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Argyropoulos M, Wynell-Mayow W, Johnson O, Faroug R, Johal KS, Deol RS, Hakmi A, Mordecai S. Charcot neuro-osteoarthropathy: a review of key concepts and an evidence-based surgical management algorithm. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2024; 5:1344359. [PMID: 39219847 PMCID: PMC11362032 DOI: 10.3389/fcdhc.2024.1344359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 07/17/2024] [Indexed: 09/04/2024]
Abstract
Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.
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Affiliation(s)
| | - William Wynell-Mayow
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
- Imperial College Healthcare NHS Trust, Faculty of Medicine, Imperial College London, Stevenage, United Kingdom
| | - Oscar Johnson
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Radwane Faroug
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | | | | | - Atef Hakmi
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Simon Mordecai
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
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2
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Bouman CMB, Mens MA, Wellenberg RHH, Streekstra GJ, Bus SA, Busch-Westbroek TE, Nieuwdorp M, Maas M. Assessment of bone marrow edema on dual-energy CT scans in people with diabetes mellitus and suspected Charcot neuro-osteoarthropathy. Skeletal Radiol 2024:10.1007/s00256-024-04714-3. [PMID: 38833168 DOI: 10.1007/s00256-024-04714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVE This study aimed to quantitatively assess the diagnostic value of bone marrow edema (BME) detection on virtual non-calcium (VNCa) images calculated from dual-energy CT (DECT) in people with diabetes mellitus and suspected Charcot neuro-osteoarthropathy (CN). MATERIALS AND METHODS People with diabetes mellitus and suspected CN who underwent DECT of the feet (80kVp/Sn150kVp) were included retrospectively. Two blinded observers independently measured CT values on VNCa images using circular regions of interest in five locations in the midfoot (cuneiforms, cuboid and navicular) and the calcaneus of the contralateral or (if one foot was available) the ipsilateral foot. Two clinical groups were formed, one with active CN and one without active CN (no-CN), based on the clinical diagnosis. RESULTS Thirty-two people with diabetes mellitus and suspected CN were included. Eleven had clinically active CN. The mean CT value in the midfoot was significantly higher in the CN group (-55.6 ± 18.7 HU) compared to the no-CN group (-94.4 ± 23.5 HU; p < 0.001). In the CN group, the difference in CT value between the midfoot and calcaneus was statistically significant (p = 0.003); this was not the case in the no-CN group (p = 0.357). The overall observer agreement was good for the midfoot (ICC = 0.804) and moderate for the calcaneus (ICC = 0.712). Sensitivity was 100.0% and specificity was 71.4% using a cutoff value of -87.6 HU. CONCLUSION The detection of BME on VNCa images has a potential value in people with diabetes mellitus and suspected active CN.
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Affiliation(s)
- Carlijn M B Bouman
- Amsterdam UMC, Radiology and Nuclear Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - Marieke A Mens
- Amsterdam UMC, Radiology and Nuclear Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands.
| | - Ruud H H Wellenberg
- Amsterdam UMC, Radiology and Nuclear Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - Geert J Streekstra
- Amsterdam UMC, Radiology and Nuclear Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Biomedical Engineering and Physics, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - Sicco A Bus
- Amsterdam UMC, Location University of Amsterdam, Rehabilitation Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - Tessa E Busch-Westbroek
- Amsterdam UMC, Location University of Amsterdam, Rehabilitation Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Amsterdam UMC, Internal and Vascular Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- Amsterdam UMC, Radiology and Nuclear Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
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Kress GT, Swerdlow M, Shin L. Lepromatous Leprosy and Charcot Neuroarthropathy of Insensate Feet: A Case Report. Cureus 2024; 16:e61362. [PMID: 38947585 PMCID: PMC11214381 DOI: 10.7759/cureus.61362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2024] [Indexed: 07/02/2024] Open
Abstract
Leprosy is a chronic infection of the skin, eyes, and peripheral nerves due to the slow-growing, acid-fast bacillus Mycobacterium leprae. Devastating complications include Charcot neuroarthropathy and insensate hands and feet. We present the case of an 81-year-old female with rheumatoid arthritis and 50 years of polar lepromatous leprosy who suffered from bilateral collapsed arches, flat feet, and bone deformities of Charcot feet.
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Affiliation(s)
- Gavin T Kress
- Vascular Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Mark Swerdlow
- Vascular Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Laura Shin
- Vascular Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
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Rogero RG, Swamy S, Bettin CC. The Differentiation Between Infection and Acute Charcot. Orthop Clin North Am 2024; 55:299-309. [PMID: 38403375 DOI: 10.1016/j.ocl.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.
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Affiliation(s)
- Ryan G Rogero
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA
| | - Samhita Swamy
- University of Tennessee Health Science Center College of Medicine, 847 E Parkway S, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA.
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Mauricio D, Gratacòs M, Franch-Nadal J. Diabetic microvascular disease in non-classical beds: the hidden impact beyond the retina, the kidney, and the peripheral nerves. Cardiovasc Diabetol 2023; 22:314. [PMID: 37968679 PMCID: PMC10652502 DOI: 10.1186/s12933-023-02056-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023] Open
Abstract
Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.
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Affiliation(s)
- Dídac Mauricio
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain.
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, IR Sant Pau, Barcelona, Spain.
- Department of Medicine, University of Vic - Central University of Catalonia, Vic, Spain.
| | - Mònica Gratacòs
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
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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
Charcot can be a difficult clinical entity to diagnose in the acute phase, and clinicians should have a high clinical suspicion in neuropathic patients who present with erythema, edema, and warmth of the foot or ankle. Immobilization and nonweight-bearing should be immediately initiated when the diagnosis of Charcot has been made and patients should remain nonweight-bearing until the affected bones/joints have coalesced. Educating patients and managing expectations is crucial to improve compliance with the conservative treatment of Charcot and avoid the long-term sequelae including severe deformity, ulceration and infection, and amputation.
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Affiliation(s)
- Mallory Schweitzer
- Multicare Podiatry Associates, 315 M.L.K Jr. Way, Tacoma, WA 98405, USA.
| | - Stephen Rockhill
- Franciscan Foot and Ankle Institute, 34509 9th Avenue South, Federal Way, WA 98003, USA
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Abstract
There are many similarities between nondiabetic and diabetic Charcot neuroarthropathy (CN) but many of the underlying causes causing nondiabetic neuropathy and CN are associated with poor bone quality. Patient workup for nondiabetic CN should include the underlying cause of the neuropathy and optimization of bony healing, such as vitamin D supplementation and bisphosphonate or calcitonin administration. Surgical reconstruction should include the most robust fixation possible, as nondiabetic patients with CN are more prone to delayed union.
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Prevalence of Vitamin D Deficiency in Patients With Charcot Arthropathy: A Single-Center Analysis. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202210000-00007. [PMID: 36734652 PMCID: PMC9592263 DOI: 10.5435/jaaosglobal-d-22-00162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/14/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Vitamin D deficiency may be a potentially modifiable risk factor in patients with orthopaedic conditions including Charcot arthropathy. The purpose of this study was to determine the prevalence of vitamin D deficiency and insufficiency in patients with Charcot arthropathy. METHODS All patients with Charcot arthropathy seen in our foot and ankle surgery clinic from January 2017 through June 2021 were screened for serum 25-hydroxyvitamin D levels. Patients were categorized as sufficient, insufficient, or deficient based on previously accepted guidelines. The prevalence of vitamin D deficiency and insufficiency was calculated. RESULTS A total of 57 subjects were included in this study after meeting the inclusion criteria. Of these, 27 (47.4%) were found to be deficient in vitamin D, 21 (36.8%) were insufficient in vitamin D, and 9 (15.8%) were sufficient in vitamin D. Overall, 84.2% of the cohort was found to be either insufficient or deficient in vitamin D. CONCLUSION Vitamin D insufficiency and deficiency is highly prevalent in patients with Charcot arthropathy. As such, it is possible that this may play a role in the pathogenesis of Charcot arthropathy and may represent a potentially modifiable risk factor that could be optimized during the management of patients with Charcot arthropathy.
