand in peripheral blood mononuclear cells in patients with acute Charcot neuroarthropathy. Int J Med Sci 2016; 13:875-880. [PMID: 28090190 PMCID: PMC5236002 DOI: 10.7150/ijms.14579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 07/08/2016] [Indexed: 11/06/2022] Open
Abstract
Introduction. The receptor activator of nuclear factor-kB (RANK), ligand (RANK-L) and osteoprotegerin (OPG) are implicated in the pathogenesis of acute Charcot neuroarthropathy (CN). Materials and Methods. This study aimed to investigate the expression of RANK-L and OPG in peripheral blood mononuclear cells (PBMC) from patients with acute CN. Results. We found that the expression of RANK-L was lower in patients with acute CN as compared with diabetic control subjects and healthy control participants; whereas OPG expression was not detected in patients and in both control groups. RANK-L expression at the onset of disease was inversely correlated with the index of polyunsaturation (PUI), a bone marrow MRS-derived measurable index that allows evaluation of disease activity in acute CN, and recovery time. Finally, the expression of RANK-L increased at the time of healing compared with the values found during the acute phase. Conclusions. In conclusion, our preliminary data provide a first step in applying analysis of RANK-L expression in peripheral blood cells to the diagnosis of acute CN. Based on our data we also suggest that analysis of RANK-L expression could be a complementary tool that can be employed to obtain quantitative parameters that may help clinicians to monitor disease activity in patients with acute CN.
Collapse
Affiliation(s)
- Alberto Bergamini
- Department of Internal Medicine, Hematology/Oncology Unit, Tor Vergata University, Rome, Italy Department of Public Health and Cellular Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Francesca Bolacchi
- Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Caterina Delfina Pesce
- Department of Internal Medicine, Hematology/Oncology Unit, Tor Vergata University, Rome, Italy Department of Public Health and Cellular Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Giada Veneziano
- Department of Internal Medicine, Hematology/Oncology Unit, Tor Vergata University, Rome, Italy Department of Public Health and Cellular Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Girardi
- Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Laura De Corato
- Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Maria Teresa Mondillo
- Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Ettore Squillaci
- Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| |
Collapse
|
31
|
Folestad A, Ålund M, Asteberg S, Fowelin J, Aurell Y, Göthlin J, Cassuto J. Offloading treatment is linked to activation of proinflammatory cytokines and start of bone repair and remodeling in Charcot arthropathy patients. J Foot Ankle Res 2015; 8:72. [PMID: 26692902 PMCID: PMC4676128 DOI: 10.1186/s13047-015-0129-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/30/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Proinflammatory cytokines are an integral part of the osteolytic activity of Charcot arthropathy but are also central to normal bone healing. As there are no previous longitudinal studies investigating their role during the recovery phase of Charcot, we set out to monitor systemic levels of proinflammatory cytokines from Charcot presentation until a clinically and radiographically documented chronic state has been reached. METHODS Twenty-eight consecutive Charcot patients were monitored during 2 years by repeated foot radiographs, MRI and plasma levels of interleukin [IL]-6, IL-8, IL-1β, Tumor Necrosis Factor [TNF]-α, and IL-1 receptor antibody (IL-1RA). Charcot patients were treated with total contact cast (TCC) on the first day of inclusion. Neuropathic diabetic controls (n = 20) and Healthy subjects (n = 20) served as reference. RESULTS Plasma IL-6, IL-8, IL-1β and TNF-α in the acute and chronic phase of Charcot were below or at the level of diabetic controls and healthy, whereas IL-1RA/IL-1β ratio was continuously higher in Charcot patients. IL-6, TNF-α and IL-1RA began to increase one week after offloading to reach a peak after 4 months before gradually receding. CONCLUSIONS A sustained increase of IL-6 and TNF-α starting shortly after offloading and paralleled by accelerated bone healing on radiographs, suggest that offloading, by activating the inflammatory stage, has a key role to play in the onset of coupled bone remodeling. High IL-1RA/IL-1β ratio in Charcot patients at presentation supports a counter-balancing anti-inflammatory role for IL-1RA in the acute phase whereas a high ratio after two years, possibly due to renewed weight-bearing on a deformed foot, signal need for continued anti-inflammatory activity and contradicts a "cold" biological state in the chronic phase.
