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Svendsen OL, Jansen RB. Does Improvement of Glycemic Control Cause Acute Charcot Foot in Patients with Diabetes? Exp Clin Endocrinol Diabetes 2025; 133:120-132. [PMID: 39842459 PMCID: PMC11903110 DOI: 10.1055/a-2498-6826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 12/02/2024] [Indexed: 01/24/2025]
Abstract
Recent studies have suggested that improved glycemic control in patients with diabetes may cause acute Charcot foot. To conduct a narrative review of studies investigating whether improved glycemic control in patients with diabetes causes acute Charcot foot.Publications found by searching PubMed, EMBASE, and Cochrane Library as well as reference lists of identified publications were reviewed.Very few publications were found, primarily consisting of case reports and case studies without control groups, documenting instances where cases of acute Charcot foot had been preceded by improved glycemic control. Recent large multicenter randomized placebo-controlled clinical trials of anti-hyperglycemic agents in patients with diabetes, where significant improvement of glycemic control occurred, have not reported incidences of acute Charcot foot.There is so far no solid evidence to suggest that improvement of glycemic control in patients with diabetes causes acute Charcot foot.
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Affiliation(s)
- Ole Lander Svendsen
- Department of Endocrinology, Copenhagen Diabetes Foot
Center, Bispebjerg Frederiksberg University Hospital, Copenhagen,
Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen,
Denmark
| | - Rasmus Bo Jansen
- Department of Endocrinology, Copenhagen Diabetes Foot
Center, Bispebjerg Frederiksberg University Hospital, Copenhagen,
Denmark
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Julien CA, Ha Van G, M'Bemba J, Bourgeon M, Dardari D, Lepeut M, Dumont I, Zemmache MZ, Serrand C, Bouillet B, Sultan A, Schuldiner S. Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic foot expert centers (The EPiChar Study). Acta Diabetol 2023; 60:1209-1218. [PMID: 37184671 DOI: 10.1007/s00592-023-02101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/09/2023] [Indexed: 05/16/2023]
Abstract
AIM To evaluate the real-life diagnosis and therapeutic means of Charcot Neuroosteoarthropathy (CN) in French-Belgian diabetic foot expert centers. METHODS We collected clinical characteristics, results of exams and therapeutic pathways of consecutive adult patients with diabetic osteoarthropathy seen in consultation or hospitalization from January 1 to December 31, 2019 in 31 diabetic foot expert centers. The primary outcome was to describe the diagnostic and management methods for CN according to patient clinical characteristics, the clinical-radiological characteristics of acute and chronic CN and discharge means. RESULTS 467 patients were included: 364 with chronic CN and 103 in the acute phase. 101 patients had bilateral chronic CN. Most patients were male (73.4%), treated with insulin (73.3%), and with multicomplicated diabetes. In the acute phase, edema and increased foot temperature were present in 75% and 58.3% of cases, respectively. Diagnosis confirmation was usually by MRI and the mode of discharge was variable. In the chronic phase, orthopedic shoes were prescribed in 81.5% of cases. CONCLUSIONS This observational study highlights the diagnostic and therapeutic practices in 31 diabetic foot centers. Our results highlight that the use of MRI and the modalities of offloading, an essential treatment in the acute phase, need to be better standardized. Centers were highly encouraging about creating a patient registry.
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Affiliation(s)
- Carole-Anne Julien
- Service des Maladies métaboliques et Endocriniennes, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Georges Ha Van
- Service de Diabétologie, AP-HP La Pitié Salpétrière, Paris, France
| | | | - Muriel Bourgeon
- Service Endocrinologie, AP-HP Kremlin Bicêtre, Kremlin Bicêtre, France
| | - Dured Dardari
- Service de Diabétologie, CH Sud Francilien, Corbeil-Essonnes, France
| | - Marc Lepeut
- Service de Diabétologie, CH Roubaix, Roubaix, France
| | | | - Mohammed Zakarya Zemmache
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Chris Serrand
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Benjamin Bouillet
- Service d'Endocrinologie, Diabétologie, Maladies Métaboliques, CHU Dijon, Dijon, France
| | - Ariane Sultan
- 10PhyMedExp, INSERM U1046, UMR 9214, Univ Montpellier, Service Des Maladies Métaboliques, CHU Montpellier, Montpellier, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service Des Maladies Métaboliques Et Endocriniennes, CHU Nîmes, Clinique du Pied Gard Occitanie, Route de Carnon, 30240, Le Grau du Roi, France.
