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Ten years of Charcot: what have we learned?

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  #31  
Old 2nd February 2012, 06:11 AM
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Default Re: Ten years of Charcot: what have we learned?

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Reading through the many posts in this and other threads brings to mind this question: Do any of you know if there has been a review of the literature regarding Charcot neuropathy in NON-diabetics? Aside from having some degree of neuropathy, what other traits do they generally share with diabetic Charcot patients and where do they differ?

Also, has anyone seen anything written from the non-diabetic Charcot patient's perspective?

Thanks much.
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Old 3rd February 2012, 04:02 PM
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Default Re: Ten years of Charcot: what have we learned?

Charcot foot: Skin temperature as a good clinical parameter for predicting disease outcome.
Moura-Neto A, Fernandes TD, Zantut-Wittmann DE, Trevisan RO, Sakaki MH, Santos AL, Nery M, Parisi MC.
Diabetes Res Clin Pract. 2012 Jan 30
Quote:
Twenty-eight diabetics presenting with acute Charcot foot were immobilized and the temperature difference between limbs measured at each month. All patients had monthly follow-up visits for a year and the relapse rate was zero. We found that skin temperature is a good parameter to ensure safe immobilization withdrawal.
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Old 27th February 2012, 12:06 PM
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Default Re: Ten years of Charcot: what have we learned?

Doppler spectrum analysis: A potentially useful diagnostic tool for
planning the treatment of patients with Charcot arthropathy of the foot?

T. Wu, P-Y. Chen, C-H. Chen, and C-L. Wang
J Bone Joint Surg Br 2012;94-B 344-347
Quote:
It is difficult to determine the safe timing of weight-bearing or reconstructive surgery in patients with Charcot arthropathy of the foot and ankle. In this study the Doppler spectrum of the first dorsal metatarsal artery was used to monitor the activity of the disease activity and served as a guideline for management. A total of 15 patients (seven men and eight women) with acute diabetic Charcot arthropathy of the foot and ankle were immobilised in a non-weight-bearing cast. They were followed at two-week intervals and bilateral Doppler spectra of the first dorsal metatarsal arteries were obtained using a 10 MHz linear ultrasound probe. The patients were allowed to start weight-bearing or undergo surgery after the Doppler spectrum had returned to normal pattern. The Doppler spectra in the unaffected limbs were triphasic in pattern, whereas those in limbs with active Charcot arthropathy showed monophasic forward flow. They returned to normal after a mean of 13.6 weeks (6 to 20) of immobilisation. Three patients underwent pan-talar arthrodesis to correct gross instability and deformity.

Doppler spectrum analysis of the foot may reflect the activity of the disease in patients with Charcot arthropathy, and may be used as a guide to begin weight-bearing or undergo reconstructive surgery.
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  #34  
Old 17th March 2012, 02:05 PM
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Default Re: Ten years of Charcot: what have we learned?

Diabetic Nephropathy but not HbA1c is Predictive for Frequent Complications of Charcot Feet - Long-term follow-up of 164 Consecutive Patients with 195 Acute Charcot Feet.
Sämann A, Pofahl S, Lehmann T, Voigt B, Victor S, Möller F, Müller U, Wolf G.
Exp Clin Endocrinol Diabetes. 2012 Mar 15.
Quote:
To investigate the clinical characteristics, treatment and long-term outcome of patients with acute Charcot feet (CF).Single-center retrospective analysis. Treatment of CF: stage-dependent immobilization/weight-off therapy, orthopaedic/adjusted shoes, foot surgery. 164 consecutive participants (type 1 vs. type 2 diabetes): 12 vs. 150, non-diabetic peripheral neuropathy: n=2, presented with 195 (17 vs. 176) CF. Mean follow-up: 4.7±2.5 (range 2.2-9.8) vs. 5.4±2.9 (range 0.8-18.8) years, vital at follow-up: 100 vs. 88%.Baseline characteristics: age: 43.7±10.9 vs. 57.9±8.9 years (p<0.001), male gender: 66.7 vs. 77.3%, diabetes duration: 19.2±9.1 vs. 13±8.6 years (p=0.018), GHb: 8.1±2.4 vs. 7.6±1.6%, BMI: 24±5.3 vs. 33.7±6.5 kg/m2 (p<0.001), Levine 1: 18.2 vs. 7.4%, Levine 2: 45.5 vs. 65.9%, Sanders 2: 58.3 vs. 68.5%, Sanders 3: 33.3 vs. 45%. Therapy: immobilization for 6±4.2 vs. 5.4±4.5 months, orthopaedic/adjusted shoes: 27.3 vs. 20.5%, foot surgery: 11.8 vs. 18.2%. Major complications: 50 vs. 56% (rocker bottom deformities: 23.5 vs. 46.3%, foot ulcerations: 17.6 vs. 24.6%, CF amputations: 0 vs. 6%), not CF amputations: 16.7 vs. 15.3%, second episodes of CF: 41.6 vs. 18.3% after 5-132months. Diabetic nephropathy was associated with an increase, intensive antihypertensive therapy with a decrease of complications.Patients with CF are middle-aged, overweight males with type 2 diabetes above 10 years. Patients with type 1 diabetes are younger, have normal BMI and longer diabetes duration. Major complications and second episodes of CF are frequent. Diabetic nephropathy could be a risk factor for CF related complications. The awareness for CF must be improved.
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  #35  
Old 5th May 2012, 01:31 PM
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Default Re: Ten years of Charcot: what have we learned?