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Hester T, Kavarthapu V. Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy. Foot Ankle Clin 2022; 27:583-594. [PMID: 36096553 DOI: 10.1016/j.fcl.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.
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Affiliation(s)
- Thomas Hester
- Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Venu Kavarthapu
- Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Pilot study for treatment of symptomatic shoulder arthritis utilizing cooled radiofrequency ablation: a novel technique. Skeletal Radiol 2022; 51:1563-1570. [PMID: 35029737 DOI: 10.1007/s00256-022-03993-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/08/2022] [Accepted: 01/09/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To introduce cooled radiofrequency nerve ablation (C-RFA) as an alternative to managing symptomatically moderate to severe glenohumeral osteoarthritis (OA) in patients who have failed other conservative treatments and who are not surgical candidates or refuse surgery. MATERIAL AND METHODS This prospective pilot study includes a total of 12 patients experiencing chronic shoulder pain from moderate to severe glenohumeral OA. Patients underwent anesthetic blocks of the axillary, lateral pectoral, and suprascapular nerves to determine candidacy for C-RFA treatment. Adequate response after anesthetic block was over 50% immediate pain relief. Once patients were deemed candidates, they underwent C-RFA of the three nerves 2-3 weeks later. Treatment response was evaluated using the clinically validated American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) to assess pain, stiffness, and functional activities of daily living. Follow-up outcome scores were collected up to 6 months after C-RFA procedure. RESULTS Twelve patients underwent C-RFA procedure for shoulder OA. VAS scores significantly improved from 8.8 ± 0.6 to 2.2 ± 0.4 6 months after the C-RFA treatment (p < 0.001). Patient's ASES score results significantly improved in total ASES from 17.2 ± 6.6 to 65.7 ± 5.9 (p < 0.0005). No major complications arose. No patients received re-treatment or underwent shoulder arthroplasty. CONCLUSION Image-guided axillary, lateral pectoral, and suprascapular nerve C-RFA has minimal complications and is a promising alternative to treat chronic shoulder pain and stiffness from glenohumeral arthritis.
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Muacevic A, Adler JR. Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing. Cureus 2022; 14:e28036. [PMID: 36120283 PMCID: PMC9473675 DOI: 10.7759/cureus.28036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 01/26/2023] Open
Abstract
Introduction The treatment for severe fixed hindfoot osteoarthritis secondary to Charcot-Marie-Tooth disease (CMT) is tibiotalocalcaneal (TTC) arthrodesis. In our centre, we have noticed a disproportionate rate of periprosthetic fractures in CMT patients following TTC arthrodesis with retrograde hindfoot nailing. The aim of this study was to test this hypothesis by evaluating our local cohort of TTC arthrodesis with retrograde hindfoot nailing. Methods A retrospective review of patients who had TTC arthrodesis with intramedullary nailing was conducted over a seven-year period. Results There were 45 patients (30 male, 15 female) in our cohort. Forty-one patients achieved radiological and clinical fusion of their TTC arthrodesis. All three patients who had CMT sustained periprosthetic fracture at the tip of the nail at an average of four (range: 2.5-6) months from index operation. In comparison, no patients in the rest of the cohort sustained periprosthetic fractures. The nail position of the patients with CMT was central in both planes in all three patients. None of the patients with CMT had abutment of the cortex on either plane. Conclusion We found that there was a disproportionate rate of periprosthetic fractures in CMT patients in our cohort of TTC arthrodesis with retrograde hindfoot nailing. This suggests that CMT is a significant risk factor. The authors propose a longer nail to reduce the lever arm, with a long period of protected weight bearing till union, followed by consideration of elective removal of the nail to prevent this phenomenon from occurring.
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Alternative treatment of hip pain from advanced hip osteoarthritis utilizing cooled radiofrequency ablation: single institution pilot study. Skeletal Radiol 2022; 51:1047-1054. [PMID: 34609519 DOI: 10.1007/s00256-021-03927-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To establish the effectiveness of cooled radiofrequency ablation in managing hip pain from osteoarthritis at 6 months after receiving treatment in patients who failed conservative treatments and are not surgical candidates due to comorbidities or unwillingness to undergo arthroplasty surgery by targeting the femoral and obturator branches and assessing the degree of hip pain relief and change of function. MATERIALS AND METHODS This prospective pilot study includes a total of 11 consecutive patients experiencing persistent chronic hip pain in the setting of advanced osteoarthritis. Patients initially underwent anesthetic blocks of the obturator and femoral nerve branches to determine cooled radiofrequency ablation candidacy. After adequate response to the anesthetic blocks (> 50% immediate pain relief), patients were subjected to the procedures 2-3 weeks later. Treatment response was evaluated utilizing clinically validated questionnaires and visual analog score in order to assess impact on pain severity, stiffness, and functional activities of daily living. Follow-up outcome scores were collected up to 6 months after cooled radiofrequency ablation procedure. RESULTS A total of 11 hips were treated consecutively between August 2019 and March 2020 (mean patient age 61.4 years; 8 M:3F). The mean total HOOS score improved significantly from baseline at 17.0 ± 6.0 to 52.9 ± 5.4 at a mean of 6.2 months after treatment (p < 0.0001), with significant improvement in mean pain score from 16.1 ± 6.6 to 53.4 ± 7.4 (p < 0.0001) and mean stiffness score from 15.0 ± 8.1 to 53.6 ± 11.0 (p < 0.0001). No major complications were encountered. No patients went on to re-treatment, surgery, or other intervention. CONCLUSION Image-guided obturator and femoral nerve cooled radiofrequency ablation is effective and safe in treating chronic hip pain/stiffness in the setting of advanced osteoarthritis.
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Role of Autonomous Neuropathy in Diabetic Bone Regeneration. Cells 2022; 11:cells11040612. [PMID: 35203263 PMCID: PMC8870009 DOI: 10.3390/cells11040612] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 01/11/2023] Open
Abstract
Diabetes mellitus has multiple negative effects on regenerative processes, especially on wound and fracture healing. Despite the well-known negative effects of diabetes on the autonomous nervous system, only little is known about the role in bone regeneration within this context. Subsequently, we investigated diabetic bone regeneration in db−/db− mice with a special emphasis on the sympathetic nervous system of the bone in a monocortical tibia defect model. Moreover, the effect of pharmacological sympathectomy via administration of 6-OHDA was evaluated in C57Bl6 wildtype mice. Diabetic animals as well as wildtype mice received a treatment of BRL37344, a β3-adrenergic agonist. Bones of animals were examined via µCT, aniline-blue and Masson–Goldner staining for new bone formation, TRAP staining for bone turnover and immunoflourescence staining against tyrosinhydroxylase and stromal cell-derived factor 1 (SDF-1). Sympathectomized wildtype mice showed a significantly decreased bone regeneration, just comparable to db−/db− mice. New bone formation of BRL37344 treated db−/db− and sympathectomized wildtype mice was markedly improved in histology and µCT. Immunoflourescence stainings revealed significantly increased SDF-1 due to BRL37344 treatment in diabetic animals and sympathectomized wildtypes. This study depicts the important role of the sympathetic nervous system for bone regenerative processes using the clinical example of diabetes mellitus type 2. In order to improve and gain further insights into diabetic fracture healing, β3-agonist BRL37344 proved to be a potent treatment option, restoring impaired diabetic bone regeneration.
