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Liu PL, Diao JY, Wang Q, Liu H, Zhang Y, Liang JQ, Zhang F, Liang XJ, Zhao HM. Cartilage Damage Pathological Characteristics of Diabetic Neuropathic Osteoarthropathy. Anal Cell Pathol (Amst) 2023; 2023:7573165. [PMID: 37197158 PMCID: PMC10185426 DOI: 10.1155/2023/7573165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 05/19/2023] Open
Abstract
Background Diabetic neuropathic osteoarthropathy (DNOAP) is a rare and easily missed complication for diabetes that leads to increased morbidity and mortality. DNOAP is characterized by progressive destruction of bone and joint, but its pathogenesis remains elusive. We herein aimed to investigate the pathological features and pathogenesis of the cartilages damage in DNOAP patients. Methods The articular cartilages of eight patients with DNOAP and eight normal controls were included. Masson staining and safranine O/fixed green staining (S-O) were used to observe the histopathological characteristics of cartilage. The ultrastructure and morphology of chondrocytes were detected by electron microscopy and toluidine blue staining. Chondrocytes were isolated from DNOAP group and control group. The expression of receptor activator of nuclear factor kappaB ligand (RANKL), osteoprotegerin (OPG), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and Aggrecan protein was evaluated by western blot. Reactive oxygen species (ROS) levels were measured using a 2',7'-dichlorofluorescin diacetate (DCFH-DA) probe. The percentage of apoptotic cells was determined by flow cytometry (FCM). The chondrocytes were cultured with different glucose concentrations to observe the expression of RANKL and OPG. Results Compared with the control group, the DNOAP group showed fewer chondrocytes, subchondral bone hyperplasia, and structural disorder, and a large number of osteoclasts formed in the subchondral bone area. Moreover, mitochondrial and endoplasmic reticulum swellings were observed in the DNOAP chondrocytes. The chromatin was partially broken and concentrated at the edge of nuclear membrane. The ROS fluorescence intensity of chondrocyte in DNOAP group was higher than that in normal control group (28.1 ± 2.3 vs. 11.9 ± 0.7; P < 0.05). The expression of RANKL, TNF-α, IL-1β, and IL-6 protein in DNOAP group was higher than that in normal control group, whereas OPG and Aggrecan protein were lower than that in normal control group (both P < 0.05). FCM showed that the apoptotic rate of chondrocyte in DNOAP group was higher than that in normal control group (P < 0.05). The RANKL/OPG ratio showed significant upward trend when the concentration of glucose was over than 15 mM. Conclusions DNOAP patients tend to have severe destruction of articular cartilage and collapse of organelle structure including mitochondrion and endoplasm reticulum. Indicators of bone metabolism (RANKL and OPG) and inflammatory cytokines (IL-1β, IL-6, and TNF-α) play an important role in promoting the pathogenesis of DNOAP. The glucose concentration higher than 15 mM made the RANKL/OPG ratio change rapidly.
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Affiliation(s)
- Pei-Long Liu
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an 710054, China
| | - Jia-Yu Diao
- Cardiovascular Department, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Qiong Wang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an 710054, China
| | - Huan Liu
- School of Public Health, Xi'an Jiaotong University, Xi'an 710086, China
| | - Yan Zhang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an 710054, China
| | - Jing-Qi Liang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an 710054, China
| | - Feng Zhang
- School of Public Health, Xi'an Jiaotong University, Xi'an 710086, China
| | - Xiao-Jun Liang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an 710054, China
| | - Hong-Mou Zhao
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an 710054, China
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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.
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Abstract
The Charcot diabetic foot presents unique challenges to the podiatric surgeon in the quest to salvage the limb. This disorder is an intersection of prototypical metabolic diseases and neurodegenerative disorder. Furthermore, it can be considered a disease of bone and ligaments that is often complicated by peripheral vascular disease and serious deep infection. Presently, simplistic ablative surgical procedures and the brace-makers art, still have a valid place in treating this disorder. Newer methods of surgical reconstruction are rapidly evolving to address distorted and nonfunctional limb. This article seeks to evidence the principles and practice of beaming the Charcot midfoot. As will be presented, the beam is a load-sharing device, which can be surgically introduced in an intramedullary method to restore architecture and strength to the Charcot foot. Problems with beam failure and migration have resulted in unsatisfactory outcomes as will be discussed. New Charcot-specific beams are currently reaching the podiatric surgeon with hopes of improving durability. In this article, we aim to address the surgical art of the beam, the engineering principles of beaming, and the novel introduction of a truss/tie rod configuration of beaming.
