Use of NaF and FDG PET/CT Scan for the Assessment of Charcot Joint in Charcot-Marie-Tooth Disease: All That Glitters is Gold?

Increasingly Charcot neuroarthropathy (CN) is being recognized in patients with Charcot-Marie-Tooth (CMT) disease. In this report, we describe a case of CN in a CMT patient, adding to the very scarce literature describing this association. We additionally report his unique evaluation with fluorodeoxyglucose (FDG) and sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) scanning, the study of which is limited in CN despite its promising role. A 54-year-old known case of CMT, presented with left foot pain, and swelling for 4 months. Weakness and sensory deficits as a result of CMT were evident in both lower and upper limbs. His x-ray was suggestive of CN. Both FDG and NaF PET/CT scanning demonstrated increased tracer uptake in the first tarsometatarsal joint (TMTJ), in keeping with CN. Recognition of the association of CMT with CN is of vital importance as early diagnosis relies on high clinical suspicion. Characterizing risk factors of CN in CMT patients is still under study. Moreover, there is lack of data evaluating the role of PET/CT in CN and specifically in the context of CMT.

Rare complication of rheumatoid arthritis: Charcot Neuro-osteoarthropathy.

BACKGROUND: Rheumatoid arthritis (RA) is an autoimmune disease.However, there are few cases of Charcot Neuro-osteoarthropathy (CN) caused by rheumatoid diseases in clinical reports. It is not easy to pay attention to the diagnosis of CN in the complications of rheumatoid disease, which greatly increases the probability of misdiagnosis and missed diagnosis. This case reported a rare complication of rheumatoid arthritis, Charcot arthritis, and the molecular mechanism and diagnosis and treatment of CN caused by RA were systematically discussed. CASE PRESENTATION: The patient, a 79-year-old woman, was hospitalized due to bilateral shoulder pain, limited activity for half a year, aggravated for 4 months to the hospital. During this period, the symptoms did not improve after treatment with acupuncture and Chinese medicine. The patient was previously diagnosed with rheumatoid arthritis for more than 3 years and intermittent irregular use of methylprednisolone and methotrexate for 2 years. She had a history of osteoporosis. PHYSICAL EXAMINATION: symmetrical malformed swelling of the finger joints of both hands; Bilateral supraspinatus and deltoid muscle atrophy, tenderness at the acromion, and attachment of the long head tendon of the biceps brachii were observed. The left Dugas test and the right Dugas test were positive.Blood test: anti-cyclic citrullinated peptide antibody (A-CCP) 33.10U/ml (normal range: 0-5RU/ml); antinuclear antibody quantification (ANA) 47.40AU/ml (normal range: Negative or < 32); anti-double stranded DNA IgG antibody quantification (dsDNA) 31.00 IU/ml (normal range: 0-100 IU/ml); D-Dimer 6.43 µg/ml (normal range: 0-0.5 mg/L); erythrocyte sedimentation rate (ESR) was 27 mm/h (normal range: < 20 mm/60 min). C-reactive protein (CRP) 39.06 mg/L(0.068-8 mg/L).MRI 3.0 T enhancement of bilateral shoulder joints, cervical spine and thoracic spine showed: 1.Large bone destruction, cartilage injury, multiple effusion, synovitis, obvious on the right side. 2.Intervertebral disc degeneration, cervical 3/4, 4/5, 5/6, 6/7 disc herniation, with cervical 3/4 obvious, posterior central herniation; CONCLUSIONS: Rheumatoid arthritis complicated with Charcot's joint is rare. Clinically, patients with rheumatoid diseases should not ignore Charcot's joint complications because of rareness. Early blood inflammatory markers, neuro electrophysiology, and imaging MRI of rheumatoid CN are of great significance for the diagnosis of this mild or early neurovascular inflammation. Early diagnosis and treatment are helpful to prevent further joint injury. The clinical diagnosis, treatment, and molecular mechanism of osteolysis in RA and peripheral sensory nerve injury remain to be further revealed.

Management of the Hindfoot and Ankle in Charcot Arthropathy.