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Shazadeh Safavi K, Janney C, Shazadeh Safavi P, Kunzler D, Jupiter D, Panchbhavi V. Inappropriate antibiotic administration in the setting of Charcot arthropathy: A case series and literature review. Prim Care Diabetes 2022; 16:202-206. [PMID: 34893452 DOI: 10.1016/j.pcd.2021.11.009] [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: 06/22/2021] [Revised: 11/15/2021] [Accepted: 11/28/2021] [Indexed: 11/20/2022]
Abstract
AIMS Differentiating Charcot neuropathic osteoarthropathy (CN) from infection is challenging. The diagnosis of CN is often missed or delayed, resulting in inappropriate and delayed treatment. We hypothesized that the misdiagnosis of CN results in inappropriate antibiotic prescriptions and explore the sequelae of unnecessary antibiotic use. METHODS A retrospective review of patient electronic medical records from January 2010 to December 2017 was conducted for those diagnosed with CN after being referred to an orthopaedic foot and ankle specialist. RESULTS Our review showed 58 of 103 (56%) patients received antibiotics on the date, or within the next 7 days, of referral to foot and ankle orthopaedic specialist. The antibiotic of choice given on referral were as follows: Sulfamethoxazole/Trimethoprim 18 of 58 (31%), doxycycline 13 of 58 (22%), clindamycin 13 of 58 (22%), cephalexin 9 of 58 (16%), minocycline 5 of 58 (9%). CONCLUSION Missed diagnoses for CN are common and result in complications stemming from inappropriate treatment, delays in appropriate therapy, and may accelerate antibiotic resistance. Misdiagnosis of CN contributes to the inappropriate use of prescription antibiotics.
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Affiliation(s)
- Kiya Shazadeh Safavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States.
| | - Cory Janney
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States; Naval Medical Center San Diego, San Diego, CA 91941, United States
| | | | - Daniel Kunzler
- Department of Orthopaedic Surgery Baylor Scott & White, Temple, TX 76502, United States
| | - Daniel Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Vinod Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, United States
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Stauch CM, Fanburg-Smith JC, Walley KC, King JL, Murie B, Kim M, Koroneos Z, Waning D, Elfar JC, Aynardi MC. Animal model detects early pathologic changes of Charcot neuropathic arthropathy. Ann Diagn Pathol 2022; 56:151878. [PMID: 34953234 DOI: 10.1016/j.anndiagpath.2021.151878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/01/2022]
Abstract
Charcot neuropathic arthropathy is a degenerative, debilitating disease that affects the foot and ankle in patients with diabetes and peripheral neuropathy, often resulting in destruction, amputation. Proposed etiologies include neurotraumatic, inflammatory, and neurovascular. There has been no previous animal model for Charcot. This study proposes a novel rodent model of induced neuropathic arthropathy to understand the earliest progressive pathologic changes of human Charcot. High-fat-diet-induced obese (DIO) Wild-type C57BL/6J mice (n = 8, diabetic) and age-matched low-fat-diet controls (n = 6) were run on an inclined high-intensity treadmill protocol four times per week for 7 weeks to induce mechanical neurotrauma to the hind-paw, creating Charcot neuropathic arthropathy. Sensory function and radiologic correlation were assessed; animals were sacrificed to evaluate hindpaw soft tissue and joint pathology. With this model, Charcot-DIO mice reveals early pathologic features of Charcot neuropathic arthropathy, a distinctive subchondral microfracture callus, perichondral/subchondral osseous hypertrophy/osteosclerosis, that precedes fragmentation/destruction observed in human surgical pathology specimens. There is intraneural vacuolar-myxoid change and arteriolosclerosis. The DIO mice demonstrated significant hot plate sensory neuropathy compared (P < 0.01), radiographic collapse of the longitudinal arch in DIO mice (P < 0.001), and diminished bone density in DIO, compared with normal controls. Despite exercise, high-fat-DIO mice increased body weight and percentage of body fat (P < 0.001). This murine model of diet-induced obesity and peripheral neuropathy, combined with repetitive mechanical trauma, simulates the earliest changes observed in human Charcot neuropathic arthropathy, of vasculopathic-neuropathic etiology. An understanding of early pathophysiology may assist early diagnosis and intervention and reduce patient morbidity and mortality in Charcot neuropathic arthropathy.
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Affiliation(s)
- Christopher M Stauch
- Penn State College of Medicine, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - Julie C Fanburg-Smith
- Penn State College of Medicine, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Pathology, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Pediatrics, Milton S. Hershey Medical Center in Hershey, PA, United States of America.
| | - Kempland C Walley
- Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - Jesse L King
- Penn State College of Medicine, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - Benjamin Murie
- Department of Pathology, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - Morgan Kim
- Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - Zachary Koroneos
- Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - David Waning
- Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - John C Elfar
- Penn State College of Medicine, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
| | - Michael C Aynardi
- Penn State College of Medicine, Milton S. Hershey Medical Center in Hershey, PA, United States of America; Department of Orthopedics, Milton S. Hershey Medical Center in Hershey, PA, United States of America
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17
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Patel S, Baker L, Perez J, Vulcano E, Kaplan J, Aiyer A. Risk factors for nonunion following tibiotalocalcaneal arthrodesis: A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:7-13. [PMID: 33685828 DOI: 10.1016/j.fas.2021.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The goal of this study is to review the literature to identify risk factors for nonunion after tibiotalocalcaneal arthrodesis (TTCA) and stratify them based on strength of evidence. METHODS Five databases were searched from inception to May 17th, 2020. Abstracts and full-text articles were screened for those that included risk factors predictive of nonunion following TTCA. RESULTS Eight studies involving 624 patients were included and 33 potential risk factors for nonunion were identified. Strong evidence supported prior peripheral neuropathic conditions as risk factors for nonunion following surgery (OR: 2.86, 95% CI: 1.56-5.23). CONCLUSION TTCA is an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior peripheral neuropathic conditions have strong evidence for failure to achieve union. Surgeons should be cognizant of these risks when performing TTCA and carefully monitor patients with the aforementioned comorbidity to achieve successful results.
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Affiliation(s)
- Sumit Patel
- Department of Orthopaedics at Miller School of Medicine, University of Miami, Miami, FL, United States.
| | - Lauren Baker
- Department of Orthopaedics at Miller School of Medicine, University of Miami, Miami, FL, United States.
| | - Jose Perez
- Department of Orthopaedics at Miller School of Medicine, University of Miami, Miami, FL, United States.
| | - Ettore Vulcano
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai, New York City, NY, United States.
| | | | - Amiethab Aiyer
- Department of Orthopaedics at Miller School of Medicine, University of Miami, Miami, FL, United States.
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18
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Bilello J, Jupiter DC. A Pilot Survey: Knowledge of Charcot Neuroarthropathy Among Family and Internal Medicine Practitioners. J Foot Ankle Surg 2021; 60:1204-1206. [PMID: 34148799 DOI: 10.1053/j.jfas.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy secondary to diabetes mellitus is a serious complication, requiring specialist management. As a relatively rare pathology bearing similarity to other, more common diseases, it may be misdiagnosed at initial presentation, potentially leading to delays in appropriate management. We conducted a 2-part online survey of primary care physicians within an academic medical institution to assess knowledge of presentation, complications, diagnosis, and treatment of Charcot neuropathy. The first section was designed to assess physician knowledge of Charcot foot, while the second section was completed only by physicians who were familiar with the condition and was designed to gauge their level of knowledge. Most clinicians were familiar with Charcot, encountering it at least annually. They identified common signs of Charcot (eg, swelling, pain) and complications due to its mismanagement (eg, ulcer, amputation). However, there was some disagreement on how to diagnose the pathology, with some relying on film, others referring to specialists, and some saying they were unsure. There was uncertainty on when to choose surgical options; fewer than half referred to specialists for help with this decision, and a quarter were unsure how to make the decision. While, in general, clinicians were aware of Charcot and its characteristics, there was confusion regarding how to diagnose or appropriate nonsurgical treatment.
