Care of the pediatric foot in myelodysplasia

Foot deformity is present in almost all patients paralyzed by myelomeningocele. This article outlines the pertinent pathoanatomy resulting in differing foot deformities and their effects on normal gait. Treatment of these deformities is discussed, and the most common deformities present for the different levels of paralysis are outlined. Emphasis is placed on surgical and orthotic treatments, which result in functional improvements for the pediatric patient with spina bifida.

Musculoskeletal problems of neurogenic origin

A number of neurological disorders can manifest as isolated pain or as joint, muscle or bone alterations. These manifestations can raise significant diagnostic challenges when they occur early, before the development of neurological and/or radiological abnormalities. This chapter discusses neuropathic osteoarthropathies, neurofibromatosis, Parkinson's disease, multiple sclerosis and the complications of central nervous system lesions.

Charcot arthropathy in spina bifida

This multicenter study was undertaken to identify the prevalence of Charcot arthropathy in the spina bifida population; to evaluate the relationship of neurosegmental level, ambulatory level, and distribution of joint involvement; and to assess treatment results and make treatment recommendations. Sixteen patients were identified with Charcot arthropathy based on clinical and radiographic criteria ranging in age from 9 to 42 years. There were 15 ankles, seven knees, and four hips identified with Charcot arthropathy. Six patients underwent surgery and modification of orthoses, eight had a modification of orthoses only, one had no modification, and one was lost to follow-up. Mean follow-up was 4 years and 9 months (with four good, 17 fair, and five poor results). The best results were seen in 13 compliant patients with a brace modification, whereas poor results were seen in three patients with poor brace compliance. Based on our study, we have noted the prevalence of Charcot arthropathy in spina bifida to be one in 100 cases.

Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity

During a 10-year period, 237 patients (129 women, 108 men) with a diagnosis of neuropathic (Charcot) arthropathy of the foot and ankle were treated in a tertiary care university hospital medical center. During this period, 115 of the patients (48.5%) were treated nonoperatively as outpatients with local skin and nail care, accommodative shoe wear, and custom foot orthoses. A total of 120 (50.6%) underwent 143 operations. Surgery included 21 major limb amputations, 29 ankle fusions, 26 hindfoot fusions, 23 exostectomies, and 23 debridements for osteomyelitis. It is widely accepted that patients with diabetes are at risk for developing foot ulcers, which can lead to lower extremity amputation. Within the population of diabetic patients, it is widely accepted that patients with neuropathic (Charcot) arthropathy of the foot and ankle have one of the highest likelihoods of having to undergo lower extremity amputation. The current emphasis in care of the foot of a diabetic patient involves a multidisciplinary team approach combining patient education, skin and nail care, and accommodative shoe wear. As data from prophylactic programs become available, resource allocation and cost of care can be compared with this benchmark baseline. This benchmark analysis can be used by those who are responsible for allocating resources and projecting healthcare costs for this "high utilization"/high risk patient population.

[Surgical management of neuropathy and osteoarthropathy of the diabetic food]

Along with angiopathy, neuropathy and osteoarthropathy are the most important effects of diabetes mellitus with regard to the foot. Because diagnosis in cases of these two consequences are very frequently wrong and too late, the diagnostic procedure and differential diagnosis will be discussed first. The goal of surgical and conservative treatment is a functioning foot and not amputation and provision of a prosthesis. The five types of osteoarthropathy together with the operative procedure for each are introduced: at the forefoot, resection of from one to all metatarsal radii whilst sparing the toes; at the metatarsus, the removal of projecting fragments; at the dorsal foot, resectioning arthroplasty. The operative procedures usual in traumatology cannot simply be transferred to osteoarthropathy. Arthrodeses and spongiosa grafting are doomed to failure in the neuropathic area, or at least carry the onus of a much longer period of convalescence. Resectioning arthroplasty for constructing a stiff pseudarthrosis is an alternative. The results are, however, only lasting if perfect orthopedic care and regular care and checking of the feet are guaranteed thereafter.

Healing of Charcot's joint by pamidronate infusion

Treatment of Charcot's joints remains difficult, and involves prolonged periods without weightbearing, immobilization, and surgical salvage procedures to avoid amputation. We describe the efficacy of pamidronate in treating a patient with Charcot's joint, due to hereditary sensory neuropathy, that caused loss of pain sensation. The bone and joint destruction in our patient's left foot was stopped by bisphosphonate treatment, and signs of a reconstructive healing process were observed on the control radiographs. The treatment was administered intravenously every 4 months for 2 years, without restriction on weightbearing, since the patient had refused a plaster cast and an orthotic device. This observation suggests that treatment with bisphosphonates should be used before, or in combination with, other treatment in such cases.

