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Tsatlidou M, Vasiliadis AV, Metaxiotis D. What the Physician Needs to Know about Charcot Arthropathy and Ankle Fracture Treatment Dilemma: A Case Report and a Possible Medical Approach and Treatment Algorithm. J Orthop Case Rep 2024; 14:45-51. [PMID: 38910990 PMCID: PMC11189088 DOI: 10.13107/jocr.2024.v14.i06.4498] [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] [Received: 03/17/2024] [Revised: 04/22/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Charcot arthropathy consists of a rapid and destructive complication of the joints following the loss of innervation caused by many complicated etiologies. Diabetic neuropathy has become the most common etiological factor. Case Report We present a case of a 64-year-old female patient with a history of chronic renal failure on hemodialysis, hypertension, hypothyroidism, and Type 2 diabetes, complicated with neuropathy and Charcot disease, who referred to our department. Initially, the patient was managed with a restraint orthotic device due to a bimalleolar ankle fracture. An unsuccessful treatment and the presence of a pressure ulcer with pus-like drainage on the lateral malleolus 2 months later led to the decision for a below-knee amputation. Conclusion High clinical suspicion by the attending physician may reduce the risk of complications and lead to proper treatment with better outcomes.
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Affiliation(s)
- Maria Tsatlidou
- nd Orthopaedic Department, General Hospital of Thessaloniki “Papageorgiou”, 56429 Thessaloniki, Greece
| | - Angelo V Vasiliadis
- nd Orthopaedic Department, General Hospital of Thessaloniki “Papageorgiou”, 56429 Thessaloniki, Greece
- Department of Orthopaedic Surgery and Sports Medicine, Croix-Rousse Hospital, 69002 Lyon, France
| | - Dimitrios Metaxiotis
- nd Orthopaedic Department, General Hospital of Thessaloniki “Papageorgiou”, 56429 Thessaloniki, Greece
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Greco T, Mascio A, Comisi C, Polichetti C, Caravelli S, Mosca M, Mondanelli N, Troiano E, Maccauro G, Perisano C. RANKL-RANK-OPG Pathway in Charcot Diabetic Foot: Pathophysiology and Clinical-Therapeutic Implications. Int J Mol Sci 2023; 24:ijms24033014. [PMID: 36769345 PMCID: PMC9917950 DOI: 10.3390/ijms24033014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
Charcot Foot (CF), part of a broader condition known as Charcot Neuro-Osteoarthropathy (CNO), is characterized by neuropathic arthropathy with a progressive alteration of the foot. CNO is one of the most devastating complications in patients with diabetes mellitus and peripheral neuropathy but can also be caused by neurological or infectious diseases. The pathogenesis is multifactorial; many studies have demonstrated the central role of inflammation and the Receptor Activator of NF-κB ligand (RANKL)-Receptor Activator of NF-κB (RANK)-Osteoprotegerin (OPG) pathway in the acute phase of the disease, resulting in the serum overexpression of RANKL. This overexpression and activation of this signal lead to increased osteoclast activity and osteolysis, which is a prelude to bone destruction. The aim of this narrative review is to analyze this signaling pathway in bone remodeling, and in CF in particular, to highlight its clinical aspects and possible therapeutic implications of targeting drugs at different levels of the pathway. Drugs that act at different levels in this pathway are anti-RANKL monoclonal antibodies (Denosumab), bisphosphonates (BP), and calcitonin. The literature review showed encouraging data on treatment with Denosumab, although in a few studies and in small sample sizes. In contrast, BPs have been re-evaluated in recent years in relation to the high possibility of side effects, while calcitonin has shown little efficacy on CNO.
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Affiliation(s)
- Tommaso Greco
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-3807-582-118
| | - Antonio Mascio
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Comisi
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Polichetti
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Silvio Caravelli
- U.O.C. II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Massimiliano Mosca
- U.O.C. II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Giulio Maccauro
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Carlo Perisano
- Orthopedics and Trauma Surgery Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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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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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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Gendaszewska-Darmach E, Garstka MA, Błażewska KM. Targeting Small GTPases and Their Prenylation in Diabetes Mellitus. J Med Chem 2021; 64:9677-9710. [PMID: 34236862 PMCID: PMC8389838 DOI: 10.1021/acs.jmedchem.1c00410] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
![]()
A fundamental role
of pancreatic β-cells to maintain proper
blood glucose level is controlled by the Ras superfamily of small
GTPases that undergo post-translational modifications, including prenylation.
This covalent attachment with either a farnesyl or a geranylgeranyl
group controls their localization, activity, and protein–protein
interactions. Small GTPases are critical in maintaining glucose homeostasis
acting in the pancreas and metabolically active tissues such as skeletal
muscles, liver, or adipocytes. Hyperglycemia-induced upregulation
of small GTPases suggests that inhibition of these pathways deserves
to be considered as a potential therapeutic approach in treating T2D.