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Affiliation(s)
- Joshua Bilello
- Medical Student, School of Medicine, The University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX.
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19
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Cates NK, Wagler EC, Bunka TJ, Elmarsafi T, Tefera E, Kim PJ, Liu GT, Evans KK, Steinberg JS, Attinger CE. Charcot Reconstruction: Outcomes in Patients With and Without Diabetes. J Foot Ankle Surg 2021; 59:1229-1233. [PMID: 32921562 DOI: 10.1053/j.jfas.2020.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/12/2020] [Accepted: 05/21/2020] [Indexed: 02/03/2023]
Abstract
The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.
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Affiliation(s)
- Nicole K Cates
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Emily C Wagler
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Taylor J Bunka
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Tammer Elmarsafi
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington DC
| | - Paul J Kim
- Attending Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - George T Liu
- Attending Physician, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Karen K Evans
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - John S Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC.
| | - Christopher E Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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20
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Tsuihiji K, Daniel BW, Kageyama T, Sakai H, Fuse Y, Tsukuura R, Yamamoto T. Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: A case report and literature review. Microsurgery 2021; 41:473-479. [PMID: 33595121 DOI: 10.1002/micr.30724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 01/06/2021] [Accepted: 02/05/2021] [Indexed: 11/07/2022]
Abstract
Charcot foot is can result in bone deformities and soft tissue defects. We report a case of alcohol-induced Charcot (AIC) foot with soft tissue defect including the weight-bearing zone of the heel and osteomyelitis, which was successfully reconstructed with free tensor fascia lata true-perforator flap (TFLtp). A 56-year-old male suffered from AIC foot with an 18 × 6 cm defect. Based on the preoperative ultrasound, we identified the overlying upper thigh area offering one of the thickest dermis. A TFLtp flap was raised sparing the TFL muscle based on one perforator without including the main trunk of the transverse/ascending branch of the lateral femoral circumflex vessel. The TFLtp flap was transferred to the heel and anastomosed to the posterior tibial artery in an end-to-side fashion. The patient complained no postoperative discomfort of the donor site and was able to walk on his foot after 5 weeks. This case report highlights that the TFLtp flap may offer thick dermis, faster surgery due to perforator level dissection and a concealed donor site.
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Affiliation(s)
- Kanako Tsuihiji
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Bassem W Daniel
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takashi Kageyama
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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21
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Rogers R, Dhatariya KK. Bilateral Charcot Neuroarthropathy in Pregnancy: A Case Report and Review of the Influence of Pregnancy Hormones on Ligament Laxity. AACE Clin Case Rep 2021; 7:57-60. [PMID: 33851021 PMCID: PMC7924155 DOI: 10.1016/j.aace.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To describe the case of a woman with long-standing poorly controlled type 1 diabetes mellitus who developed bilateral Charcot foot while pregnant. To the best of our knowledge, this is the first reported case of this condition in pregnancy. METHODS We performed a retrospective review of physical paper medical records; electronically held laboratory results, including glycated hemoglobin; and imaging reports, including plain radiographs and magnetic resonance imaging. RESULTS The Charcot feet were treated by standard offloading in total-contact casts or below-knee removable walking boots. As 1 side resolved, the patient was stepped down into normal footwear on one side and a below-knee walking boot on the other. A review of the literature suggests that the increase in ligamentous laxity associated with a rise in circulating hormones, such as relaxin, increases the risk of developing Charcot neuroarthropathy. CONCLUSION Bilateral concurrent Charcot neuroarthropathic foot is uncommon, and to our knowledge, this is the first reported case in pregnancy. We present a possible explanation for why there is an increased risk for the development of Charcot neuroarthropathy in pregnancy.
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Affiliation(s)
- Rebecca Rogers
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, United Kingdom
| | - Ketan K. Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, United Kingdom
- Norwich Medicine School, University of East Anglia, Norwich, Norfolk, United Kingdom
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22
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Multidisciplinary Approach for the Management and Treatment of Diabetic Foot Infections with a Resorbable, Gentamicin-Loaded Bone Graft Substitute. J Clin Med 2020; 9:jcm9113586. [PMID: 33172111 PMCID: PMC7694758 DOI: 10.3390/jcm9113586] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022] Open
Abstract
Diabetic patients are at increased risk of developing foot ulcers which may cause bone infections associated with a high probability of both amputation and mortality. Therefore, prompt diagnosis and adequate treatment are of key importance. In our Diabetic Foot Unit, effective multidisciplinary treatment of osteomyelitis secondary to diabetes involves the application of a gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute to fill residual bone voids after debridement. The data of all patients treated with the gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute for diabetic foot infections with ulcer formation and osteomyelitis at metatarsals, calcaneus and hindfoot at our institute from July 2013 to September 2016 were retrospectively collected and evaluated. A total of 35 patients were included in this retrospective single-arm case series and were either continuously followed up for at least one year or until healing was confirmed. Nineteen lesions affected the distal row of tarsus/talus, ten the calcaneus and a further six were located at the metatarsals. While all of the metatarsal lesions had healed at 1-year follow-up, the healing rate in the hindfoot region was lower with 62.5% at the calcaneus and 72.2% at the distal tarsus and talus at 12 months, respectively. The overall cure rate for ulcerous bone infection was 81.3%. In two calcaneal lesions (25%) and two lesions of distal tarsus/talus (11.1%) amputation was considered clinically necessary. Promising results were achieved in the treatment of diabetic foot infections with soft tissue ulcers by a multidisciplinary approach involving extensive debridement followed by adequate dead space management with a resorbable gentamicin-eluting bone graft substitute.
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23
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Cho JH, Min TH, Chun DI, Won SH, Park SY, Kim K, Yi Y. Bone Mineral Density in Diabetes Mellitus Foot Patients for Prediction of Diabetic Neuropathic Osteoarthropathic Fracture. J Bone Metab 2020; 27:207-215. [PMID: 32911585 PMCID: PMC7571244 DOI: 10.11005/jbm.2020.27.3.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Diabetic neuropathic osteoarthropathy (DNOAP) is known as debilitating diabetes complications. The aim of study is to compare bone mineral density (BMD) among diabetic foot and DNOAP, and investigate the impact of BMD proceeded from diabetic foot to DNOAP. METHODS A DNOAP group (subgroup A and subgroup B) and control group were examined for this study. Subgroup A (n=21) were patients diagnosed with DNOAP with the development of new foot and ankle fractures, whereas subgroup B (n=4) were patients being managed with the diabetic foot before a diagnosis of DNOAP. BMD was also evaluated before the diagnosis. Control group (n=30) was diabetic foot patients without DNOAP. The demographic data, clinical and radiologic data, comorbidities, and BMD were compared for each group. And optimal BMD score was reviewed to predict fractures in neuropathic arthropathy. RESULTS BMD was significantly lower in DNOAP group (group A and B) compared with control group. Also neuropathic arthropathy group showed poor radiological results. After comparisons of 2 group lumbar and femur BMD was significantly different, but logistic regression analysis revealed that low femur T-score could be risk predictors of the condition. Base on the data of group B and control group, the cut-off point for predicting foot and ankle fracture-related with DNOAP was -1.65 of femur BMD. CONCLUSIONS Low BMD shows greater incidence in foot and ankle fracture patients associated with neuropathic arthropathy. A femur T score can be a risk predictor of diabetic neuropathic arthropathy for diabetic foot patients.
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Affiliation(s)
- Jae-Ho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Korea
| | - Tae-Hong Min
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Dong-Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sung-Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Su Yeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kwonwoo Kim
- Department of Health Administration, Sejong Public Health Center, Sejong, Korea
| | - Young Yi
- Department of Orthopaedic Surgery, Seoul Foot and Ankle Center, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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24
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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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25
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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.