Collapse
Affiliation(s)
- Agnetha Folestad
- />Department of Orthopaedics, CapioLundby Hospital, Göteborg, Sweden
| | - Martin Ålund
- />Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Susanne Asteberg
- />Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jesper Fowelin
- />Diabetes Care Unit, Department of Medicine, Frölunda Specialist Hospital, Västra Frölunda, Göteborg, Sweden
| | - Ylva Aurell
- />Department of Radiology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jan Göthlin
- />Department of Radiology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jean Cassuto
- />Orthopaedic Research Unit, Sahlgrenska University Hospital, Staben, Hus U1, 431 80 Mölndal, Sweden, Göteborg University, Göteborg, Sweden
| |
Collapse
|
32
|
Younis BB, Shahid A, Arshad R, Khurshid S, Masood J. Charcot osteoarthropathy in type 2 diabetes persons presenting to specialist diabetes clinic at a tertiary care hospital. BMC Endocr Disord 2015; 15:28. [PMID: 26065885 PMCID: PMC4465003 DOI: 10.1186/s12902-015-0023-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 06/01/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charcot osteoarthropathy or charcot foot is a rare, chronic, non-communicable condition of bones and joints which may results into severe deformity and more prone to develop ulcers possibly leading to amputation. The purpose of this study was to determine the prevalence of Charcot osteoarthropathy and its association with age, BMI, gender, duration of diabetes, HBA1c and peripheral neuropathy. METHODS A total of 1931 subjects with type 2 diabetes having mean age 50.72 ± 10.66 years presenting in a specialist diabetes clinic at shalamar hospital, Lahore, Pakistan were enrolled. The diagnosis of Charcot osteoarthropathy was made by examination of both dorsal and plantar surfaces of foot for swelling, erythema, increase in temperature and any musculoskeletal deformity which was later confirmed by radiographs. Assessment of neuropathy was carried out by checking the sense of pressure, joint position and vibration. BMI (Body Mass Index), fasting blood glucose (FBG) and HbA1C were determined. RESULTS In all subjects including male 704 (36.45 %) and female 1227 (63.55 %), 0.4 % subjects had charcot deformity, while 0.2 %, 0.15 % and 0.05 % subjects having right, left and bilateral deformity respectively. Bilaterally symmetrical neuropathy was diagnosed in 25.4 % in subjects. There was a significant association (p < 0.05) of deformity with duration of diabetes, HbA1C and neuropathy, however no significant association (p > 0.05) was found with age, BMI, weight, height and gender. CONCLUSION There is a need to have a special care of persons with diabetes regarding blood glucose control and development of peripheral neuropathy. Early identification and management of risk factors may prevent the occurrence of charcot deformity. Patients must be educated about the foot care.
Collapse
Affiliation(s)
- Bilal Bin Younis
- Department of Endocrinology Medicine, Shalamar Medical and Dental College Lahore, Shalamar Link Road Lahore, Postal address: 2-J Gulberg III, Lahore, Pakistan.
| | - Adeela Shahid
- Department of Physiology, Shalamar Medical and Dental College, Lahore, Pakistan.
- Department of Physiology and Cell Biology, University of Health Sciences, Lahore, Pakistan.
| | - Rozina Arshad
- Department of Endocrinology Medicine, Shalamar Medical and Dental College Lahore, Shalamar Link Road Lahore, Postal address: 2-J Gulberg III, Lahore, Pakistan.
| | - Saima Khurshid
- Department of Endocrinology Medicine, Shalamar Medical and Dental College Lahore, Shalamar Link Road Lahore, Postal address: 2-J Gulberg III, Lahore, Pakistan.
| | - Junaid Masood
- Department of Endocrinology Medicine, Shalamar Medical and Dental College Lahore, Shalamar Link Road Lahore, Postal address: 2-J Gulberg III, Lahore, Pakistan.
| |
Collapse
|
33
|
Abstract
Charcot foot syndrome is an uncommon complication of diabetes but is potentially devastating in its consequences. Outcome is made worse by widespread professional ignorance leading to delayed diagnosis, but it is also hampered by lack of understanding of its causes and lack of treatments with proven effectiveness, other than offloading. There remains a desperate need for studies into its causes as well as comparative audit and trials designed to determine the best treatment for this difficult condition. Such work can probably only be effectively carried out through the establishment of multicentre networks. Nevertheless, improved understanding in recent years of the likely role of inflammatory pathways has raised awareness of the multiple ways in which the effects of neuropathy may be manifest in the development of the Charcot foot. This awareness is also leading to the realization that similar processes may conceivably contribute to the refractoriness of other foot diseases in diabetes, including both chronic unhealing ulcers and osteomyelitis.