Neuropathic destabilization of the hindfoot and/or ankle is a significant complication for the patient with diabetes/neuropathy. The loss of ligamentous integrity and bony destruction results in a limb that is not stable for weight bearing. This loss of independence adds significant health risks to the patient. Management of this disease process is both time consuming and technically demanding for both the practitioner and the patient. Attention to detail and aggressive decision making is often necessary to salvage the limb. The goal for treatment is to produce a stable, weight-bearing limb that is shoeable and free from soft-tissue ulceration.

Intraoperative Radiation Exposure During Midfoot Charcot Reconstruction.

While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ .05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5 ± 5.39 mGy and 256.64 ± 130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p = .32) or fluoroscopy times (p = .71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p = .01) body mass index (p = .03) and number of stages (p = .04). Similarly, a relationship existed between fluoroscopy time with weight (p = .02), body mass index (p = .03), and number of beams/screws (p = .003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.

Prevalence of Ankle Charcot Neuroarthropathy Presenting in a Tertiary Care Center.

Charcot neuroarthropathy's (CN) anatomic classification was originally formulated by the Brodsky article and the Trepman et al modification, including midfoot (type 1), rearfoot (type 2), ankle (type 3a), calcaneus (type 3b), multiarticular (type 4), and forefoot (type 5). In these classic studies, ankle joint and multijoint CN are reported as 9% and 6% to 9%, respectively, but we believe ankle CN to be more common than that in a tertiary setting. We retrospectively reviewed patients presenting initially or as referral between 2004 and 2020. Initial presentation radiographs were reviewed and classified by 3 authors based on Brodsky's model with Trepman and colleagues' modification, and any discrepancies were reviewed by the fourth author. A total of 175 patients (205 feet) were assessed. This revealed 80 cases classified as type 1 (39.0%), 23 cases type 2 (11.2%), 17 cases type 3a (8.3%), 2 cases type 3b (1.0%), and 83 cases type 4 (40.5%). After subdividing type 4, total prevalence included 150 with type 1 anatomic location (73.2%), 103 type 2 (50.2%), 44 type 3a (21.5%), and still 2 type 3b (1.0%). This study revealed a similar prevalence of isolated ankle CN (8.5%) compared to the Trepman et al article (9%), however, in total, ankle CN (21.5%) occurred 2.4-times more than the original 9%. Our study also found there to be a higher prevalence of ankle CN in the setting of multiarticular CN, which has not been evaluated in past studies. The prevalence of multiarticular CN was found to be 4.5-fold greater than the Trepman article (6%-9%).

Neuropathic arthropathy of the shoulder secondary to operated syringomyelia: a case-based review.

Neuropathic arthropathy (NA) is a long-term progressive disorder that causes joint destruction in the existence of a neurologic deficit. Minor injuries and fractures are commonly overlooked until the visible joint deterioration becomes persistent. Syringomyelia is one of the important causes of NA. The appearance of clinical signs in syringomyelia is caused by longitudinal cysts formed in the cervical and cervicothoracic regions of the spinal cord. Depending on the existence of the underlying disorder, the number and localization of the syrinxes, a range of symptoms, involving pain, sensation deficit, loss of motor function, and deep tendon reflex abnormality, emerge. The case is here described of a 68-year-old female patient with shoulder NA following syringomyelia, who partially responded to the rehabilitation program. Furthermore, the available case reports were comprehensively reviewed on Web of Science, Scopus, and PubMed/Medline. Furthermore, the available case reports were comprehensively evaluated on Web of Science, Scopus, and PubMed/Medline. Thus, we aimed to present the demographic characteristics, symptoms, physical examination signs, treatment, and follow-up parameters of syringomyelia-related shoulder NA cases.

Multi-joint Charcot arthropathy caused by cervical spondylotic myelopathy and adult degenerative scoliosis with syringomyelia: a case report.