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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.
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26
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Unilateral Distal Extremity Swelling. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2019.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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27
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Buse AM, Mihai DA, Lupu L, Salmen T, Stegaru D, Radulian G. The Charcot Neuroarthropathy as Onset of Type 2 Diabetes - a Diagnostic Challenge. MAEDICA 2020; 15:122-125. [PMID: 32419872 PMCID: PMC7221283 DOI: 10.26574/maedica.2020.15.1.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Introduction: The Charcot neuro-osteoarthropathy is a devastating complication of diabetes, with negative impact on both prognosis and quality of life. Moreover, the diagnostic is often missed or delayed. Case report: A 50 years old male patient with dyslipidemia, overweight and hypertension was referred to our Diabetes Department in the context of newly diagnosed diabetes (HbA1C=11.7%), four days after left hallux trans-metatarsal amputation and debridement of the dorsal collection, for wet gangrene of the left hallux, with dorsal extension. The diagnostic of diabetic neuro-osteoarthropathy of the left foot was delayed several months. A good glycemic control was achieved with insulin glargine and metformin. We look further to introducing modern antidiabetic drugs with not only proven cardiovascular benefit but also good impact on weight. The patient needs to be managed by a multidisciplinary team, which has to include a podiatrist and a vascular surgeon. Conclusions: This case suggest the importance of rising diabetes and diabetic peripheral polyneuropathy awareness in all medical fields.
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Affiliation(s)
- Alexandru-Madalin Buse
- "N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Doina-Andrada Mihai
- "N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Leonard Lupu
- "N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Teodor Salmen
- "N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Daniela Stegaru
- "N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Gabriela Radulian
- "N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
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28
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Sun S, Diggins NH, Gunderson ZJ, Fehrenbacher JC, White FA, Kacena MA. No pain, no gain? The effects of pain-promoting neuropeptides and neurotrophins on fracture healing. Bone 2020; 131:115109. [PMID: 31715336 PMCID: PMC6934100 DOI: 10.1016/j.bone.2019.115109] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 12/30/2022]
Abstract
Neuropeptides and neurotrophins are key regulators of peripheral nociceptive nerves and contribute to the induction, sensitization, and maintenance of pain. It is now known that these peptides also regulate non-neuronal tissues, including bone. Here, we review the effects of numerous neuropeptides and neurotrophins on fracture healing. The neuropeptides calcitonin-gene related peptide (CGRP), substance P (SP), vasoactive intestinal peptide (VIP), and pituitary adenylate cyclase-activating peptide (PACAP) have varying effects on osteoclastic and osteoblastic activity. Ultimately, CGRP and SP both accelerate fracture healing, while VIP and PACAP seem to negatively impact healing. Unlike the aforementioned neuropeptides, the neurotrophins nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) have more uniform effects. Both factors upregulate osteoblastic activity, osteoclastic activity, and, in vivo, stimulate osteogenesis to promote fracture healing. Future research will need to clarify the exact mechanism by which the neuropeptides and neurotrophins influence fracture healing. Specifically, understanding the optimal expression patterns for these proteins in the fracture healing process may lead to therapies that can maximize their bone-healing capabilities and minimize their pain-promoting effects. Finally, further examination of protein-sequestering antibodies and/or small molecule agonists and antagonists may lead to new therapies that can decrease the rate of delayed union/nonunion outcomes and fracture-associated pain.
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Affiliation(s)
- Seungyup Sun
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Nicklaus H Diggins
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Zachary J Gunderson
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Jill C Fehrenbacher
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, IN, USA
| | - Fletcher A White
- Department of Anesthesia, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA
| | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA.
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Taylor K, Bain SC. Foot deformity in a man with Type 2 diabetes. Diabet Med 2020; 37:157-158. [PMID: 30897242 DOI: 10.1111/dme.13950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2019] [Indexed: 11/27/2022]
Affiliation(s)
- K Taylor
- Abertawe Bro Morgannwg University Health Board, Singleton Hospital, Swansea, UK
| | - S C Bain
- Abertawe Bro Morgannwg University Health Board, Singleton Hospital, Swansea, UK
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New Concepts in the Management of Charcot Neuroarthropathy in Diabetes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:391-415. [PMID: 32124412 DOI: 10.1007/5584_2020_498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Charcot Neuroarthropathy (CN) is an uncommon, debilitating and often underdiagnosed complication of chronic diabetes mellitus though, it can also occur in other medical conditions resulting from nerve injury. Till date, the etiology of CN remains unknown, but enhanced osteoclastogenesis is believed to play a central role in the pathogenesis of CN, in the presence of neuropathy. CN compromises the overall health and quality of life. Delayed diagnosis can result in a severe deformity that can act as a gateway to ulceration, infection and in the worst case, can lead to limb loss. In an early stage of CN, immobilization with offloading plays a key role to a successful treatment. Medical therapies seem to have limited role in the treatment of CN.In case of severe deformity, proper footwear or bracing may help prevent further deterioration and development of an ulcer. In individuals with a concomitant ulcer with osteomyelitis, soft tissue infection and severe deformity, where conservative measures fall short, surgical intervention becomes the only choice of treatment. Early diagnosis and proper management at an early stage can help prevent the occurrence of CN and amputation.
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Davidson IU, Quinones DJ, Haines CM, Kilgore KL, Keith MW, Moore TA. A Rare Case of Cervical Charcot After Spinal Cord Injury: A Case Report. JBJS Case Connect 2019; 9:e0362. [PMID: 31789666 DOI: 10.2106/jbjs.cc.18.00362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE We present a rare case of cervical Charcot disease that was diagnosed in a paraplegic patient by loss of function caudal to the original level of spinal cord injury. Clinical imaging, diagnosis, differentials, and operative management are discussed. CONCLUSIONS Charcot disease of the cervical spine is rare and very difficult to diagnose in the paraplegic patient population. High clinical suspicion should be maintained in these patients who demonstrate any form of neurologic deterioration, mechanical instability, or change in spinal alignment. It is often necessary to rule out infection. Spinal decompression and surgical stabilization is the treatment of choice.
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Affiliation(s)
| | | | | | - Kevin L Kilgore
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
- Research Service, Louis Stokes VAMC, Cleveland, Ohio
| | - Michael W Keith
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Timothy A Moore
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
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Mitochondrial dysfunction is the cause of one of the earliest changes seen on magnetic resonance imaging in Charcot neuroarthopathy - Oedema of the small muscles in the foot. Med Hypotheses 2019; 134:109439. [PMID: 31644972 DOI: 10.1016/j.mehy.2019.109439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/17/2019] [Indexed: 12/20/2022]
Abstract
The hypothesis laid out in this thesis states that the early changes seen on an MR imaging in those with early Charcot neuroarthopathy may be due to mitochondrial dysfunction. In a Charcot foot, there is movement between bones. In an attempt to prevent this movement, the small muscles of the foot contract continuously when the foot is weight bearing. This contraction takes energy in the form of ATP. However, the reduction of glucose transport into the muscle cells due to insulin resistance / insufficiency, leads to reduction in the ATP producing capacity of the mitochondria. The ATP depletion affects the cell membrane gradient leading to mitochondrial and cellular swelling. These early cellular changes could then be picked up with MR imaging as muscle oedema.