Charcot foot: Skin temperature as a good clinical parameter for predicting disease outcome
Arnaldo Moura-Neto, Tulio Diniz Fernandes, Denise Engelbrecht Zantut-Wittmann, Rafael Ortiz Trevisan, Marcos Hideyo Sakaki, Alexandre Leme Godoy Santos, Marcia Nery, Maria Candid, Ribeiro Parisi
Diabetes Research and Clinical Practice Volume 96, Issue 2, May 2012, Pages e11–e14
Quote:
Twenty-eight diabetics presenting with acute Charcot foot were immobilized and the temperature difference between limbs measured at each month. All patients had monthly follow-up visits for a year and the relapse rate was zero. We found that skin temperature is a good parameter to ensure safe immobilization withdrawal.
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  #36  
Old 1st June 2012, 11:54 AM
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Default Re: Ten years of Charcot: what have we learned?

Pressure pain thresholds at the diabetic Charcot-foot: an exploratory study.
Chantelau E, Wienemann T, Richter A.
J Musculoskelet Neuronal Interact. 2012 Jun;12(2):95-101.
Quote:
Objective: Painless mechanical trauma is believed to induce neuroosteoarthropathy at the neuropathic foot in diabetes (diabetic Charcot-foot). To investigate pressure nociception at the diabetic foot, we measured the pain perception thresholds for deep pressure (DPPPT, using Algometer II®) and cutaneous pressure (CPPPT, using calibrated monofilaments).

Methods: In 24 diabetic patients with painless neuropathy (11 with a chronic, inactive Charcot-foot and a history of foot ulcer, and 13 control patients who never had an ulcer), and in 20 healthy subjects, CPPPT (at palmar and plantar digital skinfolds) and DPPPT (over musculus abductor pollicis, musculus hallucis longus, and over metacarpophalangeal and metatarsophalangeal joints) was measured.

Results: At the hands, DPPPT and CPPPT were similar in patients and healthy subjects. At the feet, CPPPT was above the upper safety limit of measurement (512 mN) in 2/20 healthy subjects, and in 11/11 Charcot patients compared to 6/13 neuropathic controls (p=0.005). At the feet, median DPPPT was similar in all groups. In Charcot patients only, DPPPT was higher over metatarsophalangeal joint than over m. hallucis longus (p=0.048).

Conclusion: Perception thresholds for cutaneous pressure pain, but not for deep pressure pain, may be extremely elevated at the diabetic neuropathic foot, and particularly at the Charcot-foot.
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Old 1st June 2012, 01:05 PM
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Default Re: Ten years of Charcot: what have we learned?

Peripheral and Central Bone Mineral Density in Charcot’s Neuroarthropathy Compared in Diabetic and Nondiabetic Populations
Robert M. Greenhagen, Dane K. Wukich, Rachel H. Jung, Vassilios Vardaxis, Robert M. Yoho
J Am Podiatr Med Assoc 102(3): 213–222, 2012
Quote:
Background: This prospective study was performed to compare calcaneal and lumbar bone mineral density (BMD) in individuals with and without diabetes mellitus. We compared bone density with the time from onset of Charcot’s neuroarthropathy (CN) in patients with unilateral, nonoperative, reconstructive-stage CN. The final purpose was to investigate the role that sex, age, and serum vitamin D level may have in osseous recovery.