This Perspective presents how inhibition of various points in the
mevalonate pathway might affect protein prenylation and functioning
of diabetes-affected tissues and contribute to chronic inflammation
involved in diabetes mellitus (T2D) development. We also demonstrate
the currently available molecular tools to decipher the mechanisms
linking the mevalonate pathway’s enzymes and GTPases with diabetes.
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Affiliation(s)
- Edyta Gendaszewska-Darmach
- Institute of Molecular and Industrial Biotechnology, Faculty of Biotechnology and Food Sciences, Lodz University of Technology, Stefanowskiego Street 4/10, 90-924 Łódź, Poland
| | - Malgorzata A Garstka
- Core Research Laboratory, Department of Endocrinology, Department of Tumor and Immunology, Precision Medical Institute, Western China Science and Technology Innovation Port, School of Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, DaMingGong, Jian Qiang Road, Wei Yang district, Xi'an 710016, China
| | - Katarzyna M Błażewska
- Institute of Organic Chemistry, Faculty of Chemistry, Lodz University of Technology, Żeromskiego Street 116, 90-924 Łódź, Poland
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Ochoa-Précoma R, Pacheco-Soto BT, Porchia LM, Torres-Rasgado E, Pérez-Fuentes R, Gonzalez-Mejia ME. Association between Osteoprotegerin and Charcot Neuroarthropathy: a systematic review. Acta Diabetol 2021; 58:475-484. [PMID: 33394132 DOI: 10.1007/s00592-020-01638-x] [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: 08/25/2020] [Accepted: 11/08/2020] [Indexed: 11/09/2022]
Abstract
AIMS Osteoprotegerin (OPG) has been associated with Charcot Neuroarthropathy (CN); however, three studied OPG polymorphisms (1181C > G, 245A > C and 950 T > C) have yielded conflicting results. Therefore, this meta-analysis was conducted to determine the difference in serum OPG concentrations between healthy controls and diabetics with and without CN and the effect OPG polymorphisms have on CN development. METHODS PubMed, LILAC, SCOPUS, and EBSCO databases and retrieved publications' bibliographies were searched for studies that examined for OPG and CN. Depending on the heterogeneity, fixed or random effects were used to calculate the pooled odds ratio (OR) or standard difference in means (SDM) with 95% confidence intervals (95%CI) for 5 genetic models (heterozygous, homozygous, dominant, recessive, and allelic) and serum concentrations, respectively. RESULTS Seven publications (12 studies) demonstrated that serum OPG concentrations were more elevated in subjects with CN (SDM = 0.719, 95%CI = 0.555-0.883, p < 0.001). When CN was compared to healthy controls or diabetics, the difference was more prominent for healthy controls (SDM = 1.043, 95%CI = 0.676-1.409, p < 0.001) than diabetics (SDM = 0.639, 95%CI = 0.456-0.821, p < 0.001) and the SDM difference was significant (p = 0.013). Using 6 publications (9 studies), neither the 1181C > G or the 950 T > C polymorphisms showed any significant associations for any genetic model. For the 245A > C polymorphism, only the homozygous genetic model showed a significant association between the polymorphism and CN (OR = 2.850, 95%CI: 1.051-7.729, p = 0.040). CONCLUSIONS Here, we determined a potential correlation between the CN and serum OPG concentrations and that only the CC genotype of the 245A > C polymorphism showed an increased risk of developing CN.
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Affiliation(s)
- Renata Ochoa-Précoma
- Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Calle 13 Sur 2901, Colonia Volcanes, 72420, Puebla, México
| | - Blanca T Pacheco-Soto
- Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Calle 13 Sur 2901, Colonia Volcanes, 72420, Puebla, México
| | - Leonardo M Porchia
- Laboratorio de Fisiopatología en Enfermedades Crónicas, Centro de Investigación Biomédica de Oriente, IMSS. Delegación Puebla. Carretera Federal Atlixco Metepec Km, 4.5, Colonia Centro, 74360, Atlixco, Puebla, México
| | - Enrique Torres-Rasgado
- Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Calle 13 Sur 2901, Colonia Volcanes, 72420, Puebla, México
| | - Ricardo Pérez-Fuentes
- Laboratorio de Fisiopatología en Enfermedades Crónicas, Centro de Investigación Biomédica de Oriente, IMSS. Delegación Puebla. Carretera Federal Atlixco Metepec Km, 4.5, Colonia Centro, 74360, Atlixco, Puebla, México
| | - M Elba Gonzalez-Mejia
- Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Calle 13 Sur 2901, Colonia Volcanes, 72420, Puebla, México.