Collapse
Affiliation(s)
- W J Jeffcoate
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, UK
| |
Collapse
|
34
|
Petrova NL, Dew TK, Musto RL, Sherwood RA, Bates M, Moniz CF, Edmonds ME. Inflammatory and bone turnover markers in a cross-sectional and prospective study of acute Charcot osteoarthropathy. Diabet Med 2015; 32:267-73. [PMID: 25251588 DOI: 10.1111/dme.12590] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 11/27/2022]
Abstract
AIMS To assess markers of inflammation and bone turnover at presentation and at resolution of Charcot osteoarthropathy. METHODS We measured serum inflammatory and bone turnover markers in a cross-sectional study of 35 people with Charcot osteoarthropathy, together with 34 people with diabetes and 12 people without diabetes. In addition, a prospective study of the subjects with Charcot osteoarthropathy was conducted until clinical resolution. RESULTS At presentation, C-reactive protein (P = 0.007), tumour necrosis factor-α (P = 0.010) and interleukin-6 (P = 0.002), but not interleukin-1β, (P = 0.254) were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. Serum C-terminal telopeptide (P = 0.004), bone alkaline phosphatase (P = 0.006) and osteoprotegerin (P < 0.001), but not tartrate-resistant acid phosphatase (P = 0.126) and soluble receptor activator of nuclear factor-κβ ligand (P = 0.915), were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. At follow-up it was found that tumour necrosis factor-α (P = 0.012) and interleukin-6 (P = 0.003), but not C-reactive protein (P = 0.101), interleukin-1β (P = 0.457), C-terminal telopeptide (P = 0.743), bone alkaline phosphatase (P = 0.193), tartrate-resistant acid phosphatase (P = 0.856), osteoprotegerin (P = 0.372) or soluble receptor activator of nuclear factor-kβ ligand (P = 0.889), had significantly decreased between presentation and the 3 months of casting therapy time point, and all analytes remained unchanged from 3 months of casting therapy until resolution. In people with Charcot osteoarthropathy, there was a positive correlation between interleukin-6 and C-terminal telopeptide (P = 0.028) and tumour necrosis factor-α and C-terminal telopeptide (P = 0.013) only at presentation. CONCLUSIONS At the onset of acute Charcot foot, serum concentrations of tumour necrosis factor-α and interleukin-6 were elevated; however, there was a significant reduction in these markers at resolution and these markers may be useful in the assessment of disease activity.
Collapse
Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | | |
Collapse
|
35
|
Petrova NL, Petrov PK, Edmonds ME, Shanahan CM. Inhibition of TNF-α Reverses the Pathological Resorption Pit Profile of Osteoclasts from Patients with Acute Charcot Osteoarthropathy. J Diabetes Res 2015; 2015:917945. [PMID: 26137498 PMCID: PMC4468294 DOI: 10.1155/2015/917945] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 02/01/2023] Open
Abstract
We hypothesised that tumour necrosis factor-α (TNF-α) may enhance receptor activator of nuclear factor-κβ ligand- (RANKL-) mediated osteoclastogenesis in acute Charcot osteoarthropathy. Peripheral blood monocytes were isolated from 10 acute Charcot patients, 8 diabetic patients, and 9 healthy control subjects and cultured in vitro on plastic and bone discs. Osteoclast formation and resorption were assessed after treatment with (1) macrophage-colony stimulating factor (M-CSF) and RANKL and (2) M-CSF, RANKL, and neutralising antibody to TNF-α (anti-TNF-α). Resorption was measured on the surface of bone discs by image analysis and under the surface using surface profilometry. Although osteoclast formation was similar in M-CSF + RANKL-treated cultures between the groups (p > 0.05), there was a significant increase in the area of resorption on the surface (p < 0.01) and under the surface (p < 0.01) in Charcot patients compared with diabetic patients and control subjects. The addition of anti-TNF-α resulted in a significant reduction in the area of resorption on the surface (p < 0.05) and under the surface (p < 0.05) only in Charcot patients as well as a normalisation of the aberrant erosion profile. We conclude that TNF-α modulates RANKL-mediated osteoclastic resorption in vitro in patients with acute Charcot osteoarthropathy.