Methods: Thirty-three individuals were divided into three groups: controls and patients with diabetes mellitus with and without CN. Peripheral instantaneous x-ray imaging and dual-energy x-ray absorptiometry were performed.

Results: The calcaneal BMD of patients with diabetes mellitus and CN was lower than that of the control group (P < .01) but was not significantly lower than that of patients with diabetes mellitus alone. There was no statistically significant difference in lumbar T-scores between groups. Women demonstrated lower BMD than did men (P = .02), but patients 60 years and older did not demonstrate significantly lower BMD than did patients younger than 60 years (P = .135). A negative linear relationship was demonstrated between time and BMD in patients with CN.

Conclusions: The results of this study suggest that lumbar BMD does not reflect peripheral BMD in patients with diabetes mellitus and reconstructive-stage CN. This study has clinical implications when reconstructive osseous surgery is planned in patients with CN.
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  #38  
Old 16th June 2012, 05:00 AM
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Default Re: Ten years of Charcot: what have we learned?

Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker.
Christensen TM, Gade-Rasmussen B, Pedersen LW, Hommel E, Holstein PE, Svendsen OL.
J Diabetes Complications. 2012 Jun 12.
Quote:
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±21days (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±44days. The primary period of off-loading was not statistically significantly different for those not requiring versus those requiring re-casting: 142±24days compared to 134±41days. 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.
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  #39  
Old 28th July 2012, 12:33 PM
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Default Re: Ten years of Charcot: what have we learned?

Charcot arthropathy presenting with primary bone resorption.
Jones CW, Agolley D, Burns K, Gupta S, Horsley M.
Foot (Edinb). 2012 Jul 24.
Quote:
BACKGROUND:
The clinical presentation of acute Charcot arthropathy in the diabetic population usually follows the Eichenholtz classification. We present three usual cases of Charcot arthropathy presenting with rapid primary bone resorption in the absence of subluxation, dislocation and/or fracture.

METHODS:
A review of the literature was performed. To our knowledge Charcot arthropathy has not been previously described as primary bone resorption.

CASE REPORTS:
Three cases encountered at our specialist multidisciplinary High Risk Foot Clinic (HRFC) presented with primary bony resorption without features of subluxation, dislocation and/or fracture.

DISCUSSION:
Aggressive primary bone resorption was initially thought due to infection; a diagnostic dilemma that delayed optimal treatment. Late bone resorption in typical Charcot is linked to unregulated proinflammatory cytokines (IL-1β, IL-6 and TNFα) that lead to increased osteoclastic activity. The pathophysiology of osteolysis in aggressive primary bony resorption may relate to a disturbance in the balance between RANK-L and OPG.

CONCLUSION:
Primary resorption of bone without subluxation, dislocation and/or fracture can represent an active Charcot process. Prudent use of serial radiography and early MRI to look for the widespread bone and soft tissue oedema is recommended.
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  #40  
Old 7th August 2012, 12:51 PM
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Default Re: Ten years of Charcot: what have we learned?

Medical management of Charcot Arthropathy.
Petrova NL, Edmonds ME.
Diabetes Obes Metab. 2012 Aug 1.
Quote:
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 versus non-weightbearing 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 demonstrated a reduction of bone turnover, although, they did not show 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 summarizes 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.
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  #41  
Old 18th August 2012, 01:30 PM
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Default Re: Ten years of Charcot: what have we learned?

Plantar Temperature Response to Walking in Diabetes with and without Acute Charcot: The Charcot Activity Response Test.
Najafi B, Wrobel JS, Grewal G, Menzies RA, Talal TK, Zirie M, Armstrong DG.
J Aging Res. 2012;2012:140968.
Quote:
Objective. Asymmetric plantar temperature differences secondary to inflammation is a hallmark for the diagnosis and treatment response of Charcot foot syndrome. However, little attention has been given to temperature response to activity. We examined dynamic changes in plantar temperature (PT) as a function of graduated walking activity to quantify thermal responses during the first 200 steps.

Methods. Fifteen individuals with Acute Charcot neuroarthropathy (CN) and 17 non-CN participants with type 2 diabetes and peripheral neuropathy were recruited. All participants walked for two predefined paths of 50 and 150 steps. A thermal image was acquired at baseline after acclimatization and immediately after each walking trial. The PT response as a function of number of steps was examined using a validated wearable sensor technology. The hot spot temperature was identified by the 95th percentile of measured temperature at each anatomical region (hind/mid/forefoot).

