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Raspovic KM, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Wukich DK. Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3653. [PMID: 37179484 DOI: 10.1002/dmrr.3653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin. METHODS We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted. RESULTS We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission. CONCLUSIONS There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease.
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Affiliation(s)
- Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Wukich DK, Frykberg RG, Kavarthapu V. Charcot neuroarthropathy in persons with diabetes: It's time for a paradigm shift in our thinking. Diabetes Metab Res Rev 2024; 40:e3754. [PMID: 38069459 DOI: 10.1002/dmrr.3754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 03/13/2024]
Abstract
The aim of this paper is to review the recent literature regarding the epidemiology and surgical management of Charcot neuro-osteoarthropathy (CNO). We propose that a fundamental change in the approach and assumptions regarding the historical treatment of active CNO should be considered. Although the true incidence and prevalence of CNO in the US population with diabetes are not known, we estimated the incidence to be 27,602 per year and the prevalence to be 208,880 persons. In persons with diabetes, the incidence of CNO is higher than that of prostate, lung, kidney, and thyroid cancer, and in the entire US population, the incidence of CNO is higher than that of multiple myeloma, soft tissue sarcoma, and primary bone sarcoma. In persons with diabetes, the incidence of CNO is higher than fractures of the femoral shaft, distal femur, tibia, talus, calcaneus and Lisfranc ligament injuries. Surgical techniques have evolved over the past half century, and surgery is the standard for treating displaced fractures and intra-articular injuries. Since CNO is a fracture, dislocation, or fracture dislocation in patients with neuropathy, why do we treat CNO differently? Elsewhere in the skeleton displaced osseous and ligament injuries are treated surgically. Based on the information presented in this manuscript, we suggest that it is time for a paradigm shift in the treatment of persons with CNO. While uncommon, CNO in persons with diabetes is not rare. Given the advances in surgical techniques, surgical intervention should be considered earlier in persons with CNO who are at risk for developing deformity related foot ulceration.
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Affiliation(s)
- Dane K Wukich
- University of Texas Southwestern Orthopaedic Surgery, Dallas, Texas, USA
| | - Robert G Frykberg
- Podiatric Medicine, Midwestern University Glendale, Glendale, Arizona, USA
| | - Venu Kavarthapu
- Orthopaedic Surgeon - King's College Hospital, London, UK
- Orthopaedic Lead, King's Diabetic Foot Unit, London, UK
- University of Southern Denmark, Odense, Denmark
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Wukich DK, Schaper NC, Gooday C, Bal A, Bem R, Chhabra A, Hastings M, Holmes C, Petrova NL, Santini Araujo MG, Senneville E, Raspovic KM. Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023). Diabetes Metab Res Rev 2024; 40:e3646. [PMID: 37218537 DOI: 10.1002/dmrr.3646] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Arun Bal
- Secretary, International Association of Diabetic Foot Surgeons, Mumbai, India
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Crystal Holmes
- The Division of Metabolism, Endocrinology and Diabetes, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nina L Petrova
- Department of Diabetes, Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Sammarco VJ, Sammarco JA, Baratz ME, Sammarco GJ. Midfoot Fusion Using Superconstructs for the Charcot Foot: Current Techniques and Complications. Instr Course Lect 2024; 73:231-245. [PMID: 38090901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-
tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.
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Julien CA, Ha Van G, M'Bemba J, Bourgeon M, Dardari D, Lepeut M, Dumont I, Zemmache MZ, Serrand C, Bouillet B, Sultan A, Schuldiner S. Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic foot expert centers (The EPiChar Study). Acta Diabetol 2023; 60:1209-1218. [PMID: 37184671 DOI: 10.1007/s00592-023-02101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/09/2023] [Indexed: 05/16/2023]
Abstract
AIM To evaluate the real-life diagnosis and therapeutic means of Charcot Neuroosteoarthropathy (CN) in French-Belgian diabetic foot expert centers. METHODS We collected clinical characteristics, results of exams and therapeutic pathways of consecutive adult patients with diabetic osteoarthropathy seen in consultation or hospitalization from January 1 to December 31, 2019 in 31 diabetic foot expert centers. The primary outcome was to describe the diagnostic and management methods for CN according to patient clinical characteristics, the clinical-radiological characteristics of acute and chronic CN and discharge means. RESULTS 467 patients were included: 364 with chronic CN and 103 in the acute phase. 101 patients had bilateral chronic CN. Most patients were male (73.4%), treated with insulin (73.3%), and with multicomplicated diabetes. In the acute phase, edema and increased foot temperature were present in 75% and 58.3% of cases, respectively. Diagnosis confirmation was usually by MRI and the mode of discharge was variable. In the chronic phase, orthopedic shoes were prescribed in 81.5% of cases. CONCLUSIONS This observational study highlights the diagnostic and therapeutic practices in 31 diabetic foot centers. Our results highlight that the use of MRI and the modalities of offloading, an essential treatment in the acute phase, need to be better standardized. Centers were highly encouraging about creating a patient registry.
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Affiliation(s)
- Carole-Anne Julien
- Service des Maladies métaboliques et Endocriniennes, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Georges Ha Van
- Service de Diabétologie, AP-HP La Pitié Salpétrière, Paris, France
| | | | - Muriel Bourgeon
- Service Endocrinologie, AP-HP Kremlin Bicêtre, Kremlin Bicêtre, France
| | - Dured Dardari
- Service de Diabétologie, CH Sud Francilien, Corbeil-Essonnes, France
| | - Marc Lepeut
- Service de Diabétologie, CH Roubaix, Roubaix, France
| | | | - Mohammed Zakarya Zemmache
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Chris Serrand
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Benjamin Bouillet
- Service d'Endocrinologie, Diabétologie, Maladies Métaboliques, CHU Dijon, Dijon, France
| | - Ariane Sultan
- 10PhyMedExp, INSERM U1046, UMR 9214, Univ Montpellier, Service Des Maladies Métaboliques, CHU Montpellier, Montpellier, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service Des Maladies Métaboliques Et Endocriniennes, CHU Nîmes, Clinique du Pied Gard Occitanie, Route de Carnon, 30240, Le Grau du Roi, France.