[Charcot foot. A serious complication of diabetes mellitus]

The Charcot foot is a destructive disease seen in patients with peripheral neuropathy due to diabetes mellitus. I present a case where a man aged 52 years contracted bilateral Charcot foot with total destruction of the mid feet one and a half years after initial symptoms. The case illustrates how rapidly the destruction occurs and the importance of early diagnosis.

[POEMS-Syndrome--unusual manifestation with bilateral Charcot's Joint]

HISTORY AND CLINICAL FINDINGS

A 45-year-old patient with no significant past medical history was admitted 8 weeks after minor foot trauma with injury of the left ankle joint with massive destructive arthropathy. On admission the arch of both feet was flattened and both feet showed massive painless soft tissue swelling. Due to loss of muscle strength elevation of feet and toes was reduced and there was a "stocking-like" loss of sensation of the lower extremity. The gait was ataxic. No other abnormalities were detected besides hepatomegaly and hyperhidrosis.

INVESTIGATIONS

Advanced polyneuropathy was confirmed by nerve conduction study. Laboratory tests revealed paraproteinaemia type IgG-lambda. Bone marrow biopsy, bone scan and skeletal survey did not provide additional information. Sonography confirmed hepatosplenomegaly, endocrinological work up showed impaired glucose tolerance and lowered testosterone levels. Based on these findings the diagnosis of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes) was established.

TREATMENT AND COURSE

Plasma exchange was unsuccessful and due to worsening of the symptoms long term treatment with cyclophosphamide was started. Furthermore the patient received NSAIDs for symptomatic relief and orthopedic shoes. One year after initial presentation the patient continues to walk.

CONCLUSION

Usually neurogenic arthropathy is associated with diabetes mellitus, syringomyelia or with infections. Our report illustrates that POEMS syndrome might present with Charcot arthritis.

Staging of Charcot neuroarthropathy along the medial column of the foot in the diabetic patient

Diabetes mellitus is the leading cause of Charcot neuroarthropathy. The most common location is along the medial column of the foot. Over a 2-year period, the process can result in a severely deformed foot, which is highly prone to ulcers, infection, and subsequent amputation. To help identify the early stages of the disease process, the histories, physical examinations, and radiographs of 40 patients with 51 neuropathic feet were evaluated. We were able to identify five stages of Charcot deformities. Stage 0 is a clinical stage in which the patient presents with a locally swollen, warm, and often painful foot. Radiographs are negative and technetium 99 bone scan is markedly positive. Indium and gallium scans are normal. Stage 1, in addition to the clinical findings, demonstrates periarticular cysts, erosions, localized osteopenia, and sometimes diastases. Stage 2 is marked by joint subluxations, usually starting between the second cuneiform and the base of the second metatarsal and spreading laterally. Stage 3 is identified by joint dislocation and arch collapse. Stage 4 is the healed and stable end result of the process. Clinically, there is no temperature gradient between the two feet. Radiographically, there is bony trabeculation across joint spaces indicative of mature fusion. Treatment of stage 0 consists of limited weightbearing and close observation while the diagnosis becomes clear. Stage 1 is treated with casting followed by a University of California Biomechanics Lab orthosis (UCBL), to maintain the arch while allowing limited weightbearing. In stage 2, a partial weightbearing total contact cast followed by a Charcot restraint orthotic walker (CROW) is used. Surgery may be needed at this stage, while the joints are still reducible. Arthrodesis with rigid fixation is recommended. Stage 3 is treated with casting for the acute phase, then with a patellar-tendon-bearing ankle-foot orthosis, CROW, or caliper orthosis. If ulcers are present, they are treated with weekly local debridement, antibiotics, and total contact casting. Occasionally decompressive ostectomy is required. Stage 4 may need surgical removal of the bony prominences causing the nonhealing ulcers. Extra-depth shoes and pressure-relieving orthoses are also used. Twenty-five percent of our patients diagnosed and treated in the early stages (stages 0, 1 and 2) did not develop deformity. Surgery to prevent deformity is recommended early, before the destructive stage (stage 3). Close follow-up, especially in a noncompliant population is necessary.

Ankle fractures in diabetics

Ankle fractures are common and good results are expected. Insulin dependent diabetes mellitus is also common, and long-standing disease is associated with peripheral neuropathy. A trauma unit will inevitably receive patients with both problems. We describe two salutary lessons and suggest how our experience with diabetic neuroarthropathy might be avoided.

The role of combined magnetic field bone growth stimulation as an adjunct in the treatment of neuroarthropathy/Charcot joint: an expanded pilot study

This study was designed to assess the value of combined magnetic field (CMF) bone growth stimulation in the treatment of acute, phase 1, Charcot neuroarthopathy. Thirty-one subjects were studied. Initially 10 controls and 11 study patients were examined. When the initial results were analyzed, 10 additional study patients were added. The result was a statistically significant reduction in time to consolidation, 23.8 weeks for the control versus 11 weeks for the study group. Additionally, less destruction of the bony architecture was noted in the study group as compared to the control. Thus the results of this expanded pilot study demonstrate the efficacy of CMF in accelerating the consolidation process of acute, phase 1, Charcot joint, and decreasing the amount of residual deformity.