Results. During initial activity, the PT was reduced in all participants, but the temperature drop for the nonaffected foot was 1.9 times greater than the affected side in CN group (P = 0.04). Interestingly, the PT in CN was sharply increased after 50 steps for both feet, while no difference was observed in non-CN between 50 and 200 steps.

Conclusions. The variability in thermal response to the graduated walking activity between Charcot and non-Charcot feet warrants future investigation to provide further insight into the correlation between thermal response and ulcer/Charcot development. This stress test may be helpful to differentiate CN and its response to treatment earlier in its course.
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  #42  
Old 2nd November 2012, 06:15 PM
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Default Re: Ten years of Charcot: what have we learned?

Impact of Charcot neuroarthropathy on metatarsal bone mineral density and geometric strength indices
David J. Gutekunst et al
Bone (in press)
Quote:
Charcot neuroarthropathy (CN), an inflammatory condition characterized by rapid and progressive destruction of pedal bones and joints, often leads to deformity and ulceration in individuals with diabetes mellitus (DM) and peripheral neuropathy (PN). Repetitive, unperceived joint trauma may trigger initial CN damage, causing a proinflammatory cascade that can result in osteolysis and contribute to subsequent neuropathic fracture. We aimed to characterize osteolytic changes related to development and progression of CN by measuring bone mineral density (BMD) and geometric strength indices using volumetric quantitative computed tomography. Twenty individuals with DM + PN were compared to twenty age-, sex-, and race-matched individuals with DM + PN and acute CN. We hypothesized that individuals with acute CN would have decreased BMD and decreased total area, cortical area, minimum section modulus, and cortical thickness in the diaphysis of the second and fifth metatarsals. Results showed BMD was lower in both involved and uninvolved feet of CN participants compared to DM + PN participants, with greater reductions in involved CN feet compared to uninvolved CN feet. There was a non-significant increase in total area and cortical area in the CN metatarsals, which helps explain the finding of similar minimum section modulus in DM + PN and CN subjects despite the CN group's significantly lower BMD. Larger cortical area and section modulus are typically considered signs of greater bone strength due to higher resistance to compressive and bending loads, respectively. In CN metatarsals, however, these findings may reflect periosteal woven bone apposition, i.e., a hypertrophic response to injury rather than increased fracture resistance. Future research using these techniques will aid further understanding of the inflammation-mediated bony changes associated with development and progression of CN and other diseases.
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  #43  
Old 5th November 2012, 11:06 PM
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Default Re: Ten years of Charcot: what have we learned?

Self-reported outcomes of trans-tibial amputations for non-reconstructable Charcot neuroarthropathy in patients with diabetes: a preliminary report
D. K. Wukich, K. T. Pearson
Diabetic Medicine (in press)
Quote:
Aims
Lower-extremity amputation in patients with diabetes is associated with premature mortality and impaired ambulatory status. Despite advances in limb salvage techniques, certain patients will require major amputation. The hypothesis of this study is that self-reported outcomes of patients with non-reconstructable Charcot neuroarthropathy and chronic osteomyelitis improve after trans-tibial amputation.

Methods
Self-reported outcome was assessed using the Medical Outcome Study Short Form 36-item health survey (SF-36) and the Foot and Ankle Ability Measure. The study group included 13 patients with diabetes who underwent a trans-tibial amputation and completed both the Medical Outcome Study SF-36 and the Foot and Ankle Measure pre- and post-operatively.

Results
Significant improvement after trans-tibial amputation occurred in the SF-36 Physical Component Summary score and both the Foot and Ankle Measure Activity of Daily Living and Sports scores at a mean follow-up of 79 weeks (range 53–122 weeks). Although the SF-36 Mental Component Summary score improved, the improvement did not achieve statistical significance (P = 0.30). Twelve of the 13 patients were satisfied with the amputation and had no reservations.

Conclusions
In a select group of Charcot neuroarthropathy patients with chronic osteomyelitis, trans-tibial amputation resulted in improvement in self-reported outcomes. Although major lower-extremity amputation is a devastating complication in patients with diabetes, the results of this study provides some evidence for optimism in these high-risk patients.
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Old 1st December 2012, 02:46 PM
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Default Re: Ten years of Charcot: what have we learned?