BACKGROUND: Charcot arthropathy, also known as neuropathic arthropathy, is a rare disease whose early diagnosis and treatment are very difficult. Generally, diabetes is considered the most common cause of Charcot arthropathy. Although Charcot arthropathy of other secondary etiology has been reported, in most cases only a single joint is accumulated, and rarely involving the feet and shoulders. Clinically, Charcot arthropathy due to delayed diagnosis leads to joint destruction and severe cases abound. CASE PRESENTATION: What we report is an unprecedented case, in which the patient was diagnosed as left shoulder joint, interdigital joint Charcot arthropathy caused by cervical spondylotic myelopathy (CSM) and left knee and right ankle Charcot arthropathy caused by adult degenerative scoliosis (ADS) complicated by syringomyelia. The 82-year-old male patient was admitted to the hospital for complaining of pain in the left knee joint. Except for scoliosis that was discovered 10 years ago, the patient denied any other obvious past medical history. Clinical/surgical manifestations, detailed physical examinations and auxiliary examinations all indicated the presence of polyarticular Charcot arthropathy, but common causes of Charcot arthropathy such as diabetes and syphilis have not been detected. After making a comprehensive differential diagnosis, we finally made the above diagnosis. CONCLUSIONS: This previously unreported case describes the complexity and etiological diversity of Charcot arthropathy. We recommend that patients with CSM and/or scoliosis, spinal deformity undergo further examination and regular follow-up. A detailed medical history and careful physical examination are necessary for the correct diagnosis of Charcot arthropathy. Although the early diagnosis of Charcot arthropathy cannot change the natural course of the disease, it is beneficial to alleviate symptoms and prevent serious complications.

Progression to Hindfoot Charcot Neuroarthropathy After Midfoot Charcot Correction in Patients With and Without Subtalar Joint Arthrodesis.

Charcot neuroarthropathy (CNA) is a disabling and progressive disease that affects the bones and joints of the foot. Successful Charcot reconstruction focuses on restoring anatomic alignment, obtaining multiple joint arthrodesis, selecting stable fixation, preserving foot length, and creating a foot suitable for community ambulation in supportive shoegear. Intramedullary fixation arthrodesis of the medial and lateral columns has been previously reported to produce improvement in midfoot Charcot reconstruction. More recently, a growing trend of stabilization of the subtalar joint (STJ) has been incorporated alongside the medial and lateral column fusion. Our objectives were to retrospectively review patients who underwent midfoot Charcot reconstructive surgery, whether with or without accompanying STJ arthrodesis, and establish which patients progressed to ankle CNA. Of the 72 patients who underwent midfoot Charcot reconstruction, 28 (38.9%) underwent STJ arthrodesis, and 22 converted to ankle CNA (30.6%). Fourteen (63.6%) of 22 ankle CNA cases had not undergone STJ arthrodesis; 8 patients (36.4%) had it. A Fisher exact test was performed to identify the relationship between those without STJ arthrodesis and those progressing to ankle CNA; it revealed statistical significance (p = .001). Performing an STJ arthrodesis with midfoot Charcot reconstructive surgery may be beneficial to aiding in hindfoot stability, establishing a plantigrade foot, and providing further insight into the management of midfoot Charcot.

Neuropathic arthropathy of the shoulder as a presenting feature of Chiari malformation with syringomyelia: a case report with a systematic literature review.

BACKGROUND: Neuropathic arthropathy (NA) of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Syringomyelia, a spinal cord disease, is the leading cause of NA in the upper extremity. OBJECTIVE: We present a systematic review of NA with syringomyelia cases alongside a case report of an adult with NA of the shoulder that occurs a few 4 years after a revelation and surgical management of a Chiari malformation with syringomyelia. METHODS: A systematic review was conducted following PRISMA guidelines. A PubMed, Scopus, Isiknowledge, and manual search through references of relevant publications were used to identify all published case reports of NA. Data were collected from each case report on patient characteristics. RESULTS: The systematic review identified 56 publications and 85 patients (including ours): nearly the same number of males (n = 41) and females (n = 44). The mean age was 50,69. Presentations included reduction of mobility (n = 66), swelling (n = 61) and sensory disorder (n = 63). The pain was absent in 41 cases. In the majority of reported cases 56 (65.1%), syringomyelia was revealed by neuropathic arthropathy, and eleven patients (12.9%) had a history of syringomyelia. Treatment was categorized into non-operative management (37[43.5%]), operative management (27[31.7%]). Following-up was non-reported in 31 (36%) cases. Improvement was reported more with patients who underwent a surgical approach than medical one 28.5% versus 8.1%. CONCLUSION: Physicians need to be more aware of this destructive joint disease, rare, and often misdiagnosed. Also, it is imperative to integrate clinical, pathological, and imaging findings for accurate diagnosis and for delivering appropriate therapy.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy.