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Poonoosamy J, Lopes P, Huret P, Dardari R, Penfornis A, Thomas C, Dardari D. Impact of Intensive Glycemic Treatment on Diabetes Complications-A Systematic Review. Pharmaceutics 2023; 15:1791. [PMID: 37513978 PMCID: PMC10383300 DOI: 10.3390/pharmaceutics15071791] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/28/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023] Open
Abstract
Diabetes complications can be related to the long duration of the disease or chronic hyperglycemia. The follow-up of diabetic patients is based on the control of chronic hyperglycemia, although this correction, if obtained rapidly in people living with severe chronic hyperglycemia, can paradoxically interfere with the disease or even induce complications. We reviewed the literature describing the impact of the rapid and intense treatment of hyperglycemia on diabetic complications. The literature review showed that worsening complications occurred significantly in diabetic microangiopathy with the onset of specific neuropathy induced by the correction of diabetes. The results for macroangiopathy were somewhat mixed with the intensive and rapid correction of chronic hyperglycemia having a neutral impact on stroke and myocardial infarction but a significant increase in cardiovascular mortality. The management of diabetes has now entered a new era with new therapeutic molecules, such as gliflozin for patients living with type 2 diabetes, or hybrid insulin delivery systems for patients with insulin-treated diabetes. Our manuscript provides evidence in support of these personalized and progressive algorithms for the control of chronic hyperglycemia.
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Affiliation(s)
| | - Philippe Lopes
- LBEPS, IRBA, Université Paris Saclay, 91025 Evry, France
| | | | - Randa Dardari
- Al Fourkan Diabetes Center, Al Fourkan, Aleppo, Syria
| | - Alfred Penfornis
- Diabetology Department, Centre Hopitalier Sud Francilien, 91100 Corbeil-Essonnes, France
- Paris-Sud Medical School, Paris-Saclay University, 91100 Corbeil-Essonnes, France
| | - Claire Thomas
- LBEPS, IRBA, Université Paris Saclay, 91025 Evry, France
| | - Dured Dardari
- LBEPS, IRBA, Université Paris Saclay, 91025 Evry, France
- Diabetology Department, Centre Hopitalier Sud Francilien, 91100 Corbeil-Essonnes, France
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Jeffcoate W, Game F. The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm. Diabetes Care 2022; 45:1691-1697. [PMID: 35796768 DOI: 10.2337/dc21-2508] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.
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Affiliation(s)
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, U.K
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Dardari D, Dardari R. Why the Risk of Developing Neuroarthropathy Is Higher After Simultaneous Kidney and Pancreatic Transplantation Compared to Kidney Transplantation Only: The Role of Euglycemia. Ann Transplant 2021; 26:e928449. [PMID: 33526764 PMCID: PMC7866488 DOI: 10.12659/aot.928449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Charcot’s neuroarthropathy is a destructive complication of the joint, which is often found in patients living with diabetes. Despite the fact that its description was published almost 100 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be updated. Its prevalence is low in patients living with diabetes, but this increases in particular situations such as peripheral neuropathy, as well as after simultaneous kidney-pancreas transplantation (SPKT) in patients living with type 1 diabetes. We suggest that the development of neuroarthropathy after SPK in not only due to glucocorticoid therapy, as described, but also to the rapid passage into euglycemia. The reduced prevalence of neuroarthropathy after only kidney transplantation compared to SPK seems to validate our hypothesis.
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Affiliation(s)
- Dured Dardari
- Department of Diabetes, Sud Francilien Hospital Center 40 Avenue Serge Dassault, Corbeil-Essonnes, France.,LEBPS, Univ Evry, IRBA, Université de Paris-Saclay, Evry, France
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Dardari D, Van GH, M’Bemba J, Laborne FX, Bourron O, Davaine JM, Phan F, Foufelle F, Jaisser F, Penfornis A, Hartemann A. Rapid glycemic regulation in poorly controlled patients living with diabetes, a new associated factor in the pathophysiology of Charcot's acute neuroarthropathy. PLoS One 2020; 15:e0233168. [PMID: 32437409 PMCID: PMC7241699 DOI: 10.1371/journal.pone.0233168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Aggressive antidiabetic therapy and rapid glycemic control are associated with diabetic neuropathy. Here we investigated if this is also the case for Charcot neuroarthropathy. Research design and methods HbA1c levels and other relevant data were extracted from medical databases of 44 cases of acute Charcot neuroarthropathy. Results HbA1c levels significantly declined from 8.25% (67mmol/mol) [7.1%–9.4%](54-79mmol/mol), at -6 months (M-6), to 7.40%(54mmol/mol) [6.70%–8.03%] (50–64 mmol/mol) during the six months preceding the diagnosis of Charcot neuroarthropathy (P <0.001). Conclusions HbA1c levels significantly declined during the six months preceding the onset of Charcot neuroarthropathy. This decline seems to be a associated factor with the appearance of an active phase of Charcot neuroarthropathy in poorly controlled patients with diabetic sensitive neuropathy.