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Waibel FWA, Weber S, Selman F, Götschi T, Berli MC, Böni T, Schöni M. No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy. Clin Orthop Relat Res 2023; 481:1560-1568. [PMID: 36692512 PMCID: PMC10344513 DOI: 10.1097/corr.0000000000002546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/15/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The cause of Charcot neuro-osteoarthropathy (CN) is diabetes in approximately 75% of patients. Most reports on the clinical course and complications of CN focus on diabetic CN, and reports on nondiabetic CN are scarce. No study, to our knowledge, has compared the clinical course of patients initially treated nonoperatively for diabetic and nondiabetic CN. QUESTIONS/PURPOSES Among patients with CN, are there differences between patients with diabetes and those without in terms of (1) the frequency of major amputation as ascertained by a competing risks survivorship estimator; (2) the frequency of surgery as ascertained by a competing risks survivorship estimator; (3) frequency of reactivation, as above; or (4) other complications (contralateral CN development or ulcers)? METHODS Between January 1, 2006, and December 31, 2018, we treated 199 patients for diabetic CN. Eleven percent (22 of 199) were lost before the minimum study follow-up of 2 years or had incomplete datasets and could not be analyzed, and another 9% (18 of 199) were excluded for other prespecified reasons, leaving 80% (159 of 199) for analysis in this retrospective study at a mean follow-up duration since diagnosis of 6 ± 4 years. During that period, we also treated 78 patients for nondiabetic Charcot arthropathy. Eighteen percent (14 of 78) were lost before the minimum study follow-up and another 5% (four of 78 patients) were excluded for other prespecified reasons, leaving 77% (60 of 78) of patients for analysis here at a mean of 5 ± 3 years. Patients with diabetic CN were younger (59 ± 11 years versus 68 ± 11 years; p < 0.01), more likely to smoke cigarettes (37% [59 of 159] versus 20% [12 of 60]; p = 0.02), and had longer follow-up (6 ± 4 years versus 5 ± 3 years; p = 0.02) than those with nondiabetic CN. Gender, BMI, overall renal failure, dialysis, and presence of peripheral arterial disease did not differ between the groups. Age difference and length of follow-up were not considered disqualifying problems because of the later onset of idiopathic neuropathy and longer available patient follow-up in patients with diabetes, because our program adheres to the follow-up recommendations suggested by the International Working Group on the Diabetic Foot. Treatment was the same in both groups and included serial total-contact casting and restricted weightbearing until CN had resolved. Then, patients subsequently transitioned to orthopaedic footwear. CN reactivation was defined as clinical signs of the recurrence of CN activity and confirmation on MRI. Group-specific risks of the frequencies of major amputation, surgery, and CN reactivation were calculated, accounting for competing events. Group comparisons and confounder analyses were conducted on these data with a Cox regression analysis. Other complications (contralateral CN development and ulcers) are described descriptively to avoid pooling of complications with varying severity, which could be misleading. RESULTS The risk of major amputation (defined as an above-ankle amputation), estimated using a competing risks survivorship estimator, was not different between the diabetic CN group and nondiabetic CN group at 10 years (8.8% [95% confidence interval 4.2% to 15%] versus 6.9% [95% CI 0.9% to 22%]; p = 0.4) after controlling for potentially confounding variables such as smoking and peripheral artery disease. The risk of any surgery was no different between the groups as estimated by the survivorship function at 10 years (53% [95% CI 42% to 63%] versus 58% [95% CI 23% to 82%]; p = 0.3), with smoking (hazard ratio 2.4 [95% CI 1.6 to 3.6]) and peripheral artery disease (HR 2.2 [95% CI 1.4 to 3.4]) being associated with diabetic CN. Likewise, there was no between-group difference in CN reactivation at 10 years (16% [95% CI 9% to 23%] versus 11% [95% CI 4.5% to 22%]; p = 0.7) after controlling for potentially confounding variables such as smoking and peripheral artery disease. Contralateral CN occurred in 17% (27 of 159) of patients in the diabetic group and in 10% (six of 60) of those in the nondiabetic group. Ulcers occurred in 74% (117 of 159) of patients in the diabetic group and in 65% (39 of 60) of those in the nondiabetic group. CONCLUSION Irrespective of whether the etiology of CN is diabetic or nondiabetic, our results suggest that orthopaedic surgeons should use similar nonsurgical treatments, with total-contact casting until CN activity has resolved, and then proceed with orthopaedic footwear. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Felix W. A. Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Sabrina Weber
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Farah Selman
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopaedic Surgery, University of Zurich, Institute for Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
| | - Martin C. Berli
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Thomas Böni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
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Benard T, Lequint C, Jugnet AC, Bouly M, Winther T, Penfornis A, Dardari D. Delayed Diagnosis of Bilateral Neuroarthropathy: Serious Impact on the Development of Charcot's Foot, a Case Report. Medicina (Kaunas) 2022; 58:medicina58121763. [PMID: 36556964 PMCID: PMC9783763 DOI: 10.3390/medicina58121763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022]
Abstract
Charcot neuroarthropathy (CN) is a destructive complication of the joints in patients with diabetes and should be managed from the onset of the first symptoms to avoid joint deformity and the risk of amputating the affected joint. Here, we describe the case of a young 24-year-old patient living with type I diabetes who developed active bilateral CN in both tarsal joints. This case of neuroarthropathy was uncommon due to the bilateral presentation at the same level of the joint. Despite the patient consulting from the beginning of the symptoms, none of the physicians suspected or diagnosed CN, leading to a delay in management and the aggravation of bone destruction by CN. This highlights the importance of early management of CN with the need to refer people with suspected CN to specialised diabetic foot care centres.
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Affiliation(s)
- Tatiana Benard
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
| | - Corinne Lequint
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
| | - Anne Christine Jugnet
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
| | - Marie Bouly
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
| | - Thomas Winther
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
| | - Alfred Penfornis
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
- Paris-Sud Medical School, Paris-Saclay University, 91100 Corbeil-Essonnes, France
| | - Dured Dardari
- Centre Hopitalier Sud Francilien, Diabetology Department, 91100 Corbeil-Essonnes, France
- LBEPS, IRBA, Université d’Evry, Université Paris Saclay, 91025 Evry, France
- Correspondence: ; Tel.: +33-6-61-54-28-09
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8
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Jeffcoate W, Game F. The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm. Diabetes Care 2022; 45:1691-1697. [PMID: 35796768 DOI: 10.2337/dc21-2508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.
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Affiliation(s)
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, U.K
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Wukich DK, Raspovic KM, Jupiter DC, Heineman N, Ahn J, Johnson MJ, Liu GT, VanPelt MD, Lafontaine J, Lavery L, Kim P, Nakonezny PA. Amputation and infection are the greatest fears in patients with diabetes foot complications. J Diabetes Complications 2022; 36:108222. [PMID: 35717355 DOI: 10.1016/j.jdiacomp.2022.108222] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/30/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022]
Abstract
AIMS To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America.
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Daniel C Jupiter
- Department of Preventive Medicine and Population Health Office of Biostatistics, University of Texas Medical Branch Galveston, TX 77550, United States of America
| | - Nathan Heineman
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - George T Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Michael D VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Javier Lafontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Larry Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Paul Kim
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Paul A Nakonezny
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, United States of America
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10
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McGregor PC, Lyons MM, Pinzur MS. Quality of Life Improvement Following Reconstruction of Midtarsal Charcot Foot Deformity: A Five Year Follow-Up. Iowa Orthop J 2022; 42:109-112. [PMID: 35821917 PMCID: PMC9210442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND There is increasing interest in reconstruction of diabetes-associated Charcot foot arthropathy with the goal of improving quality of life. METHODS Twenty-four patients who completed the Short Musculoskeletal Function Assessment (SMFA) at baseline and one year following Charcot foot reconstruction were contacted and asked to complete the survey at five years following surgery. RESULTS Fourteen of the 24 patients completed the SMFA preoperatively, one year following surgery and five years postoperatively. Two patients underwent below knee amputation in the interim. Improvement was noted in all domains measured by the SMFA, with a statistically significant improvement in difficulty with daily activities at five years. CONCLUSION Correction of non-plantigrade Charcot foot arthropathy results in clinically meaningful improvement in health-related quality of life at both one and five years postoperatively, including independence with daily activities. The improvement is maintained when reevaluated at five years. This supports the modern paradigm shift towards reconstruction of this deformity. Level of Evidence: III.
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Affiliation(s)
- Patrick Cole McGregor
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, Illinois, USA
| | - Madeline M. Lyons
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, Illinois, USA
| | - Michael S. Pinzur
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, Illinois, USA
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Wang BK, Wukich DK, Sambandam S. Complications from ankle arthrodesis in diabetes-related Charcot foot syndrome. J Diabetes Complications 2021; 35:108071. [PMID: 34674895 DOI: 10.1016/j.jdiacomp.2021.108071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/13/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes. METHODS The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared. RESULTS Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001). CONCLUSION Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN. LEVEL OF EVIDENCE Cohort study; Level of evidence, 3.
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Affiliation(s)
- Benjamin K Wang
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Division of Orthopaedic Surgery, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Senthil Sambandam
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Division of Orthopaedic Surgery, Veterans Affairs North Texas Health Care System, Dallas, TX, USA.
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Gandbhir VN, Dussa K, Gujar H, Parekh A. Syringobulbia in a Setting of Charcot Arthropathy of the Elbow Secondary to Syringomyelia: A Case Report. JBJS Case Connect 2021; 11:01709767-202103000-00042. [PMID: 33957640 DOI: 10.2106/jbjs.cc.20.00272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE The authors present a case of syringobulbia in a setting of elbow arthropathy due to syringomyelia. The patient had painless elbow instability with subtle neurological findings such as ulnar neuropathy, palatal palsy, and dysphonia. As she denied surgery, she was managed with physiotherapy and orthosis. At 24 months of follow-up, she had good clinical outcome without neurological or functional worsening. CONCLUSION Many patients with neuropathic joints due to syringomyelia present to an orthopaedician before a neurologist. A high index of suspicion and thorough neurological examination is essential. Conservative management of such a joint provided good results in this patient.