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Affiliation(s)
- William Grant
- Tidewater Foot and Ankle, 760 Independence Boulevard, Virginia Beach, VA 23455, USA.
| | - Lisa Grant-McDonald
- Tidewater Foot and Ankle, 760 Independence Boulevard, Virginia Beach, VA 23455, USA
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4
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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.
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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
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5
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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.
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Affiliation(s)
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, U.K
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6
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Rabe OC, Winther-Jensen M, Allin KH, Svendsen OL. Fractures and Osteoporosis in Patients With Diabetes With Charcot Foot. Diabetes Care 2021; 44:2033-2038. [PMID: 34315699 DOI: 10.2337/dc21-0369] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/09/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Charcot foot is a serious complication of diabetes, with degeneration of the bones and joints in the foot and ankle. It is unknown whether patients with diabetes with a Charcot foot have an increased risk of osteoporosis and fractures. The aim of this study was to investigate whether patients with diabetes with a Charcot foot have an increased risk of fracture and/or osteoporosis compared with patients with diabetes without Charcot foot. RESEARCH DESIGN AND METHODS A Danish register-based, nationwide population-based matched cohort study was conducted. During 1995-2018, we identified 1,602 patients with diabetes with Charcot foot and matched them on sex and date of diagnosis of diabetes with 16,296 patients with diabetes without Charcot foot. We used logistic regression to estimate odds ratios (ORs) with 95% CIs for fracture and osteoporosis. Information about exposure, outcome, and comorbidities was retrieved from the Danish National Patient Register. RESULTS Diabetes patients with Charcot foot had higher risk of fractures compared with those without Charcot foot (i.e., ORs for any fracture, lower-leg fracture, foot fracture, and osteoporotic fracture were 1.8 [95% CI 1.6-2.0], 2.4 [2.0-2.8], 2.9 [2.6-3.3], and 1.3 [1.1-1.4], respectively). Furthermore, patients with diabetes with Charcot foot had higher risk of osteoporosis compared with the patients without Charcot foot, with an OR of 1.3 (95% CI 1.1-1.5). CONCLUSIONS Patients with diabetes with a Charcot foot have an increased risk of fractures and osteoporosis compared with patients with diabetes without a Charcot foot.
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Affiliation(s)
- Oliver Christian Rabe
- Department of Endocrinology, Copenhagen Diabetes Foot Center (CODIF), Copenhagen, Denmark.,Bispebjerg Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matilde Winther-Jensen
- Bispebjerg Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Section for Data, Biostatistics, and Pharmacoepidemiology, Center for Clinical Research and Prevention, Frederiksberg, Denmark
| | - Kristine Højgaard Allin
- Bispebjerg Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Section for Data, Biostatistics, and Pharmacoepidemiology, Center for Clinical Research and Prevention, Frederiksberg, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Demark
| | - Ole Lander Svendsen
- Department of Endocrinology, Copenhagen Diabetes Foot Center (CODIF), Copenhagen, Denmark .,Bispebjerg Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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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.
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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
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8
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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.