Collapse
Affiliation(s)
- Nina L. Petrova
- Diabetic Foot Clinic, King's College Hospital, London SE5 9RS, UK
- *Nina L. Petrova:
| | - Peter K. Petrov
- Department of Materials, Imperial College London, London SW7 2AZ, UK
| | | | | |
Collapse
|
36
|
Petrova NL, Petrov PK, Edmonds ME, Shanahan CM. Novel use of a Dektak 150 surface profiler unmasks differences in resorption pit profiles between control and Charcot patient osteoclasts. Calcif Tissue Int 2014; 94:403-11. [PMID: 24322885 DOI: 10.1007/s00223-013-9820-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/22/2013] [Indexed: 01/18/2023]
Abstract
We hypothesized that newly formed osteoclasts from patients with acute Charcot osteoarthropathy can resorb surfaces of bone more extensively compared with controls. Peripheral blood monocytes, isolated from eight Charcot patients and nine controls, were cultured in vitro on 24-well plates and bovine bone discs in duplicate with macrophage colony-stimulating factor (M-CSF) and receptor activator of nuclear factor κβ ligand (RANKL). Osteoclast formation was assessed by tartrate-resistant acid phosphatase staining (TRAcP) at day 17. Resorption was measured at day 21 after toluidine blue staining by two methods: (1) area of resorption at the surface by image analysis (%) and (2) area of resorption under the surface (μm(2)) measured by a Dektak 150 Surface Profiler. Ten 1,000 μm-long scans were performed per disc. Pits were classified as unidented, bidented, and multidented according to their shape. Although the number of newly formed TRAcP positive multinucleated cells (>3 nuclei) was similar in M-CSF + RANKL-treated cultures between controls and Charcot patients, the latter exhibited increased resorbing activity. The area of resorption on the surface by image analysis was significantly greater in Charcot patients compared with controls (21.1 % [14.5-26.2] vs. 40.8 % [35.4-46.0], median [25-75th percentile], p < 0.01), as was the area of resorption under the surface (2.7 x 10(3) μm(2) [1.6 x 10(3)- 3.9 x 10(3)] vs. 8.3 x 10(3) μm (2) [5.6 x 10(3)- 10.6 x 10(3), [corrected] p < 0.01) after profilometry. In Charcot patients pits were deeper and wider and more frequently presented as multidented pits. This application of the Dektak 150 Surface Profiler revealed novel differences in resorption pit profile from osteoclasts derived from Charcot patients compared with controls. Resorption in Charcot patients was mediated by highly aggressive newly formed osteoclasts from monocytes eroding large and deep areas of bone.
Collapse
Affiliation(s)
- Nina L Petrova
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, SE5 9RS, UK,
| | | | | | | |
Collapse
|
37
|
Abstract
Charcot neuroarthropathy is a limb-threatening, destructive process that occurs in patients with neuropathy associated with medical diseases such as diabetes mellitus. Clinicians' treating diabetic patients should be vigilant in recognizing the early signs of acute Charcot neuroarthropathy, such as pain, warmth, edema, or pathologic fracture in a neuropathic foot. Early detection and prompt treatment can prevent joint and bone destruction, which, if untreated, can lead to morbidity and high-level amputation. A high degree of suspicion is necessary. Once the early signs have been detected, prompt immobilization and offloading are important. Treatment should be determined on an individual basis, and it must be determined whether a patient can be treated conservatively or will require surgical intervention when entering the chronic phase. If diagnosed early, medical and conservative measures only will be required. Surgery is indicated for patients with severe or unstable deformities that, if untreated, will result in major amputations. A team approach that includes a foot and ankle surgeon, a diabetologist, a physiotherapist, a medical social councilor, and, most importantly, the patient and immediate family members is vital for successful management of this serious condition.