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Affiliation(s)
- Viraj N Gandbhir
- Department of Orthopaedics, T.N.M.C. and B.Y.L. Nair Ch. Hospital, Mumbai, Maharashtra, India
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Trindade M, Castro de Vasconcelos J, Ayub G, Grupenmacher AT, Gomes Huarachi DR, Viturino M, Correa-Giannella ML, Atala YB, Zantut-Wittmann DE, Parisi MC, Alves M. Ocular Manifestations and Neuropathy in Type 2 Diabetes Patients With Charcot Arthropathy. Front Endocrinol (Lausanne) 2021; 12:585823. [PMID: 33967949 PMCID: PMC8097086 DOI: 10.3389/fendo.2021.585823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/29/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Diabetes can affect the eye in many ways beyond retinopathy. This study sought to evaluate ocular disease and determine any associations with peripheral neuropathy (PN) or cardiac autonomic neuropathy (CAN) in type 2 diabetes (T2D) and Charcot arthropathy (CA) patients. DESIGN A total of 60 participants were included, 16 of whom were individuals with T2D/CA, 21 of whom were individuals with T2D who did not have CA, and 23 of whom were healthy controls. Ocular surface evaluations were performed, and cases of dry eye disease (DED) were determined using the Ocular Surface Disease Index (OSDI) questionnaire, ocular surface staining, Schirmer test, and Oculus Keratograph 5M exams. All variables were used to classify DED and ocular surface disorders such as aqueous deficiency, lipid deficiency, inflammation, and ocular surface damage. Pupillary and retinal nerve fiber measurements were added to the protocol in order to broaden the scope of the neurosensory ocular evaluation. PN and CAN were ascertained by clinical examinations involving the Neuropathy Disability Score (for PN) and Ewing's battery (for CAN). RESULTS Most ocular variables evaluated herein differed significantly between T2D patients and controls. When the controls were respectively compared to patients with T2D and to patients with both T2D and CA, they differed substantially in terms of visual acuity (0.92 ± 0.11, 0.73 ± 0.27, and 0.47 ± 0.26, p=0.001), retinal nerve fiber layer thickness (96.83 ± 6.91, 89.25 ± 10.44, and 80.37 ± 11.67 µm, p=0.03), pupillometry results (4.10 ± 0.61, 3.48 ± 0.88, and 2.75 ± 0.81 mm, p=0.0001), and dry eye symptoms (9.19 ± 11.71, 19.83 ± 19.08, and 24.82 ± 24.40, p=0.03). DED and ocular surface damage also differed between individuals with and without CA, and were associated with PN and CAN. CONCLUSION CA was found to be significantly associated with the severity of ocular findings. DED in cases of CA was also associated with PN and CAN. These findings suggest that intrinsic and complex neurosensory impairment in the eyes, peripheral sensory nerves, and the autonomic nervous system are somehow connected. Thus, a thorough ocular evaluation may be useful to highlight neurological complications and the impact of diabetes on ocular and systemic functions and structures.
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Affiliation(s)
- Marilia Trindade
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- *Correspondence: Marilia Trindade,
| | - Jessica Castro de Vasconcelos
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Gabriel Ayub
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Alex Treiger Grupenmacher
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Delma Regina Gomes Huarachi
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Marina Viturino
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Maria Lucia Correa-Giannella
- Programa de Pos-Graduação em Medicina, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
- Laboratório de Carboidratos e Radioimunoensaio (LIM-18), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Yeelen Ballesteros Atala
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Denise Engelbrecht Zantut-Wittmann
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Maria Candida Parisi
- Endocrinology Division, Department of Internal Medicine (Endocrinology), School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Monica Alves
- Department of Ophthalmology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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Lehrman JD. Combining the Benefits of Collagen and Negative Pressure Wound Therapy to Heal a Chronic Diabetic Foot Ulcer: A Case Report. Wounds 2020; 32:E11-E13. [PMID: 32335522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Diabetes affects 30 million children and adults in the United States, equivalent to 1 out of every 11 people in the country, and results in costs of $327 billion annually. Interventions that can improve healing rates and/or reduce the size of diabetic ulcers may lower the incidence of infection, rate of amputations, and cost of care. This report is on the use of a collagen wound contact layer in conjunction with negative pressure wound therapy (NPWT) to achieve healing in a chronic diabetic foot ulcer (DFU). CASE REPORT A known patient with type 1 diabetes presented with a chronic DFU of 6 months' duration. Previous treatment modalities included offloading regimens and topical therapies (ie, clostridial collagenase, human platelet-derived growth factors, and 6 applications of a human amniotic membrane allograft). A collagen wound contact layer was applied to the debrided wound bed with subsequent debridements performed every other week, weekly NPWT dressing changes, and weekly contact layer changes. A 91% reduction in wound area was seen at day 35, with complete healing at day 63, and no recurrence at 18 months. CONCLUSIONS The combination of a collagen wound contact layer and weekly NPWT had a significantly positive effect on healing in this chronic DFU. The regimen was well-tolerated and simple to administer in this case.
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Zaim A, Gojanovic B, Lädermann A, Meynard T. [From cellulitis to arthrodesis]. Rev Med Suisse 2020; 16:278-281. [PMID: 32022495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Neuropathic arthropathy is a pathology involving both upper and lower limbs. Different neurological diseases can cause this arthropathy. For instance, shoulder Charcot arthropathies are mostly associated to syringomyelia. The initial diagnosis of this arthropathy is difficult and often delayed in the presence of usually non specific symptoms. Since articular destruction is present in this disease, early diagnosis and primary management of the neurological condition is important, as it slows down the destruction of the joint.
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Affiliation(s)
- Armita Zaim
- Service de médecine interne, Hôpital de la Tour, Avenue J.-D. Maillard 3, 1217 Meyrin
| | - Boris Gojanovic
- Service de médecine du sport, Hôpital de la Tour, Avenue J.-D. Maillard 3, 1217 Meyrin
| | - Alexandre Lädermann
- Service de chirurgie orthopédique, Hôpital de la Tour, Avenue J.-D. Maillard 3, 1217 Meyrin
| | - Timon Meynard
- Service de chirurgie orthopédique, Hôpital de la Tour, Avenue J.-D. Maillard 3, 1217 Meyrin
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Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study. Acta Diabetol 2019; 56:1259-1264. [PMID: 31187250 DOI: 10.1007/s00592019-01376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/04/2019] [Indexed: 05/28/2023]
Abstract
AIMS We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN). METHODS People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression. RESULTS Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN. CONCLUSIONS People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.
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Affiliation(s)
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study. Acta Diabetol 2019; 56:1259-1264. [PMID: 31187250 DOI: 10.1007/s00592-019-01376-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
AIMS We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN). METHODS People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression. RESULTS Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN. CONCLUSIONS People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.
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Affiliation(s)
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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Rastogi A, Hajela A, Prakash M, Khandelwal N, Kumar R, Bhattacharya A, Mittal BR, Bhansali A, Armstrong DG. Teriparatide (recombinant human parathyroid hormone [1-34]) increases foot bone remodeling in diabetic chronic Charcot neuroarthropathy: a randomized double-blind placebo-controlled study. J Diabetes 2019; 11:703-710. [PMID: 30632290 DOI: 10.1111/1753-0407.12902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/22/2018] [Accepted: 01/08/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Currently, there is no consensus regarding the medical treatment of chronic Charcot neuroarthropathy (CN) of foot, except for effective off-loading. Because tarsal bones are predominantly trabecular, teriparatide may improve the macroarchitecture of foot bones in chronic CN. METHODS People with diabetes and chronic CN were randomized to receive either 20 μg teriparatide or placebo subcutaneous daily for 12 months. Thirty-eight patients were screened and data were analyzed for 20. The maximum standardized uptake (SUVmax ) value of 18 F-FDG PET/CT the region of interest, bone turnover markers and foot bone mineral density BMD were determined. The primary outcome measure was change in SUVmax g/ml. RESULTS Mid-foot was the most common region involved. After 12 months, SUVmax increased from 30.6 ± 14.7 to 37.7 ± 18.0 (P = 0.044) in the teriparatide group, but decreased from 27.6 ± 12.2 to 22.9 ± 10.4 with placebo (P = 0.148). The estimated treatment difference (ETD) was 11.9 ± 4.3 (95% CI 2.9, 20.8; P = 0.012). Similarly, P1NP increased with teriparatide (19.8 ± 5.5; P = 0.006) but decreased with placebo (-5.1 ± 3.8 ng/mL; P = 0.219); ETD was 24.8 ± 6.6 (95% CI 10.8, 38.8; P < 0.001) and CTX increased in both the teriparatide and placebo groups. Foot BMD increased by 0.06 ± 0.04 g/cm2 (P = 0.192) with teriparatide, but decreased by -0.06 ± 0.08 g/cm2 with placebo (P = 0.488; intergroup comparison, P = 0.096). CONCLUSION Teriparatide increases foot bone remodeling by an osteoanabolic action in people with CN.