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Abstract
PURPOSE OF REVIEW The goal of this review is to explore clinical associations between peripheral neuropathy and diabetic bone disease and to discuss how nerve dysfunction may contribute to dysregulation of bone metabolism, reduced bone quality, and fracture risk. RECENT FINDINGS Diabetic neuropathy can decrease peripheral sensation (sensory neuropathy), impair motor coordination (motor neuropathy), and increase postural hypotension (autonomic neuropathy). Together, this can impair overall balance and increase the risk for falls and fractures. In addition, the peripheral nervous system has the potential to regulate bone metabolism directly through the action of local neurotransmitters on bone cells and indirectly through neuroregulation of the skeletal vascular supply. This review critically evaluates existing evidence for diabetic peripheral neuropathy as a risk factor or direct actor on bone disease. In addition, we address therapeutic and experimental considerations to guide patient care and future research evaluating the emerging relationship between diabetic neuropathy and bone health.
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Affiliation(s)
- Alec T Beeve
- Department of Medicine, Division of Bone and Mineral Diseases, Washington University, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA
- Department of Biomedical Engineering, Washington University, 6201 Forsyth Blvd, Saint Louis, MO, 63105, USA
| | - Jennifer M Brazill
- Department of Medicine, Division of Bone and Mineral Diseases, Washington University, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA
| | - Erica L Scheller
- Department of Medicine, Division of Bone and Mineral Diseases, Washington University, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA.
- Department of Biomedical Engineering, Washington University, 6201 Forsyth Blvd, Saint Louis, MO, 63105, USA.
- Department of Cell Biology and Physiology, Washington University, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA.
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Dharmadas S, Kumar H, Pillay M, Jojo A, Pj T, Mangalanandan TS, Vivek L, Praveen VP, Bal A. Microscopic study of chronic charcot arthropathy foot bones contributes to understanding pathogenesis - A preliminary report. Histol Histopathol 2019; 35:443-448. [PMID: 31508805 DOI: 10.14670/hh-18-162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Charcot arthropathy (CA) is non-infective, chronic destructive condition affecting the pes architecture of long standing diabetic patients with neuropathy. Even though several theories have emerged to disclose its pathogenesis, inflammatory cytokine induced osteoclastogenesis stands as the chief culprit. Studies on micro-architecture of foot bones of acute stage CA patients, describes mainly destructive phase of bone remodelling. Increased osteoclast cell activity is reported in all studies communicated. No study has to the best of our knowledge detailed the microscopic structure of chronic stage CA foot bones. AIM To study the microscopic structure of foot bones in patients with chronic CA. MATERIALS AND METHODS Foot bones were collected from the feet of chronic CA patients (six in number) who underwent corrective foot surgery in the Department of Podiatric Surgery of a tertiary care hospital. Control samples were collected from the feet of age matched non-diabetic controls (2 in number). The samples were fixed in formalin, decalcified in 10% nitric acid, processed, sectioned and stained with haematoxylin and eosin. Histopathology and histomorphometry analysis were performed by two different pathologists. RESULTS Trabeculae of chronic CA foot bones exhibited mainly a lamellar architecture, with reduced number of osteocytes and plenty of empty lacunae. Trabecular connectivity was lost and trabeculae showed considerable thinning. Trabecular osteoids lined by active osteoblast cells was a remarkable observation. Bone area was also considerably reduced in chronic CA foot bones. CONCLUSION Chronic stage CA foot bones presented features of both healing and fragile bone. The compromised bone quality may be due to thin and fragmented trabecular structure and reduced cellularity.
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Affiliation(s)
- Salini Dharmadas
- Department of Anatomy, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Harish Kumar
- Department of Endocrinology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Minnie Pillay
- Department of Anatomy, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Annie Jojo
- Department of Pathology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India.
| | - T Pj
- Department of Pathology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kalamassery, Kochi, India.,Ernakulam Medical College, Kochi, India
| | - Thacho S Mangalanandan
- Department of Endocrinology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Lakshmanan Vivek
- Department of Endocrinology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Valiyaparambil P Praveen
- Department of Endocrinology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Arun Bal
- Department of Endocrinology, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India
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Tonge XN, Widnall JC, Jackson G, Platt S. A ten-year retrospective study investigating the rate of venous thromboembolism in patients who require immobilization in a total contact lower limb cast. Bone Joint J 2019; 101-B:691-694. [DOI: 10.1302/0301-620x.101b6.bjj-2018-1356.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population. Patients and Methods Patients treated with a lower limb cast between 2006 and 2018 were identified using plaster room records. Their electronic records and radiological reports were reviewed for details about their cast, past medical history, and any VTE recorded in our hospital within a year of casting. Results There were 136 episodes of casting in 100 patients. The mean age was 55 years (22 to 91). The mean time in a cast was 45 days (five days to eight months). A total of 76 patients had neuropathy secondary to diabetes. No patient received chemical thromboprophylaxis while in a cast. One VTE (0.7% of casting episodes) was documented. This was confirmed by Doppler scan nine days after removing the cast. Conclusion The frequency of VTE was higher than that of the general population (0.05%); this is most likely attributable to our patients’ apparent increase in VTE risk as suggested by The National Institute for Health and Care Excellence (NICE). These findings suggest that thromboprophylaxis is not routinely indicated in patients who undergo immobilization of the lower limb in a cast, although the risks of VTE should be assessed. While the cast itself does not pose an increased risk, other pathologies, such as active cancer, mean that each individual case needs to be considered on their merit. Cite this article: Bone Joint J 2019;101-B:691–694.
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Affiliation(s)
- X. N. Tonge
- Wirral University Teaching Hospital, Upton, UK
| | | | - G. Jackson
- Wirral University Teaching Hospital, Upton, UK
| | - S. Platt
- Gold Coast University Hospital, Southport, Australia
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Anthony ML, Cravey KS, Atway SA. Development of Charcot Neuroarthropathy in Diabetic Patients who Received Kidney or Kidney-Pancreas Transplants. J Foot Ankle Surg 2019; 58:475-479. [PMID: 30765253 DOI: 10.1053/j.jfas.2018.09.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 02/03/2023]
Abstract
Only a small percentage of the general diabetic population develops Charcot neuroarthropathy. Charcot arthropathy greatly increases the risk of foot complications. At our academic institution, there appeared to be an increased incidence of Charcot arthropathy in transplant patients. We hypothesized that Charcot neuroarthropathy incidence is higher in the diabetic patients who had received kidney or kidney-pancreas transplants. The charts of 1000 patients were reviewed from January 2000 to January 2011. Four hundred and eighty-seven patients were included in the study. Of these diabetic patients, 249 had received a kidney transplant and 238 a kidney-pancreas transplant. The data were analyzed for the incidence of Charcot in each group. Other risk factors and sequelae were also evaluated and analyzed. The incidence of Charcot development in the diabetic patients who had a kidney-pancreas transplant was 18.4%, 44 of 238 patients. This was significantly higher than the incidence in kidney transplant patients, which was 11.2%, 28 of 249 patients (p < .05). Peripheral arterial disease was a statistically significant independent risk factor for developing ulceration, osteomyelitis, and subsequent amputation. Type 1 diabetic patients developed Charcot at a higher rate that was also statistically significant compared with type 2 diabetic patients. In our study, diabetic patients who had undergone kidney-pancreas transplants were associated with higher risk for development of Charcot neuroarthropathy than kidney transplants alone. The incidence of Charcot development in both these transplant groups was also much higher than in the general diabetic population. This is of particular interest to clinicians and surgeons as both transplant groups were found to be high risk for subsequent foot ulceration, infection, and amputation.