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.

Radiodensity Analysis of Medial Column Superconstruct Fixation Sites in Midfoot Charcot Neuroarthropathy.

Charcot neuroarthropathy (CN) is a highly destructive, pathologic process with devastating consequences to foot structure and viability. The use of intramedullary fixation "superconstructs" allows for "re-bar" support of compromised bone and allows for some dynamic fixation. This study examines radiodensity in Hounsfield units (HU) to compare bone quality of medial column fixation targets using computed tomography scans between patients with and without midfoot CN. A retrospective chart review identified control (nondiabetic, non-CN; n = 29) and midfoot CN (n = 21) groups. Patient demographics and medical history were collected. Two reviewers measured the mean HU of a circular region of interest centered on the first metatarsal head and the anterior, middle, and posterior thirds of the talar body. Radiodensity was compared between groups, and among talar locations, Eichenholtz stages and Brodsky types, with statistical significance set at p ≤ .05. Age and body mass index were not significantly different between groups. The CN group maintained greater mean HU than the control group at the metatarsal head (p < .001), and talar body locations (p < .019). The difference in mean HU of these bones was not statistically significant between Stages 0 to 1 and Stages 2 to 3 or Brodsky Types 1 and 2. Mean HU differences among talus positions were not statistically significant. Indirect bone density analysis using HU showed an increased density in CN patients with no significant difference among talar body locations or midfoot Charcot stages and types. These results may assist in optimizing fixation length. Future studies may examine these densities in ankle CN.

Shoulder arthropathy secondary to syringomyelia: case series of 10 patients.

PURPOSE: Neuroarthropathy is a progressive joint degeneration secondary to neurological diseases. In the upper extremity, the shoulder is the most exposed, and it is mainly caused by syringomyelia. This condition is rare; therefore, the literature has documented only a few case reports or case series of small groups of patients. METHODS: We collected data about patients with shoulder arthropathy due to syringomyelia who were treated in our two institutes and collected among members of the Polish Shoulder and Elbow Society. Our analysis was based on epidemiological data, symptoms, and clinical examinations. We also examined the results of diagnostic tests, including-spinal cord MRI and shoulder X-ray, and treatment methods and their effectiveness. RESULTS: The examined group included 10 women with an average age of 63 years. Of these, nine patients reported pain, seven reported-swelling, and nine reported-weakness. In every patient, diagnosis was confirmed by X-ray of the shoulder with joint degeneration and MRI of the spinal cord with syrinx. Two patients were operated with reverse shoulder arthroplasty; the first one had excellent result-significant active range of motion improvement and reduction of symptoms, and the second one had a good result-pain relief and moderate range of motion improvement. Other patients were conservatively treated, resulting in total or partial symptoms relief but without significant range of motion improvement. CONCLUSION: Charcot shoulder secondary to syringomyelia was mainly manifested by range of motion limitation, swelling, and pain. Both conservative and surgical treatments could be a good solution. However, if reverse arthroplasty is technically possible, it seems to be the most promising treatment for recovering function.

MRI-based early diagnosis: a diabetic Charcot spine case report.

