Long-term follow-up in diabetic Charcot feet with spontaneous onset

Reliability of AOFAS diabetic foot questionnaire in Charcot arthropathy: stability, internal consistency, and measurable difference

BACKGROUND

The development of Charcot changes is known to be associated with a high rate of recurrent ulceration and amputation. Unfortunately, the effect of Charcot arthropathy on quality of life in diabetic patients has not been systematically studied because of a lack of a disease-specific instrument. The purpose of this study was to develop and test an instrument to evaluate the health-related quality of life of diabetic foot disease.

METHODS

Subjects diagnosed with Charcot arthropathy completed a patient self-administered questionnaire, and clinicians completed an accompanying observational survey. The patient self-administered questionnaire was organized into five general sections: demographics, general health, diabetes-related symptoms, comorbidities, and satisfaction. The scales measured the effect in six health domains: 1) general health, 2) care, 3) worry, 4) sleep, 5) emotion, and 6) physicality. The psychometric properties of the scales were evaluated and the summary scores for the Short-Form Health Survey (SF-36) were compared to published norms for other major medical illnesses.

RESULTS

Of the 89 enrolled patients, 57 who completed the questionnaire on enrollment returned a second completed form at 3-month followup. Over the 3-month followup period most of the patients showed an improvement in the Eichenholtz staging. The internal consistency of most was moderate to high and, in general, the scale scores were stable over 3 months. However, several of the scales suffered from low-ceiling or high-floor effects. Patients with Charcot arthropathy had a much lower physical component score on enrollment than the reported norms for other disease conditions, including diabetes.

CONCLUSIONS

Quality of life represents an important set of outcomes when evaluating the effectiveness of treatment for patients with Charcot arthropathy. This study represents an initial attempt to develop a standardized survey for use with this patient population. Further studies need to be done with larger groups of patients to refine the tool and to begin the validation process. The instrument developed could be used for comparing treatment strategies for Charcot arthropathy.

Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot)

OBJECTIVE

To determine the mortality of a population of patients diagnosed with Charcot neuropathic osteoarthropathy managed by a single specialist unit and to compare the results with a control population.

METHODS

We have undertaken a retrospective analysis of all cases of Charcot foot on the comprehensive database which has been maintained at the specialist diabetic foot clinic at the City Hospital, Nottingham since 1982. Survival and the incidence of amputation (major and minor) was compared with a control population referred with uncomplicated neuropathic ulceration. Controls were individually matched for gender, age (+/-2 years), disease type, disease duration (+/-2 years) and year of referral (+/-3 years).

RESULTS

Forty-seven cases (21 female, 26 male) of Charcot foot were identified, of whom 18 (38.3%) had Type 1 diabetes. Mean age and disease duration at presentation were 59.2 +/- 13.4 (sd) and 16.2 +/- 11.2 years, compared with 59.7 +/- 12.6 and 16.3 +/- 11.2 years, respectively, in the controls. Twenty-one (44.7%) of those with Charcot had died, after a mean interval of 3.7 +/- 2.8 years. This compared with 16 (34.0%) after a mean 3.1 +/- 2.7 years in the control group. Mean duration of follow-up in the survivors was 4.7 +/- 4.9 years (Charcot) and 5.3 +/- 3.9 years (controls). A total of 11 (23.4%) Charcot patients had had a major amputation on the side of the index lesion, compared with five (10.6%) controls. There was no difference between the two groups (P > 0.05, Chi-square).

CONCLUSIONS

The mortality in this group of patients with Charcot foot was higher than expected. Nevertheless, there was no difference between those with Charcot and those with uncomplicated neuropathic ulceration. It is possible that it is neuropathy, rather than Charcot osteoarthropathy, which is independently associated with increased mortality in diabetes. The mechanism underlying any such association is not known. There is a need for a formal, prospective, multicentre study to investigate the life expectancy and cardiovascular risk of those with Charcot osteoarthropathy.

Surgical versus accommodative treatment for Charcot arthropathy of the midfoot

BACKGROUND

The treatment of Charcot foot arthropathy is one of the most controversial issues facing orthopaedic foot and ankle surgeons. Although current orthopaedic textbooks are in almost universal agreement that treatment should be nonoperative, accommodating the deformity with orthotic methods, most peer-reviewed clinical studies recommend early surgical correction of the deformity. In a university health system orthopaedic foot and ankle clinic with a special interest in diabetic foot disorders, a moderate approach evolved for management of this difficult patient population.

METHODS

Patients with Charcot arthropathy and plantigrade feet were treated with accommodative orthotic methods. Those with nonplantigrade feet were treated with surgical correction of the deformity, followed by long-term management with commercial therapeutic footwear. The desired outcome for both groups was long-term management with standard, commercially available, therapeutic depth-inlay shoes and custom-fabricated accommodative foot orthoses. During a 6-year period, 198 patients (201 feet) were treated for diabetes-associated Charcot foot arthropathy. The location of the deformity was in the midfoot in 147 feet, in the ankle in 50, and in the forefoot in four.