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Affiliation(s)
- Dured Dardari
- Department of Diabetes, Sud Francilien Hospital Center, Corbeil-Essonnes, France
- INSERM UMRS 1138, Cordeliers Research Center, Paris, France
- Sorbonne University, Paris, France
- * E-mail:
| | - Georges Ha Van
- Department of Diabetes, Pitié-Salpêtrière Hospital, Paris, France
| | | | | | - Olivier Bourron
- INSERM UMRS 1138, Cordeliers Research Center, Paris, France
- Sorbonne University, Paris, France
- Department of Diabetes, Pitié-Salpêtrière Hospital, Paris, France
| | - Jean Michel Davaine
- INSERM UMRS 1138, Cordeliers Research Center, Paris, France
- Department of Vascular Surgery Pitié-Salpêtrière Hospital, Paris, France
| | - Franck Phan
- INSERM UMRS 1138, Cordeliers Research Center, Paris, France
- Sorbonne University, Paris, France
- Department of Diabetes, Pitié-Salpêtrière Hospital, Paris, France
| | | | | | - Alfred Penfornis
- Department of Diabetes, Sud Francilien Hospital Center, Corbeil-Essonnes, France
- Paris-Sud Medical School, Paris-Saclay University, Corbeil-Essonnes, France
| | - Agnes Hartemann
- INSERM UMRS 1138, Cordeliers Research Center, Paris, France
- Sorbonne University, Paris, France
- Department of Diabetes, Pitié-Salpêtrière Hospital, Paris, France
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Ho S, Giddie J, Dhatariya KK. BILATERAL NEUROARTHROPATHY 11 YEARS AFTER SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT FOR TYPE 1 DIABETES MELLITUS. AACE Clin Case Rep 2020; 5:e259-e262. [PMID: 31967048 DOI: 10.4158/accr-2018-0408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/23/2018] [Indexed: 11/15/2022] Open
Abstract
Objective To report a case of a man who developed bilateral Charcot arthropathic feet 11 years after a simultaneous pancreas-kidney transplant (SPKT) for type 1 diabetes mellitus (DM). The patient had remained normoglycemic after surgery. Methods We present a retrospective review of the case notes and serial imaging. Results The patient developed dense peripheral diabetic neuropathy due to poor glycemic control. His biochemical markers of DM all normalized following SPKT, and he was discharged by his primary and secondary care diabetes services. Eleven years later, he developed Charcot arthropathy in one foot and, within a month, the other foot as well. Conclusion Individuals with DM who had preoperative end organ diabetes-related damage who went into biochemical remission after SPKT may be at risk for future complications. They should not be discharged from specialist diabetes services, and they need continued education about foot care.
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Dardari D, Penfornis A, Amadou C, Phan F, Bourron O, Davaine JM, Foufelle F, Jaisser F, Laborne FX, Hartemann A. Multifocal (tarsus and knee) activation of neuroarthropathy following rapid glycaemic correction. J Diabetes Complications 2019; 33:107438. [PMID: 31668589 DOI: 10.1016/j.jdiacomp.2019.107438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/21/2019] [Accepted: 08/25/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report a case of neuroarthropathy in the tarsus and knee following rapid glycaemic normalisation in a female patient with type I diabetes. METHODS A retrospective review of case notes. RESULTS We describe the case of a female patient with type I diabetes who had developed a multifocal neuroarthropathy in only six months, probably due to a rapid glycaemic normalisation. The onset of this neuroarthropathy was not only fast but mostly multifocal affecting two levels of joints. CONCLUSION The link between the onset of multifocal neuroarthropathy and the rapid correction of chronic hyperglycaemia is probably proven in our case. Patients with chronic hyperglycaemia with sensitive neuropathy should benefit from a gradual correction of their glycaemic imbalance in order to avoid the apparition of neuroarthropathy.