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9
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de Vries TJ, El Bakkali I, Kamradt T, Schett G, Jansen IDC, D'Amelio P. What Are the Peripheral Blood Determinants for Increased Osteoclast Formation in the Various Inflammatory Diseases Associated With Bone Loss? Front Immunol 2019; 10:505. [PMID: 30941138 PMCID: PMC6434996 DOI: 10.3389/fimmu.2019.00505] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/25/2019] [Indexed: 01/18/2023] Open
Abstract
Local priming of osteoclast precursors (OCp) has long been considered the main and obvious pathway that takes place in the human body, where local bone lining cells and RANKL-expressing osteocytes may facilitate the differentiation of OCp. However, priming of OCp away from bone, such as in inflammatory tissues, as revealed in peripheral blood, may represent a second pathway, particularly relevant in individuals who suffer from systemic bone loss such as prevalent in inflammatory diseases. In this review, we used a systematic approach to review the literature on osteoclast formation in peripheral blood in patients with inflammatory diseases associated with bone loss. Only studies that compared inflammatory (bone) disease with healthy controls in the same study were included. Using this core collection, it becomes clear that experimental osteoclastogenesis using peripheral blood from patients with bone loss diseases in prevalent diseases such as rheumatoid arthritis, osteoporosis, periodontitis, and cancer-related osteopenia unequivocally point toward an intrinsically increased osteoclast formation and activation. In particular, such increased osteoclastogenesis already takes place without the addition of the classical osteoclastogenesis cytokines M-CSF and RANKL in vitro. We show that T-cells and monocytes as OCp are the minimal demands for such unstimulated osteoclast formation. In search for common and disease-specific denominators of the diseases with inflammation-driven bone loss, we demonstrate that altered T-cell activity and a different composition—such as the CD14+CD16+ vs. CD14+CD16– monocytes—and priming of OCp with increased M-CSF, RANKL, and TNF- α levels in peripheral blood play a role in increased osteoclast formation and activity. Future research will likely uncover the barcodes of the OCp in the various inflammatory diseases associated with bone loss.
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Affiliation(s)
- Teun J de Vries
- Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ismail El Bakkali
- Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Thomas Kamradt
- Institute of Immunology, Universitätsklinikum Jena, Jena, Germany
| | - Georg Schett
- Department of Internal Medicine III, Friedrich-Alexander University Erlangen-Nürnberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | - Ineke D C Jansen
- Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Patrizia D'Amelio
- Gerontology and Bone Metabolic Diseases Division, Department of Medical Science, University of Turin, Turin, Italy
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10
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Pitocco D, Scavone G, Di Leo M, Vitiello R, Rizzi A, Tartaglione L, Costantini F, Flex A, Galli M, Caputo S, Ghirlanda G, Pontecorvi A. Charcot Neuroarthropathy: From the Laboratory to the Bedside. Curr Diabetes Rev 2019; 16:62-72. [PMID: 31057120 DOI: 10.2174/1573399815666190502121945] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/26/2019] [Accepted: 04/17/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The diabetic Charcot foot syndrome is a serious and potentially limbthreatening lower-extremity complication of diabetes. INTRODUCTION The present review provides a concise account of the advances made over the last twentyfive years in understanding the pathogenesis and management of Charcot neuroarthropathy (CN). METHODS In this study, the widely known pathogenetic mechanisms underpinning CN are brought into focus, particularly the role of RANKL/RANK/OPG system and advanced glycation end production in the pathogenesis of CN. Furthermore, other potential triggering factors, namely nitric oxide, endothelial dysfunction, macro calcifications and body weight that influence CN have also been discussed. RESULTS The wide range of diagnostic tools available to clinicians for accurate staging of this pathology has been examined, particularly radiological and nuclear medicine imaging. Additionally, the difficult differential diagnosis between osteomyelitis and CN is also elucidated. CONCLUSION The review concludes with the comprehensive summary of the major promising therapeutic strategies, including conservative treatment involving orthopedic devices, pharmacological approach, and the most common surgical techniques currently employed in the diagnosis and treatment of this acute disease.