RESULTS

At a minimum 1-year follow-up, 87 of the 147 feet with midfoot disease (59.2%) achieved the desired endpoint without surgical intervention. Sixty (40.8%) required surgery. Corrective osteotomy with or without arthrodesis was attempted in 42, while debridement or simple exostectomy was attempted in 18 feet. Three patients had initial amputation (one partial foot amputation, one Syme ankle disarticulation, and one transtibial amputation), and five had amputation (two Syme ankle disarticulations and three transtibial amputations) after attempted salvage failed.

CONCLUSION

Using a simple treatment protocol with the desired endpoint being long-term management with commercially available, therapeutic footwear and custom foot orthoses, more than half of patients with Charcot arthropathy at the midfoot level can be successfully managed without surgery.

Usefulness of a brief assessment battery for early detection of Charcot foot deformity in patients with diabetes

Charcot neuroarthropathy is a significant limb-threatening complication that develops in some patients with long-term diabetes mellitus. Early diagnosis is vital to secondary prevention of the destructive process and avoidance of consequent deformity and, ultimately, amputation. The purpose of this study was to determine which historical and physical findings would be more accurate risk factor indicators in those diabetics with and without Charcot foot deformity. A controlled series of tests, historical findings, and physical examinations were performed on 41 patients with diabetes who were Charcot-free and 18 patients with diabetes with known chronic CD of the foot by using inexpensive hand-held instruments in a clinical setting. Physical examination included evaluation of vascular and neurologic characteristics. Historical findings consisted of those normally elicited from systems review or past medical history. The results indicate that simple neurologic testing combined with a thorough patient history were the most beneficial tools to determine diabetics with a higher probability of developing CD. Specifically, history of retinopathy (P <.02), nephropathy (P <.003), and previous foot ulcer (P <.01) were found to be predictive. The neurologic findings of vibratory sensation (P <.001), deep tendon reflexes (P <.05), and the 5.07 (10 g) Semmes-Weinstein monofilament test (P <.001) were also highly correlative for the development of Charcot foot deformity. Vascular examinations were found to differentiate poorly between groups. The application of this data may provide for earlier detection of Charcot arthropathy based on the predictive capabilities.

External fixation in the management of Charcot neuroarthropathy

Charcot neuroarthropathy is a complex sequela of neuropathies associated with diabetes mellitus, syringomyelia, alcoholism, and other disorders. The treatment of deformities associated with Charcot neuroarthropathy is evolving from a passive approach to one in which an earlier recognition of the emergence of the event permits an avoidance of deformity. As the understanding of the etiology and natural history of Charcot neuroarthropathy deepens, it has become apparent that many of the deformities that do develop may be reconstructed expeditiously by the surgeon with a thorough understanding of the diabetic foot and experience in the use of external fixation.

Rheumatic manifestations of diabetes mellitus

An epidemic of diabetes is currently raging in the US and developed countries, and is affecting almost 10% of the US population. The association between several rheumatic disorders and diabetes mellitus is gaining attention, and with recent data showing that more than 30% of patients with type 1 or type 2 diabetes have some hand or shoulder diseases, the magnitude of this problem is becoming more evident. Although some syndromes are observed exclusively in patients with diabetes, the majority of the rheumatic diseases found in patients with diabetes are also seen in the non-diabetes population, albeit at a much lower prevalence. The exact mechanisms by which the specific metabolic abnormalities of diabetes impact on the pathogenesis of its rheumatic manifestations are not clear. Further studies are needed to better understand the role of diabetes on the development of these disorders.

Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases

BACKGROUND AND AIMS

The incidence of diabetic Charcot neuroarthropathy has increased. The purpose here was to study the current diagnostics and treatment of the Charcot foot.

MATERIALS AND METHODS

During a time period from 1994 to 2000, a total of 36 feet were diagnosed as cases of diabetic Charcot neuroarthropathies. A retrospective analysis of patient records and radiographs was undertaken. A review of the recent literature is presented.

RESULTS

29 cases were diagnosed in the dissolution stage, 2 in coalascence, and 5 in the resolution stage. The diagnostic delay averaged 29 weeks. Treatment with cast immobilisation ranged from 4 to 37 weeks (mean 11 weeks). A total of 14 surgical procedures were carried out on 10 patients: six exostectomies, four midfoot arthrodeses, one triple arthrodesis, one tibiocalcaneal arthrodesis and two below-knee amputations. A radiological fusion was achieved in two thirds of the attempted arthrodeses.

CONCLUSIONS

A physician should always consider the Charcot neuroarthropathy when a diabetic patient has an inflamed foot. In the absence of fever, elevated CRP or ESR, infection is a highly unlikely diagnosis, and a Charcot process should primarily be considered. The initial treatment of an inflamed Charcot foot consists in sufficiently long non-weightbearing with a cast, which should start immediately after the diagnosis. The prerequisites of successful reconstructive surgery are correct timing, adequate fixation and a long postoperative non-weightbearing period. In the resolution stage most Charcot foot patients need custom-molded footwear.

