Charcot neuroarthropathy patient education among podiatrists in Scotland: a modified Delphi approach.

BACKGROUND: This evaluation sought to determine current Charcot neuroarthropathy (CN) diabetes patient education practices among Scottish National Health Service (NHS) and academic podiatrists and evaluate novel visual tools and develop expert consensus for future practice. METHODS: Questionnaires collected mixed qualitative and quantitative responses, analysed concurrently within a convergence coding matrix. Delphi methodology permitted member-checking and agreement of consensus over two rounds. RESULTS: Fourteen participants (16.28%) completed a Round One questionnaire, leading to the generation of four themes; Experience; Person-Centred Care and the Content and Context of CN patient education. Seven consensus statements were subsequently developed and six achieved over 80% agreement among 16 participants (18.60%) with a Round Two questionnaire. Respondents agreed CN patient education should be considered for all 'At-risk' individuals with diabetic peripheral neuropathy (DPN). Verbal metaphors, including the 'rocker-bottom' foot, soft or brittle bones, collapsing, walking on honeycomb and a shattering lightbulb were frequently employed. Visual tools, including visual metaphors and The Charcot Foot Thermometer, were positively evaluated and made available online. CONCLUSIONS: Key findings included respondent's belief that CN education should be considered for all individuals with DPN and the frequent use of simile, analogy and metaphor in CN education. The concept of 'remission' proved controversial due to its potential for misinterpretation.

High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot.

Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.

A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot.

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.

Surgical treatment of the Charcot foot.

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.

Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes.

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.

[Management of midfoot instability in Charcot foot with the ring fixator : Use of a hybrid technique with internal and external stabilization]. / Behandlung von Fußwurzelinstabilitäten bei Charcot-Fuß mit dem Ringfixateur : Anwendung der Hybridtechnik mit interner und externer Stabilisierung.

OBJECTIVE: Combination of external and internal fixation for improvement of stabilization in midfoot arthrodesis. INDICATIONS: Charcot foot of the midfoot with/without (infection-free) ulceration. CONTRAINDICATIONS: Severe anesthesiological risks in multimorbid patients; untreated symptomatic peripheral arterial occlusive disease; severe soft tissue infection and defect with the necessity of amputation. SURGICAL TECHNIQUE: Performing subtractive resection arthrodesis of the midfoot with locking plates and screws combined with an external ring fixator of the foot and lower leg. POSTOPERATIVE MANAGEMENT: Postoperative partial weight bearing with sole contact and walking frame for 3 months. Then removal of external fixator, CT scan and based on the result, staged increasing of stress load with short-leg cast over a period of 4-6 weeks. Podomechanotherapy with full weight bearing. RESULTS: With this surgical procedure, sufficient stabilization with fully load bearing, plantigrade foot with podomechanotherapy with the help of a combined internal and external fixation is possible. Complications (pin-tract infection or dislocation) exist, but they can be controlled. High healing rate of ulceration was achieved by bony position correction and stabilization.

Medical management of Charcot arthropathy.

Charcot arthropathy is a major complication of diabetes and it poses management challenges to health care professionals. Early diagnosis and timely intervention are essential for improved outlook of these patients. Casting therapy has been accepted as the mainstay treatment of the acute Charcot foot, although there are still controversies regarding its duration, the choice of removable and non-removable device and weight-bearing casts vs. non-weight-bearing casts. Two groups of antiresorptive therapies have been evaluated in the treatment of the acute Charcot foot, bisphosphonates (intravenous and oral) and calcitonin. These therapies have clearly shown a reduction of bone turnover, although, they have not shown a significant effect on temperature reduction. Current evidence to support their use is weak. An anabolic agent to speed up clinical resolution and fracture healing may be helpful and a clinical trial to evaluate the possible benefit of 1-84 recombinant human parathyroid hormone on fracture healing in the acute Charcot foot is in progress. This paper summarises the current approach to medical management of acute Charcot arthropathy with specific emphasis on casting and pharmacological therapy. Emerging new studies of the pathogenesis of this condition are also discussed.

Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker.

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.