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Affiliation(s)
- Dario Pitocco
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Scavone
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Di Leo
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele Vitiello
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Rizzi
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Linda Tartaglione
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Federica Costantini
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Flex
- Institute of Internal Medicine, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Galli
- Institute of Orthopedic Surgery, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Caputo
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Ghirlanda
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Pontecorvi
- Diabetes Care Unit, Institute of Endocrinology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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11
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Khan A, Petropoulos IN, Ponirakis G, Menzies RA, Chidiac O, Pasquier J, Abi Khalil C, Talal TK, Malik RA. Corneal confocal microscopy detects severe small fiber neuropathy in diabetic patients with Charcot neuroarthropathy. J Diabetes Investig 2018; 9:1167-1172. [PMID: 29380548 PMCID: PMC6123035 DOI: 10.1111/jdi.12806] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/18/2018] [Accepted: 01/21/2018] [Indexed: 01/10/2023] Open
Abstract
AIMS/INTRODUCTION The aim of the present study was to identify the extent of small fiber neuropathy in diabetic patients with Charcot neuroarthropathy (CN). MATERIALS AND METHODS A total of 20 patients with CN were compared with 20 age- and diabetes duration-matched patients with type 2 diabetes and 20 age-matched control participants. All patients underwent corneal confocal microscopy with quantification of corneal nerve morphology and assessment for vibration perception threshold, and a subset of patients with CN underwent assessment of sudomotor function and neuropathic pain. RESULTS In patients with CN compared with type 2 diabetes patients and control participants, there was a significant reduction in corneal nerve fiber density (14.94 ± 8.23 vs 23.86 ± 7.71, P = 0.004 vs 34.84 ± 9.13, P < 0.001), corneal nerve branch density (18.61 ± 16.7 vs 41.62 ± 22.67, P = 0.032 vs 76.47 ± 38.44, P < 0.001) and corneal nerve fiber length (8.40 ± 4.83 vs 14.87 ± 4.76, P = 0.001 vs 21.24 ± 6.48, P < 0.001), electrochemical skin conductance on the feet (20.57 ± 13.99 vs 61.50 ± 22.26, P < 0.001 vs 76.23 ± 12.01, P < 0.001) and hands (30.86 ± 18.10 vs 61.13 ± 19.14, P = 0.001 vs 68.31 ± 11.96, P < 0.001), and a significant increase in the vibration perception threshold in the feet (38.46 ± 15.10 vs 14.15 ± 10.25, P < 0.001 vs 7.75 ± 4.01, P < 0.001). CONCLUSIONS Patients with diabetes and CN have severe large and particularly small fiber neuropathy.
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Affiliation(s)
- Adnan Khan
- Weill Cornell Medicine‐QatarEducation CityQatar FoundationDohaQatar
| | | | | | | | - Omar Chidiac
- Weill Cornell Medicine‐QatarEducation CityQatar FoundationDohaQatar
| | | | | | | | - Rayaz A Malik
- Weill Cornell Medicine‐QatarEducation CityQatar FoundationDohaQatar
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12
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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.
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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
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13
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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.
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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
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Herlyn A, Prakasam RK, Peschel S, Allgeier S, Köhler B, Winter K, Guthoff RF, Mittlmeier T, Stachs O. Corneal Subbasal Nerve Plexus Changes in Severe Diabetic Charcot Foot Deformity: A Pilot Study in Search for a DNOAP Biomarker. J Diabetes Res 2018; 2018:5910639. [PMID: 30525053 PMCID: PMC6247393 DOI: 10.1155/2018/5910639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/31/2018] [Accepted: 09/26/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Diabetic neuroosteoarthropathy (DNOAP) early symptoms are unspecific, mimicking general infectious symptoms and rendering a diagnosis challenging. Consequently, unfavourable outcomes occur frequently, with recurrent foot ulceration, infectious complications, and eventually amputation. Corneal confocal microscopy (CCM) of the subbasal nerve plexus (SNP) is used to detect early peripheral neuropathy in diabetic patients without diabetic retinopathy. This pilot study was designed to determine if specific SNP changes manifest in severe DNOAP in comparison to a healthy control group. METHODS This pilot study utilized a matched-pair analysis to investigate SNP changes by in vivo CCM for 26 patients (mean patient age 63.7 years, range 27 to 78) with severe DNOAP defined by condition after the need for reconstructive foot surgery (n = 13) and a healthy control group (n = 13). Corneal nerve fibre length (CNFL), nerve fibre density (CNFD), nerve branch density (CNBD), average weighted corneal nerve fibre thickness (CNFTh), nerve connecting points (CNCP), and average weighted corneal nerve fibre tortuosity (CNFTo) were assessed as well as the general clinical status, diabetic status, and ophthalmologic basic criteria. RESULTS In vivo CCM revealed significantly reduced SNP parameters in the DNOAP group for CNFL (p = 0.010), CNFD (p = 0.037), CNBD (p = 0.049), and CNCP (p = 0.012) when compared to the healthy control group. Six patients (46%) of the DNOAP group suffered from diabetic retinopathy and none of the control group. CONCLUSIONS This pilot study revealed a rarefication of SNP in all measured parameters in patients with severe DNOAP. We see a potential value of CCM providing a SNP-based biomarker for early stages of DNOAP prior to the development of any foot deformities that needs to be evaluated in further studies. This trial is registered with German Clinical Trials Register (DKRS) DRKS00007537.