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Affiliation(s)
- Ashu Rastogi
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Hajela
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mahesh Prakash
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajender Kumar
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant R Mittal
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine, Los Angeles, California
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Sebastian AP, Dasgupta R, Jebasingh F, Saravanan B, Chandy B, Mahata KM, Naik D, Paul T, Thomas N. Clinical features, radiological characteristics and offloading modalities in stage 0 Acute Charcot's neuroarthropathy - A single centre experience from South India. Diabetes Metab Syndr 2019; 13:1081-1085. [PMID: 31336448 DOI: 10.1016/j.dsx.2019.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 01/14/2019] [Indexed: 11/27/2022]
Abstract
AIMS Stage 0 Acute Charcot's Neuroarthropathy (ACN)in Type 2 Diabetes patients is a challenging diagnosis with subtle clinical features and normal appearing plain radiographs of the affected foot. Delay in diagnosis can lead to progression of disease and irreversible deformities. There is a paucity of data on Stage 0 ACN from India. The aim of this study was to assess clinical and radiological characteristics and treatment outcomes in Indian Type 2 Diabetes patients with Stage 0 ACN. MATERIALS AND METHODS A comparative, case-control study was carried out amongst patients attending the Integrated Diabetes Foot Clinic at a tertiary care South Indian hospital. During the 3-year study period, a total of 1811 patients with Type 2 Diabetes Mellitus were screened. Of these, n = 10 patients with stage 0 ACN Charcot's arthropathy were identified based on clinical features and MRI imaging of the foot for confirmation of diagnosis. These were compared with an age and duration of diabetes-matched group of n = 50 patients without ACN as controls. RESULTS Our study identified 10 patients (0.5%) with Stage 0 Acute charcot neuroarthropathy (ACN) in the study population. Those with ACN had higher BMI, poorer glycaemic control and greater degree of peripheral neuropathy (p < 0.05). Clinically relative lack of pain and infrared thermometric temperature difference >2 °C in the affected foot were the most significant findings, while MRI foot was useful in early detection of active and severe stage 0 disease. Total contact cast was the preferred initial offloading modality, with delay in initiating complete immobilization leading to worse outcomes. CONCLUSIONS This is the first study to highlight the characteristic features of Stage 0 ACN in Indian Type 2 Diabetes patients. Thorough clinical evaluation, infrared thermometry and radiological findigs on MRI foot leads to early disease detection. Complete offloading, preferably with total contact casts can prevent disease progression and chronic deformities.
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Affiliation(s)
- Anjely P Sebastian
- Department of General Medicine, Christian Medical College, Vellore, 632 004, India
| | - Riddhi Dasgupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India.
| | - Felix Jebasingh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Bharathi Saravanan
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Bobeena Chandy
- Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, 632 004, India
| | - Koyeli Mary Mahata
- Department of Radiology, Christian Medical College, Vellore, 632 004, India
| | - Dukhabandhu Naik
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Thomas Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, 632 004, India
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Jansen RB, Jørgensen B, Holstein PE, Møller KK, Svendsen OL. Mortality and complications after treatment of acute diabetic Charcot foot. J Diabetes Complications 2018; 32:1141-1147. [PMID: 30301593 DOI: 10.1016/j.jdiacomp.2018.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/13/2018] [Accepted: 09/20/2018] [Indexed: 11/22/2022]
Abstract
AIMS Charcot foot is a rare but disabling complication to diabetic neuropathy, and can cause permanent, limb-threatening deformities. The aim of this study was to investigate a population of patients a Charcot foot on a case-by-case basis, in order to assess the consequences of an acute Charcot foot and its complications. METHODS The study was conducted a retrospective study of patients admitted to the Copenhagen Wound Healing Center between 1996 and 2015 with the diagnosis of Charcot foot (DM14.6) and diabetes mellitus type 1 or 2 (DE10.X and DE11.X). Physical and electronic records were used, and compared to data from the Danish Diabetes Registry. RESULTS In total 392 patients were identified of which 173 were included. There were 26% with type 1 diabetes (initial HbA1c 81.7 ± 21.4 mmol/mol) and 74% with type 2 diabetes (initial HbA1c 66.5 ± 20.3 mmol/mol). Primary off-loading was with a removable walker in 95% of the cases (average off-loading time 8.3 months). The 5-year mortality was 14% with a mean survival time of 12.7 years. There was an association between lack of compliance and occurrence of foot complications, as well as between having a Charcot foot and leaving the workforce. CONCLUSION More patients had type 1 diabetes compared to the background population, and they had a higher HbA1c than the general population of diabetes patients. A total of 67% developed complications such as ulcers, while patients non-compliant to treatment did significantly worse than those being compliant. The 5-year mortality was low, 14%, and comparable to diabetes patients without Charcot foot.
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Affiliation(s)
- Rasmus Bo Jansen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark.
| | - Bo Jørgensen
- Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Per E Holstein
- Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Klaus Kirketerp Møller
- Center for Wound Healing, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
| | - Ole Lander Svendsen
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen NV, Denmark
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Guerrero-Maestre RG, Beaton-Comulada D, Colón-Miranda R, Reyes-Martinez P. Hindfoot Fusion Nail with Adjuvant Hybrid External Fixation used as Limb-Salvage Procedure after Failed Open Reduction Internal Fixation of Ankle Fracture in a Charcot Joint: A Case Report. P R Health Sci J 2018; 37:235-238. [PMID: 30548061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The failure of the internal fixation of an ankle fracture due to Charcot joint/ neuroarthropathy is rare; such occurred in the case of a 52-year-old woman with uncontrolled diabetes who sustained a right ankle fracture after falling from standing height. The patient was treated with the internal fixation of both malleoli, which procedure failed as the patient progressed, until she eventually was diagnosed with Charcot arthropathy. The post operative images were reviewed and showed a catastrophic fixation failure with a diagnosis of Charcot neuroarthropathy. At that point, we decided to treat the problem presented with salvage arthrodesis, combining hindfoot fusion nail with adjuvant external fixation. This treatment was selected to augment stability and achieve stable fixation. The post-operative visits showed wound healing without complications and painless weight bearing. The follow-up radiographs showed tibiotalar fusion with painless union of the subtalar joint at 48 weeks.
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Affiliation(s)
- Román G Guerrero-Maestre
- Department of Orthopedic Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - David Beaton-Comulada
- Department of Orthopedic Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Roberto Colón-Miranda
- Department of Orthopedic Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Pedro Reyes-Martinez
- Department of Orthopedic Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
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23
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Chalmers BP, Tibbo ME, Trousdale RT, Lewallen DG, Berry DJ, Abdel MP. Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes. J Arthroplasty 2018; 33:2912-2918. [PMID: 29706256 DOI: 10.1016/j.arth.2018.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/15/2018] [Accepted: 04/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Neuropathic (Charcot) arthropathy of the hip is rare but can lead to joint destruction, bone loss, and dysfunction. While total hip arthroplasty (THA) may be considered a treatment option, only very limited data in the form of case reports are available on the results of THA. The goal of this study was to analyze the outcomes of primary THA for Charcot arthropathy with emphasis on implant survivorship, complications, and clinical outcomes. METHODS Eleven patients undergoing 12 primary THAs for Charcot arthropathy from 2007 to 2014 were retrospectively reviewed. All patients had a severe underlying neuropathy and clear radiographic evidence of Charcot arthropathy. Mean age was 54 years with 4 patients being female. Mean follow-up was 5 years. RESULTS Survivorship free of any revision was 75% at both 2 and 5 years. Three THAs (3/12) were revised: 2 for recurrent instability and 1 for femoral component loosening. Survivorship free of any reoperation was 67% at both 2 and 5 years. One additional THA underwent open reduction and internal fixation of a Vancouver B1 periprosthetic fracture. The overall complication rate (including revisions and reoperations) was high at 58% with 3 recurrent dislocations, 2 periprosthetic fractures, 1 femoral component loosening, and 1 delayed wound healing. Harris Hip Scores improved from a mean of 43 preoperatively to 81 postoperatively (P < .001). CONCLUSION In this study, the largest to date, we found that patients undergoing primary THA for Charcot arthropathy have a significant improvement in clinical outcomes but that there was a high risk of early complications and revisions, mostly related to recurrent instability. Specific precautions to avoid early complications, namely utilization of components that provide robust fixation and strategies that provide enhanced hip stability, should be considered. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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24
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Doria M, Viadé J, Palomera E, Pérez R, Lladó M, Costa E, Huguet T, Reverter JL, Serra-Prat M, Franch-Nadal J, Mauricio D. Short-term foot complications in Charcot neuroarthropathy: A retrospective study in tertiary care centres in Spain. ACTA ACUST UNITED AC 2018; 65:479-485. [PMID: 30108031 DOI: 10.1016/j.endinu.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the clinical characteristics of patients with Charcot neuroarthropathy (CN) in Spain and to identify predictors for CN-related complications. PATIENTS AND METHODS A retrospective study was conducted at five tertiary hospitals with diabetic foot care units in Spain. Data were collected from 83 patients, including demographic profiles, foot factors, diabetes characteristics, and presence of microvascular and macrovascular comorbidity, and a podiatric examination was also performed. Logistic regression analyses were used to determine significant predictors of the predefined clinical events. RESULTS Signs of diabetic neuropathy were found in almost all patients (98.9%) at the initial assessment, approximately half of them had diabetic retinopathy or nephropathy (61.5% and 51.8%, respectively), and peripheral artery disease was uncommon (8.6%). Thirty-eight patients (47.5%) experienced one or more relevant clinical events: 22 (27.5%) a new foot ulcer; 7 (8.7%) a major amputation; 20 (25%) were admitted to hospital; and 4 (5%) died. Only the presence of diabetic nephropathy was independently associated to development of any of the complications studied (p = 0.009; odds ratio = 3.37; 95% CI: 1.12-10.1). CONCLUSIONS Almost half the patients with CN attending specialised foot care units in tertiary hospitals experienced short-term CN-associated complications, and the risk was 3 times higher in those with a history of diabetic nephropathy.