Artropatía de Charcot. Importancia del diagnóstico en fase aguda / Charcot's neuroarthropathy. Importance of the diagnosis in the acute phase

La neuroartropatía de Charcot es una enfermedad de carácter progresivo. Está asociada con neuropatía periférica grave. Se caracteriza por inflamación, luxación articular y destrucción ósea con deformación posterior del pie. Es importante sospecharla ante todo paciente diabético con tumefacción, calor y rubor en tobillo o pie, con ausencia de sensibilidad vibratoria, al monofilamento y de reflejos rotulianos y aquíleos. Su prevalencia es baja. Actualmente la causa más frecuente es la diabetes mellitus. El objetivo del tratamiento es llegar a la etapa de consolidación con un pie plantígrado y calzable(AU)

Charcot's neuroarthropathy is a progressive disease. It is associated with severe peripheral neuropathy. It is characterized by inflammation, joint dislocation and bone destruction with subsequent foot deformity. It should be suspected in any diabetic patient who has swelling, heat and redness in the ankle or foot, with absence of vibratory sensation, to monofilament and patellar and Achilles reflexes. Its prevalence is low. Currently the most common cause is diabetes mellitus. The goal is to reach the stage of consolidation with a plantigrade foot and the possibility of wearing shoes(AU)

Descripción de un caso de neuroartropatía de Charcot y tuberculosis de tobillo / Description of a case of Charcot's neuroarthropathy and ankle tuberculosis

Presentamos a un varón de 68 años con dolor y deformidad progresiva en pie derecho, de evolución tórpida, secundario a un traumatismo. Dos años después del traumatismo presenta tumefacción dolorosa en región periaquílea externa que desemboca en fístula y precisa limpieza quirúrgica. A los 6 meses de la cirugía se obtiene cultivo positivo para M. tuberculosis y el cuadro se considera una neuroartropatía de Charcot (NC). Las causas más frecuentes de NC son diabetes, tuberculosis (TBC) y sífilis. La TBC articular es rara en los países desarrollados; es frecuente un retraso en su diagnóstico (12–18m). Cualquier articulación se puede afectar, en tobillo es infrecuente (7,4%). Puede estar precedida de un traumatismo articular (37%). El mecanismo fisiopatológico de la NC es independiente de la causa. Existen múltiples causas de NC, incluso un traumatismo menor puede desencadenar una cascada inflamatoria, que estaría iniciada por citoquinas proinflamatorias relacionadas con el sistema RANKL/OPG, que es el sistema enzimático responsable del metabolismo óseo. De diagnóstico diferencial difícil, se puede confundir con otras entidades y hay que sospecharla siempre que aparezca un cuadro inflamatorio. El tratamiento es fundamentalmente médico, en algunos casos se emplean bifosfonatos, aunque puede requerir cirugía. La rehabilitación debe ir orientada a minimizar secuelas y a la optimización funcional (AU)

A 68 years old man is presented. The patient complained of long term pain and progressive deformity of his right foot, attributed to a traumatism. Two years after the traumatism a painful inflammation was developed at the lateral region of the ankle, whith a fistulae and then surgery was needed. 6 month after surgery a positive culture for M. tuberculosis is obtained and finally a Charcot neuroarthropaty (CN) was considered. The more frequent causes of CN are diabetes, tuberculosis and syphilis. Articular tuberculosis is not common in developed countries and a delay on diagnosis is usual (12–18mo). Any articulation can be affected, but ankle is infrequent (7.4). In 37% of cases it is preceded by a traumatism. The physiopatological mechanism of CN is independent of the cause. There are multiple situations causing CN and a minor traumatism can trigger an inflammatory cascade, iniciated by proimmflamtory cytoquines related to the RNKL/OPG system, involved in the bone metabolism. The differential diagnosis is difficult because CN is similar to other conditions, but it should be suspected if an inflammatory reaction is present. Treatment is basically pharmacological, sometimes biphosphonates are used but surgery may be required. Rehabilitation is oriented to avoid sequelae and to optimize functionality (AU)

Neuromuscular deformity: treatment with external fixation.

A multiplanar foot deformity is defined by the presence of more than one deformity affecting the foot. These deformities may develop in any plane, including the frontal, sagittal, or transverse planes. This article focuses on the treatment of multiplanar neuromuscular foot deformities with external fixation, reviewing the indications, preoperative planning, techniques, and complications.

PNF-based rehabilitation in patients with severe haemophilic arthropathy--case study.