BACKGROUND: Spinal neuroarthropathy (SNA), also known as Charcot spine, is an uncommon aggressive arthropathy, secondary to loss of proprioceptive and nociceptive feedback from the spine. A diagnosis of SNA is frequently delayed due to the scarcity of symptoms in its early stages, leading to significant neurological deterioration. Therefore, prompt suspicion of the disease is critical to providing better outcomes. This case assembles two rare characteristics of SNA: diabetic aetiology and a precocious time of diagnosis, and aims to highlight the magnetic resonance imaging (MRI) findings that allowed for the diagnosis. CASE PRESENTATION: A 44-year-old woman, with long-term type 1 diabetes, presented with a two-month history of progressive lumbar pain, difficulty in maintaining an upright position, and discrete trunk forward-leaning. Diabetes-related vasculopathy and nephropathy were already known, and laboratory test results did not show any new abnormalities. A lumbar MRI revealed extensive signal intensity changes of the L2 and L3 vertebral bodies associated with marginal areas of enhancement and the involvement of regions adjacent to interapophyseal articulations and spinous processes from L2-L3 to L5-S1, in association with degenerative changes of the thoracolumbar spine. These findings were identified by the radiologist as suggestive of SNA. To rule out neoplastic and infectious disease, a bone biopsy at the L2-L3 level was executed. The pathology report revealed intervertebral disc material and fragments of fibrous tissue, with a complete absence of inflammatory cells. It was decided to perform a six-month MRI follow-up, which showed stability of the findings, confirming the hypothesis of Charcot spine. The patient was under clinical and radiological follow-up and did not require surgical fixation at the moment of diagnosis. After 2.5 years from the initial diagnosis, a new MRI revealed progression of the lesions with oedema and enlarged paravertebral soft tissues; these findings are compatible with the patient's latest complaints of lumbar pain recurrence. CONCLUSION: To the best of our knowledge, this is the first case report of an MRI-based early diagnosis of diabetic SNA, a rare disease with nonspecific symptoms in its initial stages and a wide spectrum of differential diagnoses. The MRI findings, distinctly the involvement of both anterior and posterior spinal elements, were the key to allowing for the proper diagnosis. A precocious diagnosis, although challenging, is fundamental to providing early intervention and to preventing further neurological impairment.

Charcot Arthropathy of Foot and Ankle: Radiographic and Clinical Patterns with Related Outcomes.

PURPOSE: Our aim is to retrospectively review and evaluate the patterns of affection of Charcot arthropathy of foot and ankle. METHODS: Two hundred twenty-eight patients (235 feet) with post-acute Charcot were reviewed and classified anatomically through plain radiographs into type I and type II based on single or multiple regions affected, respectively. Type I included ankle, Lisfranc (tarsometatarsal), naviculocuneiform, forefoot, and hindfoot which includes one of the following: talonavicular joint, calcaneocuboid joint, or calcaneus. Type II included peritalar, perinavicular, mid-tarsal Charcot, or any other combination. Both types were further classified into four stages (A, stable with no deformity; B, stable with deformity; C, unstable; and D, deformity/instability with associated mechanical ulcers). RESULTS: The most common type was type IIC (27.2%) followed by type IID (18.3%), while types IA and IIA represented the least common types (3.4% and 3.8%, respectively). Types IA and IIA were managed conservatively. All patients in types IC, ID, IIB, IIC, and IID and the majority of type IB received fusion surgery to achieve stability and correction of deformity. Type II D had the highest complication rate (30%). Five patients ended up with amputation, and all were stage IID. CONCLUSION: Affection of single region has better prognosis than affection of two or more regions. Stage A has the best prognosis and can be managed conservatively provided good diabetes control. Surgery is indicated in all cases of types IC, ID, IIB, IIC, and IID to achieve stability and correction of deformity and prevent complications. Mechanical ulcer (stage D) carries the worst prognosis and highest complication rate.

Are the Sanders-Frykberg and Brodsky-Trepman Classifications Reliable in Diabetic Charcot Neuroarthropathy?

The purpose of this study was to assess the intra- and inter-reader reliability of the 2 Charcot neuroarthropathy classifications (Sanders-Frykberg and Brodsky-Trepman), as well as Eichenholtz staging. We hypothesized that the inter-reader reliability, with respect to these 3 classification systems, would be moderate at best. Digital radiographic images were organized in a digital slide presentation without clinical information. All 5 reviewers underwent a standard training session administered by the principal investigator, reviewing 5 cases of Charcot neuroarthropathy. Images of 55 cases of Charcot neuroarthropathy and 5 normal cases were distributed to each of the 5 physicians electronically, who independently rated all 60 cases according to the 3 classification systems. The 95% confidence interval of the intraclass correlation coefficient estimate for Sanders-Frykberg was 0.9601 to 0.9833 at week 0 and 0.9579 to 0.9814 at week 8, which can be regarded as "excellent" reliability. For Trepman-Brodsky, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.8463 to 0.9327 at week 0 and 0.8129 to 0.9226 at week 8, which can be regarded as "good" to "excellent" reliability. For Eichenholtz, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.6841 to 0.8640 and 0.6931 to 0.8730 at weeks 0 and 8, respectively, which can be regarded as "moderate" to "good" reliability. The classification systems of Charcot neuroarthropathy are an important tool for communication among physicians. Based on the results at our institution, the Sanders-Frykberg classification exhibited the best inter-reader performance. The Trepman-Brodsky classification exhibited good to excellent reliability as well. The intraclass correlation coefficient of the Eichenholtz classification was moderate to good.