Collapse
Affiliation(s)
- Ajit Kumar Varma
- Professor, Department of Endocrinology, Diabetic Lower Limb and Podiatric Surgery, Amrita Institute of Medical Sciences and Research Center, Ponekkara, Kerala, India.
| |
Collapse
|
38
|
Kaynak G, Birsel O, Güven MF, Oğüt T. An overview of the Charcot foot pathophysiology. Diabet Foot Ankle 2013; 4:21117. [PMID: 23919113 PMCID: PMC3733015 DOI: 10.3402/dfa.v4i0.21117] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/09/2013] [Accepted: 07/01/2013] [Indexed: 01/15/2023]
Abstract
Charcot arthropathy of the foot is a rare but devastating complication of diabetes that remains to be a challenging issue for the foot and ankle surgeons. Charcot foot fails to be an obvious diagnostic option that comes to mind, even in a pathognomonic clinical appearance. The rarity of the disorder, more common pathologies that mimic the condition, and the self-limiting prognosis deviate the clinician from the right diagnosis. The clinical challenges in the diagnosis of Charcot foot require in-depth investigations of its enigmatic nature to establish useful guidelines. Yet, this goal seems to be beyond reach, without a holistic view of the immense literature concerning the pathophysiology of the disorder. The primary objective of this article is to put together and review the recent advancements about the etiology and intrinsic mechanisms of diabetic Charcot foot.
Collapse
Affiliation(s)
- Gökhan Kaynak
- Cerrahpasa Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, Istanbul, Turkey
| | | | | | | |
Collapse
|
39
|
Proton magnetic resonance spectroscopy in the evaluation of patients with acute Charcot neuro-osteoarthropathy. Eur Radiol 2013; 23:2807-13. [DOI: 10.1007/s00330-013-2894-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 03/31/2013] [Accepted: 04/03/2013] [Indexed: 10/26/2022]
|
40
|
Osterhoff G, Böni T, Berli M. Recurrence of acute Charcot neuropathic osteoarthropathy after conservative treatment. Foot Ankle Int 2013; 34:359-64. [PMID: 23520293 DOI: 10.1177/1071100712464957] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive-destructive process affecting the feet of patients with sensory neuropathy. Data on CN recurrence are underrepresented in the literature. The aim of the present study was to evaluate the rate of CN recurrence after its treatment and to find predisposing factors. METHODS Fifty-two patients (age 59 ± 11 years, 16 female) with acute CN with 57 affected feet were enrolled. Comorbidities, localization, and stage of disease at first diagnosis as well as ulcerations, need for surgery, noncompliance, and subsequent treatment (orthopedic footwear or orthotic treatment) during the course of therapy were recorded. During follow-up, the incidence of recurrence of CN was observed. Mean follow-up was 47 ± 40 months. RESULTS Diabetes was the most common reason for sensory neuropathy (79%). Recurrence of CN was seen in 13 feet (23%) with an interval of 27 ± 31 months (range, 3-102 months) after the end of initial immobilization. Patients with recurrence were immobilized for a shorter period of time and had a more advanced stage of CN at time of first diagnosis. Predictors of recurrence were noncompliance (odds ratio 19.7; confidence interval, 4.1-94.4; P < .001) and obesity (odds ratio 6.4; confidence interval, 1.6-25.9; P = .06). CONCLUSIONS Recurrence of osteoarthropathic activity is a possible complication after conservative treatment of CN. Obesity and noncompliance are strong predictors for the recurrence of CN. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Georg Osterhoff
- Department of Orthopedics, University of Zurich, Balgrist, Zurich, Switzerland
| | | | | |
Collapse
|
41
|
Petrova NL, Edmonds ME. Medical management of Charcot arthropathy. Diabetes Obes Metab 2013; 15:193-7. [PMID: 22862834 DOI: 10.1111/j.1463-1326.2012.01671.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 06/06/2012] [Accepted: 07/28/2012] [Indexed: 11/29/2022]
Abstract
Charcot arthropathy is a major complication of diabetes and it poses management challenges to health care professionals. Early diagnosis and timely intervention are essential for improved outlook of these patients. Casting therapy has been accepted as the mainstay treatment of the acute Charcot foot, although there are still controversies regarding its duration, the choice of removable and non-removable device and weight-bearing casts vs. non-weight-bearing casts. Two groups of antiresorptive therapies have been evaluated in the treatment of the acute Charcot foot, bisphosphonates (intravenous and oral) and calcitonin. These therapies have clearly shown a reduction of bone turnover, although, they have not shown a significant effect on temperature reduction. Current evidence to support their use is weak. An anabolic agent to speed up clinical resolution and fracture healing may be helpful and a clinical trial to evaluate the possible benefit of 1-84 recombinant human parathyroid hormone on fracture healing in the acute Charcot foot is in progress. This paper summarises the current approach to medical management of acute Charcot arthropathy with specific emphasis on casting and pharmacological therapy. Emerging new studies of the pathogenesis of this condition are also discussed.