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Affiliation(s)
- Montserrat Doria
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain; Diabetic Foot Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Jordi Viadé
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain
| | | | - Ricard Pérez
- Department of Radiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Melcior Lladó
- Diabetic Foot Unit, University Hospital Son Espases, Palma de Mallorca, Spain
| | - Elisabet Costa
- Department of Endocrinology and Nutrition, University Hospital Josep Trueta, Girona, Spain
| | - Teresa Huguet
- Diabetic Foot Unit, University Hospital Mutua, Terrassa, Spain
| | - Jordi Lluís Reverter
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain
| | | | - Josep Franch-Nadal
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Spain; Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, University Hospital & Health Sciences Research Institute Germans Trias i Pujol, Badalona, Spain; Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Spain; Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
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25
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Hernigou J, Boulares S, Delahaut O. Spontaneous posterior shoulder dislocation as the first symptom of a Charcot arthropathy. Acta Orthop Belg 2018; 84:73-77. [PMID: 30457503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Neuroarthropathy or Charcot disease is a destructive joint pathology. Upper limb involvement is unusual and often due to syringomyelia. We reported a patient with spontaneous posterior right shoulder dislocation. Thereafter, she presented a quick joint destruction evoking a Charcot shoulder disease after excluding infectious and rheumatologic diseases. Explorations of this Charcot disease lead to the discovery and treatment of syringomyelia. A conservative management of her shoulder neuro-arthropathy has been proposed to the patient. Shoulder involvement in Charcot disease is unusual: only 5% of cases. 18 cases have been reported in English literature. Two theories try to explain Charcot disease: neuro-vascular and neuro-traumatic. There is no efficient treatment for Charcot shoulder disease but it can be prevented by surgical treatment of syringomyelia. Charcot shoulder is a rare and morbid disease for which conservative treatment is recommended because of disappointing results of arthroplasty and arthrodesis.
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26
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Sinacore DR, Bohnert KL, Smith KE, Hastings MK, Commean PK, Gutekunst DJ, Johnson JE, Prior FW. Persistent inflammation with pedal osteolysis 1year after Charcot neuropathic osteoarthropathy. J Diabetes Complications 2017; 31:1014-1020. [PMID: 28254346 PMCID: PMC5438890 DOI: 10.1016/j.jdiacomp.2017.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/19/2016] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
AIMS To determine local and systemic markers of inflammation and bone mineral density (BMD) in the foot and central sites in participants with diabetes mellitus and peripheral neuropathy (DMPN) with and without acute Charcot neuropathic osteoarthropathy (CN). METHODS Eighteen participants with DMPN and CN and 19 participants without CN had foot temperature assessments, serum markers of inflammation [C-reactive protein, (CRP) and erythrocyte sedimentation rate, (ESR)] and BMD of the foot, hip and lumbar spine at baseline and 1year follow-up. RESULTS CN foot temperature difference was higher compared to DMPN controls at baseline (4.2±1.9°F vs. 1.2±0.9°F, P<0.01) and after 1year (2.9±3.2°F vs. 0.9±1.1°F, P<0.01). Serum inflammatory markers in the CN group were greater at baseline and remained elevated 1year later compared to DMPN controls (CRP, P=0.02, ESR, P=0.03). All pedal bones' BMD decreased an average of 3% in the CN foot with no changes in hip or lumbar spine. DMPN controls' foot, hip and lumbar spine BMD remained unchanged. CONCLUSIONS Local and systemic inflammation persists 1 year after CN with an accompanying pedal osteolysis that may contribute to mid foot deformity which is the hallmark of the chronic Charcot foot.
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Affiliation(s)
- David R Sinacore
- Applied Kinesiology Laboratory, Program in Physical Therapy, Campus Box 8502, Washington University School of Medicine, St. Louis, MO, 63108.
| | - Kathryn L Bohnert
- Applied Kinesiology Laboratory, Program in Physical Therapy, Campus Box 8502, Washington University School of Medicine, St. Louis, MO, 63108
| | - Kirk E Smith
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AK
| | - Mary K Hastings
- Applied Kinesiology Laboratory, Program in Physical Therapy, Campus Box 8502, Washington University School of Medicine, St. Louis, MO, 63108
| | - Paul K Commean
- Electronic Radiology Laboratory, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - David J Gutekunst
- Musculoskeletal Biomechanics Laboratory, Program in Physical Therapy, Doisy College of Health Sciences, Saint Louis University, St. Louis, MO
| | - Jeffrey E Johnson
- Foot & Ankle Service, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Fred W Prior
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AK
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Affiliation(s)
- Patrick K Strotman
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Taylor J Reif
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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28
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Papanas N, Pafili K, Maltezos E. Charcot osteoarthropathy and coronary artery disease in diabetes: the twilight of innocence? Acta Diabetol 2016; 53:123-4. [PMID: 25721037 DOI: 10.1007/s00592-015-0723-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/05/2015] [Indexed: 11/25/2022]
Affiliation(s)
- N Papanas
- Outpatient Clinic of the Diabetic Foot, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, G. Kondyli 22c, 68100, Alexandroupolis, Greece.
| | - K Pafili
- Outpatient Clinic of the Diabetic Foot, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, G. Kondyli 22c, 68100, Alexandroupolis, Greece
| | - E Maltezos
- Outpatient Clinic of the Diabetic Foot, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, G. Kondyli 22c, 68100, Alexandroupolis, Greece
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29
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López-Gavito E, Parra-Téllez P, Vázquez-Escamilla J. [Charcot arthropathy and diabetic foot]. Acta Ortop Mex 2016; 30:33-45. [PMID: 27627777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Diabetes mellitus is a major chronic degenerative disease, which currently is taking on alarming proportions in the population of our country. Neuropathic arthropathy is one of the most interesting degenerative joint disorders and increasingly common within the orthopedic pathology. It is defined as a progressive degenerative arthropathy, chronic and affecting one or more peripheral joints, and develops as a result of the lack of sensory perception normal in the innervation of joints. As a result the joints of the feet are subjected to trauma and repetitive injury causing a neurotraumatic effect with progressive damage to the joints of the hindfoot, midfoot and forefoot. Diagnosis includes a proper medical history, careful examination of the affected limb, conventional X-ray, scintigraphy, computed tomography and magnetic resonance imaging in some cases. Conservative treatment includes: drugs, rest of the affected limb, and the use of appliances like total-contact cast, orthotics or special shoes. Surgical treatment depends on the stage of the disease, and may require one or more surgical procedures, in order to achieve a full foot plantar support to prevent ulcers. One of the surgeries performed most often is the fusion of damaged joints. Surgery must be performed only in the coalescence phase of the disease, using internal, or external fixation or both.