A Systematic Review of Angular Deformities in Charcot Neuroarthropathy.

Charcot neuroarthropathy of the foot and ankle is associated with periarticular deformities and progressive radiographic changes. There have been studies analyzing the radiographic angulations and deformity progression in Charcot neuroarthropathy deformity. The aim of this paper is to provide systematic review of studies that evaluate foot and ankle radiographic parameters in patients with Charcot neuroarthropathy. A multidatabase search including, medline, EMBASE, Google Scholar, Cochrane Library, Clinicaltrials.gov and reference lists of included studies, was performed from 1980 to 2020. A total of 7 articles were included that analyzed radiographic angulations in Charcot neuroarthropathy deformity. The articles could be categorized into nonoperative angulation measurements, and pre- versus postoperative angulation measurements. The presence of ulcerations and the severity of the Charcot neuroarthropathy deformity were found to result from predominantly sagittal plane deformity. The deformity initiates with medial column collapse and progresses to continual lateral column collapse. Surgical intervention resulting in immediate postoperative improvement in angular measurements, however, without beaming of both the medial and lateral column, there was recurrence of the lateral column deformity. This systematic review of articles analyzing angular deformities in Charcot neuroarthropathy patients, demonstrates the progressive sagittal plane breakdown patterns of Charcot as well as the benefits of surgical intervention.

Fracture of the Bone Inducing Its Necrosis as the End Point in the Evolution of Untreated Neuroarthropathy.

We describe here the case of a female patient with type I diabetes who developed active Charcot neuroarthropathy in the foot. Due to therapeutic noncompliance, talus necrosis was discovered 2 years after the presentation of neuroarthropathy. The impact of untreated neuroarthropathy on the bone is commonly described as fracture and joint dislocation, but we describe the complete disappearance of the bony structure and its necrosis associated with active neuroarthropathy in a patient who refused offloading.

Midfoot Charcot Neuro-arthropathy Precipitated by First or Fifth ray Amputation.

BACKGROUND: Charcot Neuro-arthropathy (CN) can occur spontaneously in a neuropathic foot but is often precipitated by an insult to the foot, such as trauma. We noted an association between 1st and 5th ray amputations and the development of midfoot CN in our clinics. We therefore set out to analyse our data over a 6-year period to evaluate and improve our practice. METHODS: Our project encompassed all diabetic adults with peripheral neuropathy undergoing an amputation of the first or fifth ray between January 2013 and January 2019. Patient demographics, stump length, progression to CN, imaging reports, the need for further operative management, length of stay and operating specialty were collected. Cases that developed CN after 1st or 5th ray amputation ("CN group") were compared with a cohort composed of patients that did not ("non-CN group"). RESULTS: We identified 92 patients (98 surgical episodes) who had previous 1st or 5th ray amputations [77 males (83.7%), 15 females (16.3%), mean age 61.5 ± 13.5]. Midfoot CN developed in 16 cases (17.4%; nine following 1st ray and seven following 5th ray amputation). This represented 30.9% of all our new CN cases. CN was diagnosed within six months in six cases and up to three years in the remaining 12. Five of the 1st ray amputations were conducted with a stump length of ≤10 mm from the tarsometatarsal joint and a further one had resorbed down to it before the Charcot process. Three of the 5th ray amputations were carried out leaving a stump length ≤25 mm. Receiver Operator Curve (ROC) analysis showed no obvious diagnostic value of stump length in predicting CN (area under the curve 0.42 (95% CI 0.26 - 0.59)). Following a logistic regression analysis into effect of age, gender and peripheral vascular disease, only age was found to significantly affect the risk of developing CN (Nagelkerke R2 = 0.122, p = 0.013). CONCLUSION: This is the first report of midfoot CN developing after 1st or 5th ray amputations. The foot could be destabilised following these procedures, leading to increased pressures across the midfoot. Our small sample was unable to demonstrate a significant correlation between stump length and CN risk. However, more work is needed to ascertain this. Meanwhile, we believe this translates clinically into a need for enhanced foot protection following 1st and 5th ray amputations in our practice.