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Affiliation(s)
- Anica Herlyn
- Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Ruby Kala Prakasam
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
| | - Sabine Peschel
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
| | - Stephan Allgeier
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Bernd Köhler
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Karsten Winter
- Institute of Anatomy, University of Leipzig, Liebigstrasse 13, 04103 Leipzig, Germany
| | - Rudolf F. Guthoff
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Oliver Stachs
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
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15
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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.
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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.
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Trieb K. The Charcot foot: pathophysiology, diagnosis and classification. Bone Joint J 2017; 98-B:1155-9. [PMID: 27587513 DOI: 10.1302/0301-620x.98b9.37038] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 04/12/2016] [Indexed: 12/15/2022]
Abstract
Neuropathic changes in the foot are common with a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy is often delayed in diabetic patients with harmful consequences including amputation. The appropriate diagnosis and treatment can avoid an extensive programme of treatment with significant morbidity for the patient, high costs and delayed surgery. The pathogenesis of a Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels. In most cases, changes are due to a combination of both pathophysiological factors. The Charcot foot is triggered by a combination of mechanical, vascular and biological factors which can lead to late diagnosis and incorrect treatment and eventually to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. The clinical diagnostic pathways based on different classifications are presented. Cite this article: Bone Joint J 2016;98-B:1155-9.
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Affiliation(s)
- K Trieb
- Klinikum Wels-Grieskirchen, Grieskirchnerstr. 42, Wels, 4600, Austria
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Abstract
Diabetic neuropathies (DNs) are one of the most prevalent chronic complications of diabetes and a major cause of disability, high mortality, and poor quality of life. Given the complex anatomy of the peripheral nervous system and types of fiber dysfunction, DNs have a wide spectrum of clinical manifestations. The treatment of DNs continues to be challenging, likely due to the complex pathogenesis that involves an array of systemic and cellular imbalances in glucose and lipids metabolism. These lead to the activation of various biochemical pathways, including increased oxidative/nitrosative stress, activation of the polyol and protein kinase C pathways, activation of polyADP ribosylation, and activation of genes involved in neuronal damage, cyclooxygenase-2 activation, endothelial dysfunction, altered Na(+)/K(+)-ATPase pump function, impaired C-peptide-related signaling pathways, endoplasmic reticulum stress, and low-grade inflammation. This review summarizes current evidence regarding the role of low-grade inflammation as a potential therapeutic target for DNs.
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Affiliation(s)
- Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Metabolism Endocrinology and Diabetes, University of Michigan, 5329 Brehm Tower, 1000 Wall Street, Ann Arbor, MI, 48105, USA.
| | - Lynn Ang
- Department of Internal Medicine, Division of Metabolism, Metabolism Endocrinology and Diabetes, University of Michigan, 5329 Brehm Tower, 1000 Wall Street, Ann Arbor, MI, 48105, USA.
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, Dominos Farms, Lobby C, Suite 1300 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI, 48106-0451, USA.
| | - Katherine Gallagher
- Department of Surgery, Section of Vascular Surgery, University of Michigan Health System, 1500 East Medical Center Dr, SPC 5867, Ann Arbor, MI, 48109, USA.
| | - Eva L Feldman
- Department of Neurology, University of Michigan, 5017 AATBSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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Holmes C, Schmidt B, Munson M, Wrobel JS. Charcot stage 0: A review and consideratons for making the correct diagnosis early. Clin Diabetes Endocrinol 2015; 1:18. [PMID: 28702236 PMCID: PMC5471964 DOI: 10.1186/s40842-015-0018-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/19/2015] [Indexed: 01/28/2023] Open
Abstract
Charcot neuropathic osteoarthropathy (CN) is a rare disease (NIDDK, NIH Summary Report Charcot Workshop, 2008) that causes significant morbidity and mortality for affected patients. The disease can result in severe deformities of the foot and ankle that contribute to the development of ulcerations and amputations. Medical advances have failed to find ways to stop the progression of the disease. However, it is known that early detection of the CN has a substantial impact on patient outcomes. CN in the earliest stage is very difficult to recognize and differentiate from other similar presenting diseases. We intend to outline clinical considerations practitioners can use when evaluating a patient with early stage suspected CN.