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Affiliation(s)
- E López-Gavito
- Instituto Nacional de Rehabilitación. Secretaría de Salud de México. Calz. México Xochimilco No. 289, Tlalpan, Arenal de Guadalupe, 14389 Ciudad de México, D.F
| | - P Parra-Téllez
- Instituto Nacional de Rehabilitación. Secretaría de Salud de México. Calz. México Xochimilco No. 289, Tlalpan, Arenal de Guadalupe, 14389 Ciudad de México, D.F
| | - J Vázquez-Escamilla
- Instituto Nacional de Rehabilitación. Secretaría de Salud de México. Calz. México Xochimilco No. 289, Tlalpan, Arenal de Guadalupe, 14389 Ciudad de México, D.F
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30
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Wukich DK, Raspovic KM, Hobizal KB, Sadoskas D. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:292-6. [PMID: 26452590 DOI: 10.1002/dmrr.2748] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality. SURGICAL MANAGEMENT The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality. CONCLUSION Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use.
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MESH Headings
- Ankle/pathology
- Ankle/surgery
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/pathology
- Arthropathy, Neurogenic/rehabilitation
- Arthropathy, Neurogenic/surgery
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Decision Trees
- Diabetic Foot/complications
- Diabetic Foot/pathology
- Diabetic Foot/rehabilitation
- Diabetic Foot/surgery
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/pathology
- Diabetic Neuropathies/rehabilitation
- Diabetic Neuropathies/surgery
- Evidence-Based Medicine
- External Fixators/adverse effects
- External Fixators/trends
- Foot Deformities, Acquired/complications
- Foot Deformities, Acquired/pathology
- Foot Deformities, Acquired/rehabilitation
- Foot Deformities, Acquired/surgery
- Heel/pathology
- Heel/surgery
- Humans
- Internal Fixators/adverse effects
- Internal Fixators/trends
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Precision Medicine
- Preoperative Care/adverse effects
- Preoperative Care/trends
- Quality of Life
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - David Sadoskas
- Fellow Reconstruction and Limb Salvage Surgery UPMC Mercy Hospital, Pittsburgh, PA, USA
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31
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Abstract
With the increased number of diabetics worldwide and the increased incidence of morbid obesity in more prosperous cultures, there has become an increased awareness of Charcot arthropathy of the foot and ankle. Outcome studies would suggest that patients with deformity associated with Charcot Foot arthropathy have impaired health related quality of life. This awareness has led reconstructive-minded foot and ankle surgeons to develop surgical strategies to treat these acquired deformities. This article outlines the current clinical approach to this disabling medical condition.
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MESH Headings
- Ankle/pathology
- Ankle/surgery
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/pathology
- Arthropathy, Neurogenic/rehabilitation
- Arthropathy, Neurogenic/surgery
- Congresses as Topic
- Diabetic Foot/complications
- Diabetic Foot/pathology
- Diabetic Foot/rehabilitation
- Diabetic Foot/surgery
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/pathology
- Diabetic Neuropathies/rehabilitation
- Diabetic Neuropathies/surgery
- Evidence-Based Medicine
- External Fixators/adverse effects
- External Fixators/trends
- Foot/pathology
- Foot/surgery
- Foot Deformities, Acquired/complications
- Foot Deformities, Acquired/pathology
- Foot Deformities, Acquired/rehabilitation
- Foot Deformities, Acquired/surgery
- Humans
- Internal Fixators/adverse effects
- Internal Fixators/trends
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Postoperative Complications/prevention & control
- Precision Medicine
- Quality of Life
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- Michael S Pinzur
- Department of Orthopaedic Surgery, Loyola University Health System, Maywood, IL, 60153, USA
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32
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Abstract
Charcot neuro-osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Charcot foot when the X ray is still negative (stage 0 or incipient Charcot foot). Recent advances in imaging modalities have enabled the detection of initial signs of inflammation and underlying bone damage before overt bone and joint destruction has occurred. Casting therapy remains the mainstay of medical therapy of acute CN. If timely instituted, offloading can arrest disease activity and prevent foot deformity. In cases with severe deformity, modern surgical techniques can correct the unstable deformity for improved functional outcome and limb survival. Emerging new studies into the cellular mechanisms of severe bone destruction have furthered our understanding of the mechanisms of pathological bone and joint destruction in CN. It is hoped that these studies may provide a scientific basis for new interventions with biological agents.
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MESH Headings
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/diagnosis
- Arthropathy, Neurogenic/physiopathology
- Arthropathy, Neurogenic/therapy
- Bone Density Conservation Agents/adverse effects
- Bone Density Conservation Agents/therapeutic use
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Diabetic Foot/complications
- Diabetic Foot/diagnosis
- Diabetic Foot/physiopathology
- Diabetic Foot/therapy
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/diagnosis
- Diabetic Neuropathies/physiopathology
- Diabetic Neuropathies/therapy
- Early Diagnosis
- Evidence-Based Medicine
- Fractures, Bone/complications
- Fractures, Bone/epidemiology
- Fractures, Bone/etiology
- Fractures, Bone/therapy
- Humans
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Postoperative Complications/prevention & control
- Precision Medicine
- Protective Devices/trends
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Risk Factors
- Severity of Illness Index
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | - M E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
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33
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Abstract
In 2015, it can be said that the diabetic foot is no longer the Cinderella of diabetic complications. Thirty years ago there was little evidence-based research taking place on the diabetic foot, and there were no international meetings addressing this topic. Since then, the biennial Malvern Diabetic Foot meetings started in 1986, the American Diabetes Association founded their Foot Council in 1987, and the European Association for the Study of Diabetes established a Foot Study Group in 1998. The first International Symposium on the Diabetic Foot in The Netherlands was convened in 1991, and this was soon followed by the establishment of the International Working Group on the Diabetic Foot that has produced useful guidelines in several areas of investigation and the management of diabetic foot problems. There has been an exponential rise in publications on diabetic foot problems in high impact factor journals, and a comprehensive evidence-base now exists for many areas of treatment. Despite the extensive evidence available, it, unfortunately, remains difficult to demonstrate that most types of education are efficient in reducing the incidence of foot ulcers. However, there is evidence that education as part of a multi-disciplinary approach to diabetic foot ulceration plays a pivotal role in incidence reduction. With respect to treatment, strong evidence exists that offloading is the best modality for healing plantar neuropathic foot ulcers, and there is also evidence from two randomized controlled trials to support the use of negative-pressure wound therapy in complex post-surgical diabetic foot wounds. Hyperbaric oxygen therapy exhibits the same evidence level and strength of recommendation. International guidelines exist on the management of infection in the diabetic foot. Many randomized trials have been performed, and these have shown that the agents studied generally produced comparable results, with the exception of one study in which tigecycline was shown to be clinically inferior to ertapenem ± vancomycin. Similarly, there are numerous types of wound dressings that might be used in treatment and which have shown efficacy, but no single type (or brand) has shown superiority over others. Peripheral artery disease is another major contributory factor in the development of ulceration, and its presence is a strong predictor of non-healing and amputation. Despite the proliferation of endovascular procedures in addition to open revascularization, many patients continue to suffer from severely impaired perfusion and exhaust all treatment options. Finally, the question of the true aetiopathogenesis of Charcot neuroarthropathy remains enigmatic, although much work is currently being undertaken in this area. In this area, it is most important to remember that a clinically uninfected, warm, insensate foot in a diabetic patient should be considered as a Charcot foot until proven otherwise, and, as such, treated with offloading, preferably in a cast.
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Affiliation(s)
- K Markakis
- Manchester Royal Infirmary, Manchester, UK
| | - F L Bowling
- Manchester Royal Infirmary, Manchester, UK
- University of Manchester, Manchester, UK
| | - A J M Boulton
- Manchester Royal Infirmary, Manchester, UK
- University of Manchester, Manchester, UK
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Holcombe D. Neuropathic Edema In A Diabetic With Unilateral Thigh Swelling. J La State Med Soc 2015; 167:223-224. [PMID: 27159598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A 54-year-old woman with a history of long-standing diabetes presented with a six-week history of swelling "on the entire left side of the body." The patient said she had experienced painful swelling of the left thigh and lower leg, but also painless swelling of the "left eye and shoulder."