Charcot Midfoot Reconstruction: Does Subtalar Arthrodesis or Medial Column Fixation Improve Outcomes?

Charcot neuroarthropathy is a complication of neuropathy often secondary to diabetes mellitus and most commonly affects the midfoot. In these patients, reconstruction of the foot may be required for limb salvage. A superconstruct technique has previously been described using intramedullary beaming fixation of the midfoot and hindfoot to span the zone of injury. Inclusion of the subtalar joint in the arthrodesis construct is not consistently performed among different surgeons. The aim of this study was to describe midfoot beaming constructs and postoperative complications after midfoot reconstruction with and without subtalar arthrodesis. We reviewed medical records of patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct. Patients included in the study had at least 3 months of follow-up and had Sanders-Frykberg II/III classification of Charcot neuroarthropathy. Postoperative radiographs were evaluated for evidence of hardware failure at the latest follow-up evaluation. The main variables of interest were: hardware failure or nonunion requiring revision operation, deep infection, and unplanned reoperation. Thirty patients who underwent midfoot reconstruction were included. The mean follow-up was 67.4 ± 25.9 weeks. Twenty-two (73.3%) patients had concomitant subtalar arthrodesis and midfoot beaming. Overall complications were lower in patients with subtalar arthrodesis (40.9%) than those without subtalar arthrodesis (75%) resulting in an odds ratio of 0.271 (0.042-1.338, p = .146). Furthermore, increased number of screws used in the midfoot construct was negatively correlated with complications (r = -0.44, p = .01). An intramedullary midfoot beaming superconstruct with subtalar arthrodesis has previously been proposed to provide better fixation after midfoot beaming Charcot neuroarthropathy reconstruction. Our results suggest including the subtalar joint as part of a superconstruct for the reconstruction of Sanders-Frykberg II/III Charcot results in an 80% lower complication rate than intramedullary beaming alone. We also found an increased number of screws used in the midfoot results in a lower complication rate.

Computer-Assisted Gradual Correction of Charcot Foot Deformities: An In-Depth Evaluation of Stage One of a Planned Two-Stage Approach to Charcot Reconstruction.

The surgical treatment of Charcot foot is a widely debated topic, with issues ranging from when to operate to how to properly correct a deformity. Historically, correction of a severe deformity was attempted in 1 acute surgical procedure that frequently required open reduction and internal fixation through large incisions. This 1-time procedure would often result in complications including under- or overcorrection of the deformity, neurovascular injury, or incision dehiscence leading to possible soft-tissue infection or osteomyelitis. This retrospective case series aims to evaluate stage 1 of a planned 2-stage approach to Charcot deformity correction, consisting of gradual modification with the use of computer-assisted external fixation. The purpose of using gradual correction was to safely and accurately correct the Meary and calcaneal inclination angles, which were measured using preoperative and postoperative digital radiographs. The procedure was performed on 18 Charcot foot deformities in 18 patients. Each of the feet had a notably significant rocker bottom deformity and most contained an ulceration. Complete ulcer healing was noted in 100% (13/13) of feet with an ulcer, and a statistically significant corrected Meary's (p < .05) and calcaneal inclination angle (p < .05) to within a normal range was achieved in all deformity corrections with few postoperative problems and complications noted. Average patient follow-up was 39.6 months with a minimum of at least 12 months necessary for inclusion in the study. Therefore, gradual Charcot deformity correction through the use of computer-assisted hexapod external fixation, demonstrates safe, accurate, and reproducible characteristics that adequately prepares the lower extremity for stage 2, the implantation of rigid internal fixation.