Collapse
Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital, London, UK.
| | | |
Collapse
|
42
|
Gutekunst DJ, Smith KE, Commean PK, Bohnert KL, Prior FW, Sinacore DR. Impact of Charcot neuroarthropathy on metatarsal bone mineral density and geometric strength indices. Bone 2013; 52:407-13. [PMID: 23117208 PMCID: PMC3515650 DOI: 10.1016/j.bone.2012.10.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 10/19/2012] [Accepted: 10/22/2012] [Indexed: 01/22/2023]
Abstract
Charcot neuroarthropathy (CN), an inflammatory condition characterized by rapid and progressive destruction of pedal bones and joints, often leads to deformity and ulceration in individuals with diabetes mellitus (DM) and peripheral neuropathy (PN). Repetitive, unperceived joint trauma may trigger initial CN damage, causing a proinflammatory cascade that can result in osteolysis and contribute to subsequent neuropathic fracture. We aimed to characterize osteolytic changes related to development and progression of CN by measuring bone mineral density (BMD) and geometric strength indices using volumetric quantitative computed tomography. Twenty individuals with DM+PN were compared to twenty age-, sex-, and race-matched individuals with DM+PN and acute CN. We hypothesized that individuals with acute CN would have decreased BMD and decreased total area, cortical area, minimum section modulus, and cortical thickness in the diaphysis of the second and fifth metatarsals. Results showed BMD was lower in both involved and uninvolved feet of CN participants compared to DM+PN participants, with greater reductions in involved CN feet compared to uninvolved CN feet. There was a non-significant increase in total area and cortical area in the CN metatarsals, which helps explain the finding of similar minimum section modulus in DM+PN and CN subjects despite the CN group's significantly lower BMD. Larger cortical area and section modulus are typically considered signs of greater bone strength due to higher resistance to compressive and bending loads, respectively. In CN metatarsals, however, these findings may reflect periosteal woven bone apposition, i.e., a hypertrophic response to injury rather than increased fracture resistance. Future research using these techniques will aid further understanding of the inflammation-mediated bony changes associated with development and progression of CN and other diseases.
Collapse
Affiliation(s)
- David J. Gutekunst
- Applied Kinesiology Laboratory, Program in Physical Therapy 4444 Forest Park Blvd., Campus Box 8502, St. Louis, MO 63108
| | - Kirk E. Smith
- Electronic Radiology Laboratory, Mallinckrodt Institute of Radiology 4525 Scott Avenue, Campus Box 8131, St. Louis, MO 63110
| | - Paul K. Commean
- Electronic Radiology Laboratory, Mallinckrodt Institute of Radiology 4525 Scott Avenue, Campus Box 8131, St. Louis, MO 63110
| | - Kathryn L. Bohnert
- Applied Kinesiology Laboratory, Program in Physical Therapy 4444 Forest Park Blvd., Campus Box 8502, St. Louis, MO 63108
| | - Fred W. Prior
- Electronic Radiology Laboratory, Mallinckrodt Institute of Radiology 4525 Scott Avenue, Campus Box 8131, St. Louis, MO 63110
| | - David R. Sinacore
- Applied Kinesiology Laboratory, Program in Physical Therapy 4444 Forest Park Blvd., Campus Box 8502, St. Louis, MO 63108
| |
Collapse
|
43
|
Richard JL, Almasri M, Schuldiner S. Treatment of acute Charcot foot with bisphosphonates: a systematic review of the literature. Diabetologia 2012; 55:1258-64. [PMID: 22361982 DOI: 10.1007/s00125-012-2507-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/03/2012] [Indexed: 12/19/2022]
Abstract
AIM/HYPOTHESIS We undertook a systematic review of the literature concerning the efficacy and safety of bisphosphonates in acute Charcot neuropathic osteoarthropathy. METHODS MEDLINE, PubMed, the Cochrane Database of Systematic Reviews, and abstracts presented during the meetings of the American Diabetes Association and the European Association of Diabetes were searched for relevant publications from the period January 1990 to September 2011. RESULTS A total of ten studies on the treatment of acute Charcot osteoarthropathy with bisphosphonates were identified and included in the analysis. Only four clinical trials were published, three of which were randomised. Bisphosphonates appeared to induce significant reductions in skin temperature and bone turnover