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Affiliation(s)
- David Holcombe
- Louisiana Office of Public Health (Region VI) in Alexandria, LA
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Rosenblum JI, Weiss S, Gazes M, Amit-Kohn M. Serial casting for reconstruction of a deformed Charcot foot: a case report. Wounds 2015; 27:E7-E11. [PMID: 25974962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Charcot neuroarthropathy may occur in patients with peripheral neuropathy who do not notice pain while their bones and joints collapse or breakdown under the constant pressure of body weight. This can lead to ulcerations from severe deformity and potentially limb-threatening and life-threatening infections. Current treatments vary from immobilization to extensive reconstructive surgical interventions. METHODS Serial casting, used to correct many pediatric deformities while bones are often more pliable, was used with a 63-year-old male patient who presented with an active phase of Charcot foot with ulceration. The patient previously underwent foot reconstruction and had all hardware removed prior to serial casting. Due to the potential pliability of the bones, serial casting was attempted to reform the shape and position of the foot in a reverse Ponseti-type serial casting to create a more stable structure with less deformity that could lead to epithelial breakdown. RESULTS The patient regained full ambulation with a plantargrade foot and no wounds, and was followed without complications for 36 months. CONCLUSION Serial weekly casting was an effective modality for treatment of this patient's Charcot foot deformity.
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Petrova NL, Dew TK, Musto RL, Sherwood RA, Bates M, Moniz CF, Edmonds ME. Inflammatory and bone turnover markers in a cross-sectional and prospective study of acute Charcot osteoarthropathy. Diabet Med 2015; 32:267-73. [PMID: 25251588 DOI: 10.1111/dme.12590] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 11/27/2022]
Abstract
AIMS To assess markers of inflammation and bone turnover at presentation and at resolution of Charcot osteoarthropathy. METHODS We measured serum inflammatory and bone turnover markers in a cross-sectional study of 35 people with Charcot osteoarthropathy, together with 34 people with diabetes and 12 people without diabetes. In addition, a prospective study of the subjects with Charcot osteoarthropathy was conducted until clinical resolution. RESULTS At presentation, C-reactive protein (P = 0.007), tumour necrosis factor-α (P = 0.010) and interleukin-6 (P = 0.002), but not interleukin-1β, (P = 0.254) were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. Serum C-terminal telopeptide (P = 0.004), bone alkaline phosphatase (P = 0.006) and osteoprotegerin (P < 0.001), but not tartrate-resistant acid phosphatase (P = 0.126) and soluble receptor activator of nuclear factor-κβ ligand (P = 0.915), were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. At follow-up it was found that tumour necrosis factor-α (P = 0.012) and interleukin-6 (P = 0.003), but not C-reactive protein (P = 0.101), interleukin-1β (P = 0.457), C-terminal telopeptide (P = 0.743), bone alkaline phosphatase (P = 0.193), tartrate-resistant acid phosphatase (P = 0.856), osteoprotegerin (P = 0.372) or soluble receptor activator of nuclear factor-kβ ligand (P = 0.889), had significantly decreased between presentation and the 3 months of casting therapy time point, and all analytes remained unchanged from 3 months of casting therapy until resolution. In people with Charcot osteoarthropathy, there was a positive correlation between interleukin-6 and C-terminal telopeptide (P = 0.028) and tumour necrosis factor-α and C-terminal telopeptide (P = 0.013) only at presentation. CONCLUSIONS At the onset of acute Charcot foot, serum concentrations of tumour necrosis factor-α and interleukin-6 were elevated; however, there was a significant reduction in these markers at resolution and these markers may be useful in the assessment of disease activity.
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Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
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Bergis D, Bergis PM, Hermanns N, Zink K, Haak T. Coronary artery disease as an independent predictor of survival in patients with type 2 diabetes and Charcot neuro-osteoarthropathy. Acta Diabetol 2014; 51:1041-8. [PMID: 25344769 DOI: 10.1007/s00592-014-0669-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/15/2014] [Indexed: 10/24/2022]
Abstract
AIMS Charcot neuro-osteoarthropathy (CN) is a rare complication of diabetic foot syndrome associated with chronic inflammation of the foot and severe, limb-threatening musculoskeletal deformities. Aim of this study was to investigate patients with CN for comorbidities, amputations, ulcers, secondary diseases and mortality. METHODS The study was conducted at a specialized German hospital for patients with diabetes. One-hundred and eleven patients were enrolled, and their course was followed over a period of 15 years. Association of CN with comorbidity, foot ulcers, amputations and mortality was assessed. Clinical course of patients was followed using two standardized questionnaires. RESULTS Presence of CN was significantly associated with diabetic retinopathy (p = 0.047), plantar (p < 0.001), tarsal (p = 0.032) and middle-foot ulcers (p = 0.01). A significant correlation between the presence of CN and a history of amputations was seen (p = 0.022). Patients were at increased risk to suffer from subsequent amputations during follow-up when micro- and macrovascular comorbidities such as retinopathy (p = 0.01) and peripheral artery disease (p < 0.001) were present. Additionally, coronary artery disease (CHD) was identified as an independent predictor of mortality in the cohort of this study (OR 6.192, 95 % CI 1.155-33.208, p = 0.033). Median overall survival of patients with CN and CHD was significantly shorter than OS of patients without CHD (7.8 vs. 13.1 years, p = 0.0045, HR 2.8437, 95 % CI 0.9818-8.2364). CONCLUSIONS In our study, CHD was the most important factor of survival in CN patients. For optimal management of CN, adequate diagnostics and treatment of CHD according to current guidelines should be considered.
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Affiliation(s)
- Dominik Bergis
- Division of Endocrinology and Diabetes, Department of Internal Medicine 1, Goethe University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany,
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Abstract
Pedobarography can quantify static and dynamic foot pressure. Despite an increase in the clinical use of pedobarography, the results and the clinical diagnosis do not always correlate, leading to confusion and misdiagnosis. The authors evaluated the potential of pedobarography to diagnose several diseases associated with abnormal pressure across the plantar surface. The study included 72 patients (96 cases) between January 2009 and August 2012 with symptoms of excessive plantar pressure. The average age was 50.9 years (range, 18-92). Patients had the lesion for an average of 17 months (range, 8-29). Pedobarographic measurements were used to evaluate the compatibility between the highest pressure on pedobarography and the clinical peak pressure with plantar ulcers or calluses. Maximal peak pressure was evaluated by static and dynamic measurements using numeric and graphic measurements in pedobarography. The diagnostic validity of pedobarography was analyzed by comparing clinical peak pressure and pedobarographic measurements. The diagnostic validity of pedobarography was 17.7% to 51% for static measurement and 13.5% to 49% for dynamic measurement. The diagnostic validity of pedobarography was low for intractable plantar keratosis and metatarsal head callus associated with metatarsophalangeal dislocation in rheumatoid arthritis. However, it was 57% to 100% for Charcot arthropathy with midfoot ulcers. When used to compare numeric pressure and graphic peak pressure for each part of the foot, pedobarography showed low diagnostic correlation. Based on the study results, the diagnostic validity of pedobarography is low.
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Abstract
Patients with diabetes and peripheral neuropathy are at risk for foot deformities and mechanical imbalance of the lower extremity. Peripheral neuropathy leads to an insensate foot that puts the patient at risk for injury. When combined with deformity due to neuropathic arthropathy, or Charcot foot, the risks of impending ulceration, infection, and amputation are significant to the diabetic patient. Education of proper foot care and shoe wear cannot be overemphasized. For those with significant malalignment or deformity of the foot and ankle, referral should be made immediately to an orthopedic foot and ankle specialist.
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Affiliation(s)
- John A DiPreta
- Division of Orthopaedic Surgery, Albany Medical Center, Albany Medical College, Capital Region Orthopaedics, 1367 Washington Avenue, Suite 200, Albany, NY 12206, USA.
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Abstract
Many surgical and nonsurgical options exist with the aim of improving quality of life and preventing amputation in patients with CN. A multidisciplinary approach is necessary to achieve the best outcomes in this high-risk group. Modern advanced diagnostic and imaging techniques have improved knowledge regarding the biomechanics, biology, and pathophysiology of CN. Despite these advances, surgical management has lagged behind and is based largely on retrospective case series and expert opinion. Although the surgeons of today are better equipped to manage CN, the optimal timing and specific method of surgical treatment have yet to be defined. Multicenter, prospective studies may be the best way to study this relatively uncommon problem.
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Affiliation(s)
- Wei Shen
- University of Pittsburgh Medical Center Comprehensive Foot and Ankle Center, Pittsburgh, PA, USA
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Abstract
The Charcot foot is a problematic clinical entity that worsens in the absence of timely intervention. As of now, based on the ADA consensus report, offloading with TCC continues to remain the mainstay of therapy for CN.1 A standardized approach to the management of CN is depicted in Fig. 1. Furthermore, ongoing inflammatory activity can be controlled with antiresorptive agents, like BPPs and calcitonin; however, data acquired from larger trials with these agents are awaited. Newer agents that target the inflammatory cascade have been identified and applied in limited clinical trials in non-Charcot conditions. Their potential role in the future management of CN has yet to be established.