Haemophilia is a congenital haemorrhagic diathesis that in its most severe form leads to a seriously disabling arthropathy as a result of recurring intraarticular bleeding. Within the last couple of years there have been significant advances in the treatment of haemophiliacs that are helping to prevent crippling musculoskeletal deformities, but a relatively large number of young adults still present with advanced arthropathic changes when treatment was started too late or has failed to prevent changes from taking place. We present the case of a 44-year-old male with advanced haemophilic arthropathy of the knee and ankle joints, who, during 8 weeks of therapy that consisted of physical therapy and rehabilitation using PNF techniques (Proprioceptive Neuromuscular Facilitation), achieved mobility improvement according to the SPPB scale (Short Physical Performance Battery Test) and a reduction of pain in the knee and ankle joints, according to a VAS scale. The therapeutic regimen proved to be an effective method improving the locomotor function of the patient.

Charcot neuro-osteoarthropathy-current standards.

It is extremely important to have a high index of suspicion for Charcot neuro-osteoarthropathy (CN) and to encourage early presentation of the patient. This should be followed by a rapid diagnosis and early intervention, and with such a modern approach many CN can now be healed and deformity prevented. CN can be divided into two phases: acute active phase and chronic stable phase. The acute active phase includes those patients presenting early with normal X-ray and those presenting later with deformity and radiological changes of CN. The acute phase is characterized by unilateral erythema and oedema. The foot is at least 2 degrees C hotter than the contralateral foot. Patients should have initially an X-ray examination which, at this time, may be normal. We then proceed to two investigations: initially a technetium diphosphonate bone scan, which will detect early evidence of bone damage and also locate the site of this damage. If the result of the bone scan is positive, we would proceed to magnetic resonance imaging (MRI) examination, which would describe in more detail the nature of the bony damage. The aim of treatment is immobilization in a plaster cast until there is no longer evidence on X-ray of continuing bone destruction, and the foot temperature is within 2 degrees C of the contralateral foot. An alternative treatment is a prefabricated walking cast, such as the Aircast. A randomized controlled study of a single 90 mg pamidronate infusion has shown a significant reduction of the markers of bone turnover and skin temperature in treated, compared with control subjects although the fall in skin temperature was similar in both groups. There was a similar finding in a recent study with alendronate. Calcitonin has also been used in the acute stage and there was a more rapid transition to the stable chronic phase in the treated group compared with controls. In the chronic stable phase, the foot is no longer warm and red. There may still be oedema but the difference in skin temperature between the feet is usually less than 2 degrees C. The X-ray shows fracture healing, sclerosis and bone remodelling. The patient must now be rehabilitated and gradually moved from cast treatment to suitable footwear. The patient needs close observation to detect any relapse, which will be evident from further swelling and heat in the foot. Careful rehabilitation is always necessary after a long period in a cast.

Charcot spine in a person with congenital insensitivity to pain with anhydrosis: a case report of re-diagnosis.

We report the case of a 43-year-old woman referred for evaluation of worsening gait. Her initial evaluation led to a diagnosis of a Charcot spine and 2 spinal stabilization surgeries. Because no clear cause for the Charcot spine could be determined from the patient's history or initial evaluation, an extensive diagnostic work-up was undertaken, which ultimately led to a diagnosis of congenital insensitivity to pain with anhydrosis (CIPA). This diagnosis was known and confirmed by the patient's parents but was unknown to the patient and her treating physicians. Unique to this case is not only the significant medical implications and the value of the re-diagnosis and confirmation of this rare condition, but also the rarer occurrence of a Charcot spine in a person with CIPA.

Neuropathic arthropathy caused by syringomyelia in different joints and lesion of brachial plexus at right upper extremity: a case report.

Syringomyelia is characterized by slow progression; the joints involved most frequently are the shoulders and elbows. Neuropathic arthropathy of the hand is quite rare. Herewith, we present a case of neuropathic arthropathy (NA) of the joints in the upper limb secondary to Syringomyelia. Atypical features of the case included NA of the shoulder, elbow and metacarpophalengeal joint in the same upper limb. These atypical features superimposed shoulder subluxation and brachial plexopathy which diagnosed by electrophysiologic studies. To the best of our knowledge, our study is the first of its kind that reports a patient who had all the above mentioned symptoms in the same upper limb.