markers compared with placebo, without serious adverse events. Nevertheless, bisphosphonates did not shorten the immobilisation time. Moreover, no data were available regarding their long-term effects. CONCLUSIONS/INTERPRETATIONS Bisphosphonates have been shown to be effective for reducing bone turnover markers and skin temperature in some studies. Nevertheless, the long-term efficacy, specifically that regarding the occurrence of deformities and ulcerations, remains to be demonstrated as no follow-up studies have been published. Moreover, some studies have suggested that bisphosphonates may lengthen the resolution phase of the disease. In our opinion, the data are too weak to support the use of bisphosphonates as a routine treatment for acute Charcot neuroarthropathy.
Collapse
Affiliation(s)
- J-L Richard
- Department of Diabetology & Nutritional Diseases, Medical Centre, University Hospital of Nîmes, 30240 Le Grau du Roi, Nîmes, France.
| | | | | |
Collapse
|
44
|
Affiliation(s)
- Jonathan Valabhji
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust and Division of Medicine, Imperial College London, UK.
| |
Collapse
|
45
|
Rogers LC, Frykberg RG, Armstrong DG, Boulton AJM, Edmonds M, Van GH, Hartemann A, Game F, Jeffcoate W, Jirkovska A, Jude E, Morbach S, Morrison WB, Pinzur M, Pitocco D, Sanders L, Wukich DK, Uccioli L. The Charcot foot in diabetes. J Am Podiatr Med Assoc 2012; 101:437-46. [PMID: 21957276 DOI: 10.7547/1010437] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
Collapse
Affiliation(s)
- Lee C Rogers
- Amputation Prevention Center at Valley Presbyterian Hospital, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Larson SAM, Burns PR. The pathogenesis of Charcot neuroarthropathy: current concepts. Diabet Foot Ankle 2012; 3:DFA-3-12236. [PMID: 22396834 PMCID: PMC3284308 DOI: 10.3402/dfa.v3i0.12236] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 12/16/2011] [Accepted: 12/19/2011] [Indexed: 12/13/2022]
Abstract
The pathogenesis of Charcot neuroarthropathy (CN) has been poorly understood by clinicians and scientists alike. Current researchers have made progress toward understanding the cause of CN and possible treatment options. The authors review the current literature on the pathogenesis of this debilitating disorder and attempt to explain the roles of inflammation, bone metabolism, and advanced glycation end products.
Collapse
Affiliation(s)
- Shelly A M Larson
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
47
|
Game FL, Catlow R, Jones GR, Edmonds ME, Jude EB, Rayman G, Jeffcoate WJ. Audit of acute Charcot's disease in the UK: the CDUK study. Diabetologia 2012; 55:32-5. [PMID: 22065087 DOI: 10.1007/s00125-011-2354-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 10/03/2011] [Indexed: 01/25/2023]
Abstract
AIMS/HYPOTHESIS We studied factors associated with the development and resolution of acute Charcot foot using a web-based observational study. METHODS Clinicians managing cases of acute Charcot foot in the UK and Ireland between June 2005 and February 2007 were invited to register anonymised details on a secure website. RESULTS A total of 288 cases (age 57.0 ± 11.3 years [mean ± SD]; 71.2% male) were registered from 76 centres. Of these, 36% of patients recalled an episode of relevant trauma in the preceding 6 months, while 12% had had surgery to the affected foot. In 101 (35%) cases, ulceration was present at registration and 20% of these had osteomyelitis. Non-removable off-loading devices were used at presentation in 35.4% of cases, with removable off-loading used in 50%. Data on resolution were available for 219 patients. The median time to resolution was 9 months in patients whose initial management included the use of non-removable off-loading, compared with 12 months in the remainder (p = 0.001). Bisphosphonates were administered intravenously in 25.4% and orally in 19.4% of cases. The median time to resolution in patients who received bisphosphonates was 12 months and was longer than in those who did not (10 months, p = 0.005). CONCLUSIONS/INTERPRETATION The median time to resolution was longer than in earlier series. Although limited by being observational and non-randomised, these data suggest that the use of non-removable off-loading at presentation may shorten the time to resolution. They provide no evidence to indicate that the use of bisphosphonates is beneficial.