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Affiliation(s)
- Janice V Mascarenhas
- Department of Endocrinology, St. John's National Academy of Health Sciences, Bangalore 560034, Karnataka, India
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Abstract
The diabetic Charcot foot is rare, but a life-changing event affecting quality of life, and it risks amputation of the limb. There is no high quality evidence base governing treatment, causing clinicians to rely on low-quality, underpowered studies and expert opinion. However, CN is a treatable condition and, with lifestyle modifications and proper footwear, it does not shorten the life span of those afflicted.
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Affiliation(s)
- Lee C Rogers
- Amputation Prevention Center, Valley Presbyterian Hospital, Los Angeles, CA, USA.
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Abstract
Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. Unchecked, infection can spread contiguously to involve underlying tissues, including bone. A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.
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Affiliation(s)
- Edgar J G Peters
- Department of Internal Medicine, VU University Medical Center, Room ZH4A35, PO Box 7057, Amsterdam NL-1007MB, The Netherlands.
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Emad Y, Ragab Y, Khalifa M, Bassyouni I, El-Shaarawy N, Rasker JJ. Axial involvement with facet joint arthropathy and bony ankylosis in a case of camptodactyly, arthropathy, coxa vara, pericarditis (CACP) syndrome. Joint Bone Spine 2013; 80:520-2. [PMID: 23931850 DOI: 10.1016/j.jbspin.2013.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/14/2013] [Indexed: 11/16/2022]
Abstract
Familial arthropathy associated with congenital camptodactyly has been previously recognized as a definite clinical entity in the literature. The clinical spectrum of this disease seems to be variable. The typical features of congenital camptodactyly, arthropathy, coxa vara and pericarditis (CACP syndrome) appear to be a more frequent presentation in children from the Middle East and North Africa. Musculoskeletal presentation of this rare familial form of arthropathy is unique and heterogeneous. In all previous reports, non-inflammatory pattern of arthropathy involving the peripheral joints with typical coxa vara deformity were described, and in a few cases spine abnormalities, including kyphosis, lordosis, or scoliosis. We describe the first case of axial involvement in a typical case of CACP syndrome with facet joint arthropathy and ankylosis at L5/S1 levels.
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Affiliation(s)
- Yasser Emad
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Cairo, Egypt; Rheumatology and Rehabilitation Department, Dr. Erfan and Bagedo General Hospital, Jeddah, Saudi Arabia.
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Aragón-Sánchez J, Lázaro-Martínez JL, Quintana-Marrero Y, Álvaro-Afonso FJ, Hernández-Herrero MJ. Charcot neuroarthropathy triggered and complicated by osteomyelitis. How limb salvage can be achieved. Diabet Med 2013; 30:e229-32. [PMID: 23590722 DOI: 10.1111/dme.12191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Charcot neuroarthropathy is a severe complication in the feet of patients with diabetes, which can lead to a major amputation. Osteomyelitis and surgery for osteomyelitis have been reported as trigger mechanisms of developing Charcot neuroarthropathy. However, the development of acute Charcot neuroarthropathy triggered by osteomyelitis during conservative antibiotic treatment is not well outlined in the medical literature. CASE REPORTS Two patients apparently developed mid and rear foot Charcot neuroarthropathy, which was clinically suspected while being treated with antibiotics for osteomyelitis. One of them presented osteomyelitis of the navicular bone and subsequently developed acute Charcot neuroarthropathy of the tarsometatarsal joints. The other presented calcaneal osteomyelitis with pathological fracture and developed Charcot neuroarthropathy of the transverse tarsal joint. No offloading had been implemented in either case. A major amputation had been indicated in both cases in their teaching hospitals. Limb salvage was achieved in both cases by means of surgery, culture-guided post-operative antibiotics, intraosseus instillation of super-oxidized solution, bed rest before placing a total contact cast and stabilization of the unstable foot with a total contact cast with an opening for checking the healing course and to detect any complications. The mechanisms of the development of acute Charcot neuroarthropathy in a patient with osteomyelitis are discussed. CONCLUSIONS Osteomyelitis in the feet of patients with diabetes and neuropathy may trigger the development of acute Charcot neuroarthropathy. Fractures and dislocated joints may subsequently become infected from the index focus, producing a severe infected and unstable foot that may require a major amputation. Limb salvage can be achieved in specialized departments.
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Affiliation(s)
- J Aragón-Sánchez
- Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canaria, Spain.
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Ruosi C, Rossi D, Coppola A, Liccardo S, Granata F, Barbato A, Cimino E, Di Minno MND. Our experience about the particular surgical management of total hip replacement in two patients with severe haemophilic arthropathy: case report. Haemophilia 2013; 19:e184-6. [PMID: 23600909 DOI: 10.1111/hae.12130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2013] [Indexed: 11/28/2022]
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Stapleton JJ, Zgonis T. Concomitant osteomyelitis and avascular necrosis of the talus treated with talectomy and tibiocalcaneal arthrodesis. Clin Podiatr Med Surg 2013; 30:251-6. [PMID: 23465813 DOI: 10.1016/j.cpm.2013.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.
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Affiliation(s)
- John J Stapleton
- Foot and Ankle Surgery, VSAS Orthopaedics, Lehigh Valley Hospital, Allentown, PA 18103, USA
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Christensen TM, Gade-Rasmussen B, Pedersen LW, Hommel E, Holstein PE, Svendsen OL. Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker. J Diabetes Complications 2012; 26:430-4. [PMID: 22699112 DOI: 10.1016/j.jdiacomp.2012.05.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Recent literature on acute diabetic Charcot osteoarthropathy (CA) reports unusually long periods of off-loading. Data suggest that this might increase the re-currence rate. Subsequently we evaluated the influence of duration of off-loading on the risk of required re-casting. RESEARCH DESIGN AND METHODS In this retrospective consecutive series from 2000 to 2005, 56 people with diabetes and an acute Charcot foot were included. The inclusion criteria were an initial persistent temperature difference more than 2°C between the two feet, oedema, and typical hot spots on a bone scintigram, radiology, and a typical clinical course. Treatment was off-loading in a removable cast and 2 crutches. In-door walking was allowed. Gradually augmented weight bearing was prescribed when the skin temperature difference had decreased to a level less than 2°C and edema had subsided. Re-casting was required for immediate exacerbation during re-load as well as for recurrence - defined as new swelling and skin temperature difference of more than 2°C in the same foot occurring after a stable interval of at least one month after full weight bearing. RESULTS The duration of off-loading for all patients was 141±21 days (mean±SD). Three patients (5%) were re-casted immediately for exacerbation after re-load and 7 patients (12 %) after recurrence of the CA. Duration of re-casting was 79±44 days. The primary period of off-loading was not statistically significantly different for those not requiring versus those requiring re-casting: 142±24 days compared to 134±41 days. Neither were the differences in demographic data, metabolic regulation, BMI or localization of CA. CONCLUSIONS Patients with risk of exacerbation or recurrence of CA could not be identified in the present study and there was no relation to the duration of off-loading. Nevertheless off-loading periods with immobilisation should be kept as short as possible, due to other side effects. This can be obtained by early gradual augmented re-loading.
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Affiliation(s)
- Tomas M Christensen
- Endocrine Research unit, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark, 2400 NV Copenhagen.
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Engberg S, Jensen JEB, Kønig KB. [Charcots arthropathy causing hypoparathyroid hypercalcaemia]. Ugeskr Laeger 2012; 174:1995-1997. [PMID: 22929578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A 45-year-old woman with type 2 diabetes and multiple diabetic complications was diagnosed with hypoparathyroid hypercalcaemia. The bone scintigraphy showed Charcots arthropathy. Blood tests, computer tomography and mammography did not give any indication of malignancy, vitamin-D intoxication nor hyperthyroidism. Charcots arthropathy is not a recognized cause of hypoparathyroid hypercalcaemia, but the mechanism might be increased boneresorption. We recommend that Charcots arthropathy is considered a cause of hypoparathyroid hypercalcaemia in patients with diabetic neuropathy.
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Drouet C, Brunot B, Karcher G. [Neurogenic paraosteoarthropathy]. Rev Prat 2012; 62:168. [PMID: 22408852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Clément Drouet
- Service de médecine nucléaire, SSM hôpital de Freyming-Merlebach, 57800 Freyming-Merlebach
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