Biochemical and ultrasound tests for early diagnosis of active neuro-osteoarthropathy (NOA) of the diabetic foot

OBJECTIVES

To test the effectiveness of a combined approach to an early diagnosis of neuro-osteoarthropathy (NOA) of the diabetic foot, we studied a group of outpatients with active NOA, presenting for the first time to our Diabetic Foot Clinic in 1998, by means of an integrated approach designed to assess bone turnover.

PATIENTS AND METHODS

Fifteen consecutive diabetic patients (five Type 1 and ten Type 2 diabetic individuals, age 61.9+/-12.2 years, diabetes duration 18.7+/-8.9 years, HbA(1c) 8.4+/-1.5%) with active NOA (Group 1) were compared to nine diabetic patients with chronic stable NOA (Group 2), 14 neuropathic diabetic patients without NOA (Group 3), 13 non-neuropathic diabetic patients (Group 4) and 15 healthy controls (Group 5). Determination of serum carboxy-terminal collagen telopeptide (ICTP), bone alkaline phosphatase isoenzyme (B-ALP), osteocalcin (BGP) concentrations, as well as urinary excretion of deoxypyridinoline (DPD) were obtained in all individuals for assessment of bone reabsorption and new bone formation. Moreover in all individuals quantitative ultrasound (QUS) of the calcaneal bone was performed and mass density of lumbar spine and femur bone was determined by dual-energy X-ray absorptiometry (DEXA).

RESULTS

QUS was significantly lower in the active NOA patients as compared with other groups (P<0.01), while ICTP was higher in both NOA groups (P<0.01). Urinary DPD was higher in the neuropathic non-NOA group (P<0.01) than the other groups, and osteocalcin was higher in healthy controls compared to diabetic patients without NOA. QUS and ICTP were inversely correlated (r=0.44, P=0.000). QUS in the active NOA group was significantly (P<0.01) lower in the affected compared to the unaffected foot.

CONCLUSION

Our results indicate a possible role for an integrated approach to the diagnosis and monitoring of NOA involving the diabetic foot. DPD may identify patients at-risk for NOA, ICTP could be tested as a marker for NOA in asymptomatic cases. Finally, QUS of the calcaneal bone may be useful in discriminating active versus quiescent phases.

Charcot neuroarthropathy of the knee in Type 1 diabetes: treatment with total knee arthroplasty

BACKGROUND

Charcot neuroarthropathy is well recognized in diabetes, although it typically affects the joints of the forefoot and ankle. Neuroarthropathy affecting the knee in diabetes is extremely rare. The surgical options for treatment of Charcot neuroarthropathy remain poorly defined, particularly the use of arthroplasty with knee involvement.

METHODS

We describe a case of neuroarthropathy of the knee in a patient with Type 1 diabetes. We also describe the successful management of the disorder with total knee arthroplasty-only the third such description.

RESULTS

The case illustrates some of the typical radiological features of this uncommon condition, which may aid early diagnosis and limit morbidity.

Update on Charcot neuroarthropathy

Charcot neuroarthropathy is not uncommon in diabetic patients with peripheral neuropathy. Often, the condition is misdiagnosed for cellulitis or osteomyelitis and treatment is delayed. A high index of suspicion is required in these patients to initiate appropriate treatment early. This article covers the pathogeneses of this condition and briefly describes the recent studies performed to understand the underlying etiopathogenetic factors of this devastating condition. Lastly, it mentions the recently completed multicenter trial using bisphosphonates in diabetic Charcot neuroarthropathy.

Incidence and management of ulcers in diabetic Charcot feet

This study followed 115 patients with diabetes--who between them had 140 feet with Charcot's arthropathy--over six to 114 months (median: 48). A total of 43 patients (37%) developed ulcers in 53 feet. Their treatment was multifactorial. An offloading regimen was adopted, with the use of crutches and therapeutic sandals with soft, individually moulded insoles, followed by adjusted or bespoke shoes. Recalcitrant ulcers were treated with surgery in 16 patients (37%). Antibiotics were needed by 21 patients (49%). The incidence of ulceration was 17% per year. The median time interval between the acute component of Charcot's arthropathy and ulcer development was 36 months (range: 0-120 months). In seven patients, the ulcer developed during the acute phase. In 12 patients the ulcers were localised to the rockerbottom deformity in the mid-foot region, but in 31 patients other regions were affected. Dynamic footprint analysis was used to help adjust the offloading shoe/insole on the rockerbottom deformity. Such ulcers took twice as long to heal as other ulcers. Surgical treatment comprised: major amputation (two patients), arthrodesis for unstable ankle (three patients), toe amputations (seven patients), resection of the rockerbottom deformity (one patient) and other revisions (three patients). One patient died with an unhealed ulcer. There is a four-fold risk of ulcers in diabetic Charcot deformity compared with the overall risk of foot ulcers in diabetic feet. Healing was achieved in 40 patients (93%). The surgical intervention rate of 37% in ulcer cases in Charcot feet was low compared with the literature.