Collapse
Affiliation(s)
- F L Game
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK.
| | | | | | | | | | | | | |
Collapse
|
48
|
Rogers LC, Frykberg RG, Armstrong DG, Boulton AJM, Edmonds M, Van GH, Hartemann A, Game F, Jeffcoate W, Jirkovska A, Jude E, Morbach S, Morrison WB, Pinzur M, Pitocco D, Sanders L, Wukich DK, Uccioli L. The Charcot foot in diabetes. Diabetes Care 2011; 34:2123-9. [PMID: 21868781 PMCID: PMC3161273 DOI: 10.2337/dc11-0844] [Citation(s) in RCA: 278] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
Collapse
Affiliation(s)
- Lee C Rogers
- Valley Presbyterian Hospital, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Ndip A, Williams A, Jude EB, Serracino-Inglott F, Richardson S, Smyth JV, Boulton AJM, Alexander MY. The RANKL/RANK/OPG signaling pathway mediates medial arterial calcification in diabetic Charcot neuroarthropathy. Diabetes 2011; 60:2187-96. [PMID: 21659498 PMCID: PMC3142088 DOI: 10.2337/db10-1220] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The receptor activator of nuclear factor-κB (RANK), RANK ligand (RANKL), and osteoprotegerin (OPG) signaling pathway (RANKL/RANK/OPG signaling) is implicated in the osteolysis associated with diabetic Charcot neuroarthropathy (CN); however, the links with medial arterial calcification (MAC) seen in people with CN are unclear. This study aimed to investigate the role of RANKL/OPG in MAC in patients with CN. RESEARCH DESIGN AND METHODS Enzyme-linked immunosorbent assay and Bio-plex multiarray technology were used to quantify a range of cytokines, including RANKL and OPG in sera from 10 patients with diabetes, 12 patients with CN, and 5 healthy volunteers. Human tibial artery segments were immunohistochemically stained with Alizarin red and human RANKL antibody. Human vascular smooth muscle cells (VSMCs) were also explanted from arterial segments for in vitro studies. RESULTS We demonstrate colocalization and upregulation of RANKL expression in areas displaying MAC. Systemic levels of RANKL, OPG, and inflammatory cytokines (interleukin-8, granulocyte colony-stimulating factor) were elevated in those with CN compared with diabetic patients and healthy control subjects. Human VSMCs cultured in CN serum showed accelerated osteoblastic differentiation (alkaline phosphatase activity) and mineralization (alizarin red staining) compared with cells treated with diabetic or control serum (P < 0.05). Coincubation with OPG, the decoy receptor for RANKL, attenuated osteogenic differentiation of VSMCs and was independent of a high calcium-phosphate milieu. The accelerated mineralization induced by RANKL and CN serum correlated with nuclear translocation of nuclear factor-κB, a process abrogated by OPG. CONCLUSIONS Our data provide direct evidence that RANKL/RANK/OPG signaling is modulated in patients with CN and plays a role in vascular calcification. This study highlights this pathway as a potential target for intervention.
Collapse
Affiliation(s)
- Agbor Ndip
- Department of Medicine and Diabetes, Manchester Royal Infirmary, Manchester, UK.
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Valabhji J. Immunosuppression therapy posttransplantation can be associated with a different clinical phenotype for diabetic charcot foot neuroarthropathy. Diabetes Care 2011; 34:e135. [PMID: 21788638 PMCID: PMC3142035 DOI: 10.2337/dc11-0960] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jonathan Valabhji
- From the Department of Diabetes and Endocrinology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, U.K
| |
Collapse
|