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Pradana AS, Phatama KY, Utomo AS, Bimadi MH, Putera MA, Sukmajaya WP, Mustamsir E, Hidayat M. Union of Brodsky type 1/Eichenholtz stage III Charcot neuroarthropathy after forefoot arthrodesis. Int J Surg Case Rep 2020; 71:139-143. [PMID: 32446994 PMCID: PMC7256205 DOI: 10.1016/j.ijscr.2020.04.040] [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] [Received: 01/09/2020] [Revised: 04/10/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION One of the surgical intervention options for Charcot neuroarthropathy (CN) is arthrodesis. The arthrodesis procedure for the foot and ankle joint have been widely used in previous studies. This study aimed to evaluate the functional and radiological outcomes after arthrodesis procedure for the CN patient with Brodsky type 1/Eichenholtz stage III. PRESENTATION OF CASE A 49-years-old diabetic woman presented with alteration of her right foot's shape and a cracking sensation while walking in the last six months. Rocker-bottom deformity and a decreased sensation on the right foot were found, and the initial American Orthopaedic Foot & Ankle Society (AOFAS) score was 45. Subsequently, forefoot arthrodesis of the right foot was performed. DISCUSSION Several studies state that arthrodesis procedure is often used for CN management in order to achieve a plantigrade and stable foot. This study presents an improvement of the foot arch, AOFAS score, and union of the talus six months after surgery. CONCLUSION The arthrodesis procedure by using screws and Kirschner wire (K-wire) fixation is an effective method in CN management if the patient is compliant. This study showed a good result, anatomically restored the foot arch, and excellent radiological union, but different tools to analyze foot functional status and longer follow up period are needed for a better analysis.
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Affiliation(s)
- Ananto Satya Pradana
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia.
| | - Krisna Yuarno Phatama
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Adhi Satrio Utomo
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Muhammad Hilman Bimadi
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia.
| | - Marvin Anthony Putera
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - William Putera Sukmajaya
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Edi Mustamsir
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
| | - Mohamad Hidayat
- Department of Orthopaedics and Traumatology, Saiful Anwar Hospital-Brawijaya University, Malang, Indonesia
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Stoica SI, Tănase I, Ciobanu V, Onose G. Initial researches on neuro-functional status and evolution in chronic ethanol consumers with recent traumatic spinal cord injury. J Med Life 2019; 12:97-112. [PMID: 31406510 PMCID: PMC6685305 DOI: 10.25122/jml-2019-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/21/2019] [Indexed: 12/01/2022] Open
Abstract
We found differences related to the neuro-functional deficiency and clinical progress, among non-consumers and chronic consumers of ethanol, with recent traumatic spinal cord injury (SCI). We present a synthesis of related data on lesion mechanisms in post-traumatic myelogenous disorders, namely some of the alcohols and their actions on the nervous system, with details on the influences exerted, in such afflictions, by the chronic consumption of ethanol. The subject is not frequently approached - according to a literature review with systematic elements, which we have done before - thus constituting a niche that deserves to be further explored. The applicative component of the article highlights statistical data resulted from a retrospective study regarding the specialized casuistry from the Neuromuscular Recovery Clinic of the "Bagdasar Arseni" Emergency Clinical Hospital, following the comparative analysis of two groups of patients with recent SCI: non-consumers - the control group (n=780) - and chronic ethanol consumers - the study group (n=225) - with the addition of a prospective pilot component. Data processing has been achieved with SPSS 24. The American Spinal Injury Association Impairment Scale (AIS) mean motor scores differ significantly (tests: Mann-Whitney and t) between the control and study group in favor of the second, both at admission (p<0.001) and at discharge (p<0.001). AIS mean sensitive scores differ between the two lots, and also in favor of the study, but statistically significant only at discharge (p=0.048); the difference at admission is not significant (p=0.51) - possibly because of alcoholic-nutritional polyneuropathy. These findings, with numerous related details, later presented in the text, are surprising, which requires further studies and attempts of understanding.
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Affiliation(s)
- Simona Isabelle Stoica
- “Carol Davila” University of Medicine and Pharmacy (UMPCD), Bucharest, Romania
- Teaching Emergency Hospital “Bagdasar-Arseni” (TEHBA), Bucharest, Romania
| | - Ioana Tănase
- “Carol Davila” University of Medicine and Pharmacy (UMPCD), Bucharest, Romania
- Teaching Emergency Hospital “Bagdasar-Arseni” (TEHBA), Bucharest, Romania
| | - Vlad Ciobanu
- Politehnica University of Bucharest (PUB), Bucharest, Romania
| | - Gelu Onose
- “Carol Davila” University of Medicine and Pharmacy (UMPCD), Bucharest, Romania
- Teaching Emergency Hospital “Bagdasar-Arseni” (TEHBA), Bucharest, Romania
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