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Affiliation(s)
- Michael L Anthony
- Assistant Professor, Podiatric Medicine and Surgery Residency Program, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kimberly S Cravey
- Resident, Podiatric Medicine and Surgery Residency Program, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Said A Atway
- Assistant Professor, Podiatric Medicine and Surgery Residency Program, The Ohio State University Wexner Medical Center, Columbus, OH
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El Oraby HA, Abdelsalam MM, Eid YM, El Hilaly R, Marzouk HA. Bone Mineral Density in Type 2 Diabetes Patients with Charcot Arthropathy. Curr Diabetes Rev 2019; 15:395-401. [PMID: 29992889 DOI: 10.2174/1573399814666180711115845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 06/11/2018] [Accepted: 07/04/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Charcot arthropathy is one of the disabling diabetes complications. There are enigmatic areas concerning its underlying pathophysiology and risk predictors. Osteoporosis and local osteopenia have been postulated to have a role in Charcot arthropathy development, but it is still controversial. BACKGROUND The study aims to compare bone mineral density among type 2 diabetics with and without Charcot arthropathy. METHODS Two groups with type 2 diabetes participated in this study; Group I [30] patients with Charcot arthropathy while Group II [30] patients without charcot arthropathy. All patients underwent full clinical examination and complete history taking with special emphasis on foot problems. Laboratory investigations were done that included fasting blood sugar, postprandial blood sugar, glycosylated hemoglobin, serum calcium, serum phosphorus, and alkaline phosphatase. All patients underwent MRI for both feet and dual energy X-ray absorptiometry scan of the lumbar spine and femur. The demographic data, clinical data, the presence or absence of comorbidities and bone mineral density were compared for both groups. RESULT Bone mineral density was significantly lower in Group I than Group II with median lumber T score (-0.15, 1.99 p <0.001), median Femur T score (0.050, 2.400, p <0.001). Group I showed higher propensity for hypertension, neuropathy, micro-albuminuria with peripheral arterial disease (23.33 %) compared to Group II (p <0.001). Multiple logistic regression analysis revealed that female gender and low femur bone mineral density can be risk predictors of the condition. CONCLUSION Bone mineral density is lower in patients with Charcot arthropathy with female gender and Femur T score as risk predictors. Peripheral arterial disease shows greater incidence in Charcot patients than was previously reported.
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Affiliation(s)
- Hussein A El Oraby
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Mona M Abdelsalam
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Yara M Eid
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Rana El Hilaly
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Heba A Marzouk
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
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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
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Durgia H, Sahoo J, Kamalanathan S, Palui R, Sridharan K, Raj H. Role of bisphosphonates in the management of acute Charcot foot. World J Diabetes 2018; 9:115-126. [PMID: 30079147 PMCID: PMC6068741 DOI: 10.4239/wjd.v9.i7.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 06/14/2018] [Indexed: 02/05/2023] Open
Abstract
Diabetes mellitus is the most common cause of Charcot neuropathy affecting foot and ankle. Acute Charcot foot (CF) presents with a red and swollen foot in contrast to the painless deformed one of chronic CF. Enhanced osteoclastogenesis plays a central role in the pathogenesis of acute CF. Many studies have shown elevated levels of bone turnover markers in patients with acute CF confirming it. These findings have led clinicians to use anti-resorptive agents [bisphosphonates (BP), calcitonin, and denosumab] along with immobilization and offloading in acute CF patients. The maximum evidence among all anti-resorptive agents is available for BPs, although its quality is low. Pamidronate has been shown to reduce the markers of activity of CF like raised skin temperature, pain, edema, and bone turnover markers in the majority of studies. Intravenous BPs are known to cause acute phase reactions leading to flu-like illness following their first infusion, which can be ameliorated by oral acetaminophen. Alendronate is the only oral BP used in these patients. It needs to be taken on an empty stomach with a full glass of water to avoid esophagitis. The side-effects and contraindications to BPs should be kept in mind while treating acute CF patients with them.
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Affiliation(s)
- Harsh Durgia
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Jayaprakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Rajan Palui
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Kalyani Sridharan
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Henith Raj
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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Affiliation(s)
- Andrew Dodd
- Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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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.
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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
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Charcot arthropathy of the knee after unsuccessful spinal stenosis surgery: A case report. Int J Surg Case Rep 2017; 36:22-25. [PMID: 28511074 PMCID: PMC5440761 DOI: 10.1016/j.ijscr.2017.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/25/2017] [Accepted: 04/30/2017] [Indexed: 11/30/2022] Open
Abstract
We report here a case of a 62 years old patient with charcot arthropathy at her left knee developed one year after spinal stenosis surgery. The patient’s knee joint was already beyond the fragmentation and coalescence stages at the moment of physical examination. Unsuccessful spinal surgery affected polyneuropathy and migrated the level of the sensorineural loss proximally. Elevated level of sensorineural loss resulted in Charcot knee joint in a short period of time.
Introduction Charcot arthropathy was first described in 1868 by Jean Martin Charcot as a progressive and destructive joint disease. Diabetes, polyneuropathy, syphilis, syrengomyelia and chronic alcoholism are the main causes of the disease. In this study we present a Charcot arthropathy of the knee seen after unsuccessful spinal stenosis surgery. Presentation of case We report here a case of 62 years old patient with Charcot arthropathy at her left knee developed one year after spinal stenosis surgery. The patient’s knee joint was already beyond the fragmentation and coalescence stages at the moment of physical examination. Patient had already been treated for Charcot foot four years before spinal surgery. Because of an unsuccessful spinal surgery, proximal migration of the level of the sensorineural loss negatively affected the polyneuropathy and eventually resulted in Charcot knee joint in a short period of time. Discussion However, the etiology of the neuropathic arthropathy hasn’t been well described yet, it is usually seen at patients with diabetes mellitus as a long-term complication with or without polyneuropathy. In addition to the spinal canal pathologies, it is reported that Charcot arthropathy can be seen even after spinal anesthesia procedures. Conclusion In conclusion, spinal procedures should be applied with extra caution on the patients with polyneuropathy or any neuropathic arthropathy. It should be remembered that it is possible to encounter unexpected complications such as proximally migration of the level of sensorineural loss and progression of the actual disease after spinal procedures of these patients.
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Barwick A, Tessier J, Mirow J, de Jonge XJ, Chuter V. Computed tomography derived bone density measurement in the diabetic foot. J Foot Ankle Res 2017; 10:11. [PMID: 28270861 PMCID: PMC5335776 DOI: 10.1186/s13047-017-0192-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/27/2017] [Indexed: 11/19/2022] Open
Abstract
Background The accurate and reliable measurement of foot bone density is challenging and there is currently no gold standard technique. Such measurement is particularly valuable in populations at risk of foot bone pathology such as in those with long term diabetes. With research and development, computed tomography may prove to be a useful tool for this assessment. The aim of this study was to establish the reliability of a novel method of foot bone density measurement in people with diabetes using computed tomography. Methods Ten feet in people with diabetes were scanned with computed tomography twice with repositioning. Bone density (in Hounsfield units) was assessed in the trabecular and cortical bone in all tarsals and metatarsals. Reliability was assessed with intra-class correlation coefficients (95% confidence intervals), limits of agreement and standard error of measurement. Results The reliability of the trabecular density of most bones was excellent with intra-class correlation coefficients ranging from 0.68 to 0.91. Additionally, cortical bone density showed fair to good reliability at the talus (0.52), calcaneus (0.59), navicular (0.70), cuboid (0.69), intermediate cuneiform (0.46) and first metatarsal (0.61). Conclusions The study established the reliability of a practical method of assessing the trabecular and cortical foot bone density using computed tomography scanning. This methodology may be useful in the investigation of foot bone disease occurring in diabetes and its early diagnosis, intervention and assessment of treatment efficacy. Further development of this method is warranted. Electronic supplementary material The online version of this article (doi:10.1186/s13047-017-0192-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex Barwick
- University of Newcastle, 10 Chittaway Rd, Ourimbah, NSW 2258 Australia
| | - John Tessier
- University of Newcastle, University Dr, Callaghan, NSW 2308 Australia
| | - James Mirow
- Hunter Imaging Group, 48 Thomas Street, Cardiff, NSW 2285 Australia
| | | | - Vivienne Chuter
- University of Newcastle, 10 Chittaway Rd, Ourimbah, NSW 2258 Australia
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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: 41] [Impact Index Per Article: 5.9] [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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Płaza M, Nowakowska-Płaza A, Walentowska-Janowicz M, Chojnowski M, Sudoł-Szopińska I. Charcot arthropathy in ultrasound examination - a case report. J Ultrason 2016; 16:210-5. [PMID: 27446605 PMCID: PMC4954866 DOI: 10.15557/jou.2016.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/19/2015] [Accepted: 12/29/2015] [Indexed: 11/22/2022] Open
Abstract
This article presents a patient with a long history of type 1 diabetes mellitus complicated with neuropathy and Charcot disease. The most common cause of neuropathic osteoarthropathy, called Charcot osteoarthropathy, is poorly controlled diabetes. The clinical picture is characterized by considerable edema, redness and increased skin temperature with relatively slight pain due to injury to nerve fibers responsible for pain sensation. The differential diagnosis should include bacterial or autoimmune arthritis, arthritis associated with gout as well as venous thrombosis and injury. The contribution of a local inflammatory reaction and abnormal bone turnover with excessive osteoclast activity might play a role in the etiopathogenesis of this disease. As a result, osseous and articular destruction progresses rapidly leading to irreversible deformity of the foot. Avoiding weight-bearing and resting the foot in a specially selected plaster cast is the most important part of treatment. Patients with the aforementioned complaints are referred to radiologists for imaging examinations. An ultrasonographer should pay attention to changes typical of Charcot arthropathy, such as: inflammatory and destructive changes in joints of the foot, uneven contour of bones with thickening and periosteal hyperemia as well as soft tissue swelling.