Acute Charcot arthropathy in patients with diabetes mellitus: healing times by foot location

Foot deformity and lower extremity dysfunction are debilitating complications of diabetes mellitus which often lead to significant permanent disability. Acute diabetic neuroarthropathy (Charcot arthropathy) directly leads to foot deformity, subsequent lower-extremity complications and may lead to lower-extremity amputation, if not identified and managed appropriately. The purpose of this study is to report the healing times of acute-onset neuropathic arthropathies (fractures, joint subluxations or dislocations) in individuals with diabetes mellitus by foot location using the ambulatory method of total-contact casting (TCC). In addition, the identification of critical subject characteristic which influence healing outcomes were determined. The results indicate all (100%) of the acute (Charcot) fractures, subluxations, or dislocations healed in an average of 86+/-45 days. Acute Charcot arthropathies of the ankle, hindfoot, or midfoot take longer to heal by TCC than arthropathies localized to the forefoot. Adherence to partial weight bearing with assistive devices during casting and early institution of cast immobilization are critical factors associated with shorter healing times using TCC. Physicians, rehabilitation specialists and third-party payers should be aware of the length of time required to heal acute Charcot foot arthropathies at all locations of the foot using TCC.

Great toe neuroarthropathy: a report of two cases

Two cases of diabetic neuroarthropathy of the great toe are presented. The differential diagnosis is emphasized, and the literature regarding this unusual site for symptomatic disease is reviewed.

Is Charcot arthropathy a late sequela of osteoporosis in patients with diabetes mellitus?

It is well accepted that Charcot arthropathy is most frequently encountered in the diabetic population. Also well known is the association between diabetes and osteoporosis, even in the absence of overt renal dysfunction. Is it plausible that Charcot arthropathy is a late sequela of osteoporosis in diabetic patients, and if so, can the osteoporosis be treated early, leading to a decrease in the ultimate prevalence of Charcot arthropathy? The objective of this paper is to concisely review the literature detailing the course of Charcot neuroarthropathy and to investigate the links between Charcot arthropathy and osteoporosis among diabetic patients.

Neuropathic arthropathy of the knee associated with an intra-articular neurofibroma in a child

We describe a five-year-old child with neurofibromatosis type I who developed a Charcot knee. Infiltration of the joint by tissue associated with the disease caused damage to the proprioceptive mechanism and resulted in severe joint instability, accelerated destruction and development of neuropathic arthropathy.

Limb threatening neuropathic complications from ankle fractures in patients with diabetes

Although less common than neuropathic (Charcot) deformities in feet, ankle deformities can occur and produce significant limb threatening complications after injury in patients with longstanding diabetes. A series of six such complications, including one that resulted in amputation and several near amputations, are presented. The authors' primary purpose is to alert or remind physicians and orthopaedic surgeons of the often unanticipated but significant complications of these rare and seemingly mild ankle injuries. A secondary purpose is to point out that complications may be avoided or mitigated with early stabilization and possibly with treatment of bone resorbing, inflammatory processes characteristic of neuroarthropathies.

Charcot's joint following Keller arthroplasty. A case report

Neuropathic osteoarthropathy, i.e., Charcot's joint, has not previously been reported as a sequela of elective foot surgery. The authors present a challenging case of a patient with long-standing diabetes mellitus and peripheral neuropathy who developed neuropathic osteoarthropathy after a Keller arthroplasty for a recalcitrant hallux ulcer. The radiographic findings, diagnostic tests, and histopathology are discussed. Finally, the authors offer suggestions for surgeons contemplating a Keller arthroplasty for patients with peripheral neuropathy.

Acute Charcot's arthropathy of the foot and ankle

With the possible exception of osteomyelitis, Charcot's arthropathy is perhaps the most debilitating orthopedic sequela of diabetes mellitus. For this reason, early diagnosis and aggressive, noncompromising immobilization, pressure reduction, and consistent follow-through are paramount to effecting an acceptable result.

Charcot's foot

Diabetic osteoarthropathy is a chronic progressive arthropathy involving the bones and joints being constantly associated to somatic and autonomic peripheral neuropathy. The pathogenesis is related to sensory and motor neuropathy with morphologic foot alterations, relaxation and abnormal position on walking till complete collapse of the foot shown by the depressed longitudinal medial arch. Bone reabsorption due to osteoclasis and increased blood flow until osteomalacia appears, is characteristic of this arthropathy. The clinical features vary according to the location and severity of articular impairment and the stage of identification. The metatarsophalangeal or tarsometatarsal joint may be involved. The typical manifestation of Charcot's foot is plantar ulcer of variable location according to the weight-bearing area. Treatment tends to reduce the abnormal stress predisposing to ulceration with tailored footwear and orthoses.