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Affiliation(s)
- Dured Dardari
- Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil Essonnes, France; Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France; Sorbonne Université, 15 rue de l'Ecole de Médecine, 75006 Paris, France.
| | - Alfred Penfornis
- Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil Essonnes, France
| | - Coralie Amadou
- Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil Essonnes, France
| | - Franck Phan
- Diabetology Department, AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France; Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France; Sorbonne Université, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Olivier Bourron
- Diabetology Department, AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France; Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France; Sorbonne Université, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Jean Michel Davaine
- Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France; Vascular Surgery Department AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France; Sorbonne Université, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Fabienne Foufelle
- Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France
| | - Frédéric Jaisser
- Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France
| | - Francois-Xavier Laborne
- Clinical Research Unit centre hospitalier sud Francilien, 40 Avenue Serge Dassault, 91100 Corbeil-Essonnes, France
| | - Agnes Hartemann
- Diabetology Department, AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France; Centre de recherche des Cordeliers INSERM U1138 Team "Diabetes, metabolic diseases and comorbidities", 15 rue de l'Ecole de Médecine, 75270 Paris cedex 06, France; Sorbonne Université, 15 rue de l'Ecole de Médecine, 75006 Paris, France
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Zhao HM, Diao JY, Liang XJ, Zhang F, Hao DJ. Pathogenesis and potential relative risk factors of diabetic neuropathic osteoarthropathy. J Orthop Surg Res 2017; 12:142. [PMID: 28969714 PMCID: PMC5625723 DOI: 10.1186/s13018-017-0634-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/11/2017] [Indexed: 12/18/2022] Open
Abstract
Diabetic neuropathic osteoarthropathy (DNOAP) is an uncommon, but with considerable morbidity and mortality rates, complication of diabetes. The real pathogenesis is still unclear. The two popular theories are the neuro-vascular theory and neuro-traumatic theory. Most theories and pathways focused on the uncontrolled inflammations that resulted in the final common pathway, receptor activator of nuclear factor κβ ligand (RANKL)/osteoprotegerin (OPG) axis, for the decreased bone density in DNOAP with an osteoclast and osteoblast imbalance. However, the RANKL/OPG pathway does not explain all the changes, other pathways and factors also play roles. A lot of DNOAP potential relative risk factors were evaluated and reported in the literature, including age, gender, weight, duration and type of diabetes, bone mineral density, peripheral neuropathy and arterial disease, trauma history, and some others. However, most of them are still in debates. Future studies focus on the pathogenesis of DNOAP are still needed, especially for the genetic factors. And, the relationship between DNOAP and those potential relative risk factors are still need to further clarify.
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Affiliation(s)
- Hong-Mou Zhao
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
| | - Jia-Yu Diao
- Cardiovascular Medicine Department, The Second Affiliated Hospital of Xi'an Jiaotong University College of Medicine, No. 157 West Fifth Road, Xi'an, 710004, People's Republic of China
| | - Xiao-Jun Liang
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
| | - Feng Zhang
- School of Public Health, Health Science Center Xi'an Jiaotong University, No. 76 Yan Ta West Road, Xi'an, 710061, People's Republic of China.
| | - Ding-Jun Hao
- Spine Surgery Department, Honghui Hospital of Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China.
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Seo DK, Lee HS, Park J, Ryu CH, Han DJ, Seo SG. Diabetic Foot Complications Despite Successful Pancreas Transplantation. Foot Ankle Int 2017; 38:656-661. [PMID: 28325064 DOI: 10.1177/1071100717696246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is known that successful pancreas transplantation enables patients with diabetes to maintain a normal glucose level without insulin and reduces diabetes-related complications. However, we have little information about the foot-specific morbidity in patients who have undergone successful pancreas transplantation. The purpose of this study was to investigate the prevalence and predisposing factors for foot complications after successful pancreas transplantation. METHODS This retrospective study included 218 patients (91 males, 127 females) who had undergone pancreas transplantation for diabetes. The mean age was 40.7 (range, 15-76) years. Diabetes type, transplantation type, body mass index, and diabetes duration before transplantation were confirmed. After pancreas transplantation, the occurrence and duration of foot and ankle complications were assessed. RESULTS Twenty-two patients (10.1%) had diabetic foot complications. Fifteen patients (6.9%) had diabetic foot ulcer and 7 patients (3.2%) had Charcot arthropathy. Three patients had both diabetic foot ulcer and Charcot arthropathy. Three insufficiency fractures (1.4%) were included. Mean time of complications after transplantation was 18.5 (range, 2-77) months. Creatinine level 1 year after surgery was higher in the complication group rather than the noncomplication group ( P = .02). CONCLUSION Complications of the foot and ankle still occurred following pancreas transplantation in patients with diabetes. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Dong-Kyo Seo
- 1 Department of Orthopedic Surgery, Gangneung Asan Hospital, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Ho Seong Lee
- 2 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jungu Park
- 2 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang Hyun Ryu
- 2 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duck Jong Han
- 3 Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Gyo Seo
- 2 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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