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Affiliation(s)
- Mateusz Płaza
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Anna Nowakowska-Płaza
- Clinic of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marta Walentowska-Janowicz
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marek Chojnowski
- Department of Nuclear Medicine, Public Independent Central Teaching Hospital, Warsaw, Poland
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland; Department of Medical Imaging, Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
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Ettinger S, Plaass C, Claassen L, Stukenborg-Colsman C, Yao D, Daniilidis K. Surgical Management of Charcot Deformity for the Foot and Ankle-Radiologic Outcome After Internal/External Fixation. J Foot Ankle Surg 2016; 55:522-8. [PMID: 26898396 DOI: 10.1053/j.jfas.2015.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Indexed: 02/03/2023]
Abstract
Charcot neuropathy (CN) is a severe joint disease that makes surgical planning very challenging, because it is combined with ankle instability, serious deformities, and recurrent ulceration. The aim of the present study was to examine the rate of bone fusion after external or internal fixation in patients with CN. We retrospectively examined 58 patients with CN who had undergone reconstruction of the ankle either with tibiotalocalcaneal or tibiocalcaneal arthrodesis. The mean age was 59.1 (range 26 to 81) years at surgery. Of the 58 patients, 38 were treated using intramedullary nail arthrodesis and 19 using an external fixator (1 patient received neither). At a mean follow-up period of 31.3 (range 12 to 57) months, limb salvage and bone fusion had been achieved in 94.83%. The mean time to bone fusion was 12 (range 6 to 18) months. Three patients (5.2%) required a more proximal amputation. All but these 3 patients gained independent mobilization in custom feet orthoses or off the shelf orthoses. Of the 58 patients in the present cohort, 56 (96.6%) would undergo surgery again. In conclusion, internal and external fixation both lead to promising results in the treatment of CN. Internal fixation should be preferred when no indications of ulcer or infection are present.
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Affiliation(s)
- Sarah Ettinger
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany.
| | - Christian Plaass
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Leif Claassen
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | | | - Daiwei Yao
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Kiriakos Daniilidis
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
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Eschler A, Gradl G, Wussow A, Mittlmeier T. Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score. BMC Musculoskelet Disord 2015; 16:349. [PMID: 26573860 PMCID: PMC4647281 DOI: 10.1186/s12891-015-0809-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/07/2015] [Indexed: 01/30/2023] Open
Abstract
Background All diabetic neuroosteoarthropathy (Charcot arthropathy) treatment concepts are focused on a long-term infection-free, ulcer-free, and plantigrade sufficiently stable foot in order to avoid amputation. Reconstructive arthrodesis techniques for severe deformities are associated with high postoperative complication rates. This study reports a detailed complication analysis and provides a strategy that may help detect patients at risk for a complicated postoperative course. Methods The study comprised 43 feet in 37 patients with severe non-plantigrade or unstable Charcot deformity, Eichenholtz stages II/III (Sanders and Frykberg types II-V), who underwent reconstructive arthrodesis of the mid- and/or hindfoot. Patients were retrospectively enrolled 4.5 years postoperatively (range 1.8–11.2 years). All patients showed at least two out of five positive Pinzur high-risk criteria (immuno-compromising illnesses, large bone deformity, longstanding ulcer overlying infected bone, regional osteopenia, obesity). Follow-up included a detailed clinical analysis and radiologic assessment with emphasis on complication analysis and evaluation in accordance to the PEDIS classification system. Results Significantly lower overall complication rates, as well as re-operation, reulceration and amputation counts were found for patients with a cumulative PEDIS count below 7. For PEDIS single criteria, significantly lower overall complication rates were found for patients without signs of occlusive peripheral artery disease, an ulcer extent <0.9 cm2, ulcer depth including erosion and inflammation of the skin and subcutaneous tissues only. Soft-tissue complications affected 49 % of patients, hardware breakage 33 %, hardware loosening 19 %, non-union 18 % and amputation 21 %. Radiographs revealed a correct reconstruction and restoration of all foot axes postoperatively with partial recollapse at the lateral foot column; however, fixation strength for the medial column was maintained. Conclusions Internal corrective arthrodesis for patients within the deformed stages of Charcot deformity can provide adequate reconstruction, as assessed by intraoperative radiographic measures, that exhibit superior long-term stability for the medial column. Despite a high risk patient population, a favourable outcome in terms of overall complication, re-ulceration, and amputation rates for patients/feet with a cumulative PEDIS count below 7 was found. The cut-off value of 7 may aid clinical decision-making during preoperative planning for Charcot deformity.
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Affiliation(s)
- Anica Eschler
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057, Rostock, Germany.
| | - Georg Gradl
- Department of Trauma, Orthopedic and Reconstructive Surgery, Klinikum München Harlaching, Sanatoriumsplatz 2, D-81545, Munich, Germany.
| | - Annekatrin Wussow
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057, Rostock, Germany.
| | - Thomas Mittlmeier
- Department of Trauma, Orthopedic and Reconstructive Surgery, Klinikum München Harlaching, Sanatoriumsplatz 2, D-81545, Munich, Germany.
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Eschler A, Gradl G, Wussow A, Mittlmeier T. Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates. J Diabetes Res 2015; 2015:246792. [PMID: 26000309 PMCID: PMC4427061 DOI: 10.1155/2015/246792] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 04/02/2015] [Accepted: 04/09/2015] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates. MATERIALS/METHODS 21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis. RESULTS A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially. CONCLUSION Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.
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Affiliation(s)
- Anica Eschler
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
- *Anica Eschler:
| | - Georg Gradl
- Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Harlaching Clinic, Sanatoriumsplatz 2, 81545 Munich, Germany
| | - Annekatrin Wussow
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
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Siebachmeyer M, Boddu K, Bilal A, Hester TW, Hardwick T, Fox TP, Edmonds M, Kavarthapu V. Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint J 2015; 97-B:76-82. [DOI: 10.1302/0301-620x.97b1.34542] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2015;97-B:76–82.
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Affiliation(s)
- M. Siebachmeyer
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - K. Boddu
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - A. Bilal
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - T. W. Hester
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - T. Hardwick
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - T. P. Fox
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - M. Edmonds
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - V. Kavarthapu
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
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