Conservative treatment of Charcot artroparthy in a series of spina bifida patients: the experience of one center and review of the literature.

The present study was performed to evaluate the use of patellar tendon-bearing ankle foot orthesis for the treatment of Charcot arthropathy in a series of patients with spina bifida. A cohort of 350 spina bifida patients, ages ranging between 12 months and 22 years were evaluated in our clinic between June 1993 and March 2004. Charcot arthropathy was seen in five of these children. Treatment was initiated with nonsteroidal anti-inflammatory drugs, oral bisphosphonates and immobilization. No change was observed in the patients' symptoms after a month of treatment. At this time, a patellar tendon-bearing ankle foot orthesis was prescribed and used for a period of 6 to 24 months. All patients improved within 2 months. At the end of 2 years of follow-up, three patients are still using the brace without any complaints. One patient still has symptoms, although she is wearing her brace, but she has had significant improvement compared with the initiation of therapy. Non-weight-bearing, immobilization and surgery are the known treatment choices in Charcot arthropathy. Little experience exists about this entity and its treatment. Our experience reveals that the patellar tendon-bearing ankle foot orthesis leads to significant improvement in children with Charcot arthropathy without surgery and immobilization.

Bone mineral density during total contact cast immobilization for a patient with neuropathic (Charcot) arthropathy.

BACKGROUND AND PURPOSE: Diabetes mellitus (DM)-related neuropathic arthropathy of the foot is a destructive bone and joint process. The effect of cast immobilization and non-weight bearing on bone loss has not been well studied. The purpose of this case report is to describe the changes in bone mineral density (BMD) of the calcaneus in the feet of a patient with acute neuropathic arthropathy during total contact cast immobilization. CASE DESCRIPTION: The patient was a 34-year-old woman with type 1 DM, renal failure requiring dialysis, and a 7-week duration of neuropathic arthropathy of the midfoot. Intervention included total contact casting and minimal to no weight bearing for 10 weeks, with transition to therapeutic footwear. Ultrasound-derived estimates of BMD were taken of both involved and uninvolved calcanei. OUTCOME: Bone mineral density decreased for the involved foot (from 0.25 g/cm(2) to 0.20 g/cm(2)) and increased for the uninvolved foot (from 0.27 g/cm(2) to 0.31 g/cm(2)) during casting. DISCUSSION: The low initial BMD and further loss during casting suggest the need for transitional bracing and a well-monitored return to full activity to minimize the risk of recurrence and progression of foot deformity.

[Lower limb orthosis to relieve stress forces on the foot and its use in patients with diabetic neuropathic osteoarthropathy: Case examples]. / Die fussentlastende Unterschenkelorthese und ihre klinische Anwendung bei Patienten mit diabetisch-neuropathischer Osteoarthropathie. Fallbeispiele.

In the daily routine of treating patients with diabetic neuropathic osteoarthropathy (DNOAP), their history often reveals a prolonged course of therapy caused in part by incorrect diagnosis but also by inadequate provision of orthopedic devices. A "classic" case is that of undetected osteoarthropathy, which is erroneously interpreted as osteomyelitis. Thus, subsequent to frustrating attempts at therapy and persistence of the clinical symptoms, patients are not infrequently "offered" the option of amputation, which is performed quite proximal to the osseous lesion to "ensure treatment success." The fact that major amputations lead to a statistically significant decrease of the patient's life span is usually not taken into consideration during the decision making process for amputation. Orthopedic surgical procedures to preserve the leg should be given precedence for the sake of maintaining quality of life just as orthopedic devices and orthopedic shoes should be preferred to retain mobility before amputation is indicated in patients with DNOAP. The cases reports presented here should encourage others to implement treatment concepts with the aim of avoiding unnecessary amputations.

An unusual case of bilaterally symmetrical neuropathic osteoarthropathy of the midfoot as a result of lyme disease-induced peripheral neuropathy: a case report.

The first known report of a patient with Lyme Disease-induced peripheral neuropathy resulting in bilaterally symmetrical "Charcot" changes of the midfoot is reported. An extensive review of the literature failed to produce any known cases of neuropathic osteoarthropathy that would be linked directly or indirectly with Lyme Disease-induced peripheral neuropathy. The relationship between Lyme Disease, the secondary neurologic manifestations caused by the infection, and neuropathic osteoarthropathy are discussed.