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Affiliation(s)
- Crystal Holmes
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
| | - Brian Schmidt
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
| | - Michael Munson
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
| | - James S. Wrobel
- The Department of Internal Medicine, The University of Michigan Medical School, Metabolism, Endocrinology & Diabetes, Domino’s Farms, Lobby C, Suite 1300, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106-0451 USA
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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.
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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
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21
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Petrova NL, Shanahan CM. Neuropathy and the vascular-bone axis in diabetes: lessons from Charcot osteoarthropathy. Osteoporos Int 2014; 25:1197-207. [PMID: 24091593 DOI: 10.1007/s00198-013-2511-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/09/2013] [Indexed: 10/26/2022]
Abstract
Emerging evidence from the last two decades has shown that vascular calcification (VC) is a regulated, cell-mediated process orchestrated by vascular smooth muscle cells (VSMCs) and that this process bears many similarities to bone mineralization. While many of the mechanisms driving VSMC calcification have been well established, it remains unclear what factors in specific disease states act to promote vascular calcification and in parallel, bone loss. Diabetes is a condition most commonly associated with VC and bone abnormalities. In this review, we describe how factors associated with the diabetic milieu impact on VSMCs, focusing on the role of oxidative stress, inflammation, impairment of the advanced glycation end product (AGE)/receptor for AGE system and, importantly, diabetic neuropathy. We also explore the link between bone and VC in diabetes with a specific emphasis on the receptor activator of nuclear factor κβ ligand/osteoprotegerin system. Finally, we describe what insights can be gleaned from studying Charcot osteoarthropathy, a rare complication of diabetic neuropathy, in which the occurrence of VC is frequent and where bone lysis is extreme.
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Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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22
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Munson ME, Wrobel JS, Holmes CM, Hanauer DA. Data mining for identifying novel associations and temporal relationships with Charcot foot. J Diabetes Res 2014; 2014:214353. [PMID: 24868558 PMCID: PMC4020407 DOI: 10.1155/2014/214353] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/28/2014] [Accepted: 03/28/2014] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION. Charcot foot is a rare and devastating complication of diabetes. While some risk factors are known, debate continues regarding etiology. Elucidating other associated disorders and their temporal occurrence could lead to a better understanding of its pathogenesis. We applied a large data mining approach to Charcot foot for elucidating novel associations. METHODS. We conducted an association analysis using ICD-9 diagnosis codes for every patient in our health system (n = 1.6 million with 41.2 million time-stamped ICD-9 codes). For the current analysis, we focused on the 388 patients with Charcot foot (ICD-9 713.5). RESULTS. We found 710 associations, 676 (95.2%) of which had a P value for the association less than 1.0 × 10⁻⁵ and 603 (84.9%) of which had an odds ratio > 5.0. There were 111 (15.6%) associations with a significant temporal relationship (P < 1.0 × 10⁻³). The three novel associations with the strongest temporal component were cardiac dysrhythmia, pulmonary eosinophilia, and volume depletion disorder. CONCLUSION. We identified novel associations with Charcot foot in the context of pathogenesis models that include neurotrophic, neurovascular, and microtraumatic factors mediated through inflammatory cytokines. Future work should focus on confirmatory analyses. These novel areas of investigation could lead to prevention or earlier diagnosis.
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Affiliation(s)
- Michael E. Munson
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Lobby C, Suite 1300, Ann Arbor, MI 48106, USA
- *Michael E. Munson:
| | - James S. Wrobel
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Lobby C, Suite 1300, Ann Arbor, MI 48106, USA
| | - Crystal M. Holmes
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Lobby C, Suite 1300, Ann Arbor, MI 48106, USA
| | - David A. Hanauer
- Department of Pediatrics, University of Michigan Medical School, 5312 CC, SPC 5940, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
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Game F, Selby N, McIntyre C. Chronic Kidney Disease and the Foot in Diabetes - Is Inflammation the Missing Link. ACTA ACUST UNITED AC 2013; 123:36-40. [DOI: 10.1159/000351813] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/01/2013] [Indexed: 11/19/2022]
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