Pressure pain perception at the injured foot: the impact of diabetic neuropathy.
Wienemann T, Chantelau EA, Richter A.
J Musculoskelet Neuronal Interact. 2012 Dec;12(4):254-61.
Quote:
Background: At feet with painless diabetic neuropathy (PDN) and a healed fracture (quiescent Charcot-foot), cutaneous pressure pain perception threshold (CPPPT) is elevated beyond the range of measurement, whereas deep pressure pain perception threshold (DPPPT) may be normal. It is unknown, how these thresholds behave under the conditions of a foot injury. We therefore measured CPPPT and DPPPT in the vicinity of a unilateral active foot injury.

Patients and methods: 18 diabetic patients with PDN and plantar injury, partly involving the skeleton (Wagner grade I-II ulcer), 10 non-neuropathic subjects with acute painful skeletal injury (sprain, fracture) and 20 healthy control subjects without foot injury were studied. CPPPT was measured using calibrated monofilaments, and DPPPT was measured by Algometer II® over muscle and joint.

Results: Compared to control subjects, non-neuropathic acutely injured (and contralateral) feet displayed lowered CPPPT and DPPPT. Conversely, ulcerated and contralateral feet with PDN displayed unmeasurably elevated thresholds in 100% (CPPPT), 72% (DPPPT over joint), and 28% (DPPPT over muscle) of patients, respectively.

Conclusion: In the vicinity of an active foot injury, physiologic hyperalgesia was demonstrated in the non-neuropathic subjects, but not in the patients with PDN in whom neglect of foot trauma is, therefore, common.
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Old 10th December 2012, 06:03 PM
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Default Re: Ten years of Charcot: what have we learned?

Charcot neuroarthropathy after simultaneous pancreas-kidney transplant.
Rangel ÉB, Sá JR, Gomes SA, Carvalho AB, Melaragno CS, Gonzalez AM, Linhares MM, Medina-Pestana JO.
Transplantation. 2012 Sep 27;94(6):642-5.
Quote:
BACKGROUND:
Immunosuppressive regimen is associated with several metabolic adverse effects. Bone loss and fractures are frequent after transplantation and involve multifactorial mechanisms.

METHODS:
A retrospective analysis of 130 patients submitted to simultaneous pancreas-kidney transplantation (SPKT) and an identification of risk factors involved in de novo Charcot neuroarthropathy by multivariate analysis were used; P<0.05 was considered significant.

RESULTS:
Charcot neuroarthropathy was diagnosed in 4.6% of SPKT recipients during the first year. Cumulative glucocorticoid doses (daily dose plus methylprednisolone pulse) during the first 6 months both adjusted to body weight (>78 mg/kg) and not adjusted to body weight were associated with Charcot neuroarthropathy (P=0.001 and P<0.0001, respectively). Age, gender, race, time on dialysis, time of diabetes history, and posttransplantation hyperparathyroidism were not related to Charcot neuroarthropathy after SPKT.

CONCLUSIONS:
Glucocorticoids are the main risk factors for de novo Charcot neuroarthropathy after SPKT. Protocols including glucocorticoid avoidance or minimization should be considered.
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Old 25th December 2012, 03:41 PM
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Default Re: Ten years of Charcot: what have we learned?

Role of body mass index in acute charcot neuroarthropathy.
Ross AJ, Mendicino RW, Catanzariti AR.
J Foot Ankle Surg. 2013 Jan;52(1):6-8.
Quote:
Obesity has been posited as a predictor for the development of Charcot neuroarthropathy, a severe form of degenerative joint disease associated with peripheral neuropathy and diabetes mellitus. The present case-control study investigated the relationship between elevated (overweight and obese) body mass index and acute Charcot neuroarthropathy in a diabetic population. The final data set consisted of 49 patients, 20 (40.82%) of whom had Charcot foot and 29 (59.18%) who served as controls. In the present investigation, no statistically significant association was found between an elevated body mass index and the development of acute Charcot neuroarthropathy involving the foot.
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Old 2nd January 2013, 10:58 PM
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Default Re: Ten years of Charcot: what have we learned?

Evaluation of Roger’s Charcot Foot Classification System in South Indian Diabetic Subjects with Charcot Foot
Vijay Viswanathan, Rajesh Kesavan, Kavitha KV, Satyavani Kumpatla
The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 3, No. 2, Pages 67-70
Quote:
Background and aim: The Roger’s classification of Charcot foot, which is a two-axis system, describes the location of the affected part (x-axis) and the severity (y-axis). The aim was to evaluate this system in terms of the risk of lower extremity amputation among South Indian patients with type 2 diabetes and Charcot foot.

Research design and methods: Fifty-three subjects with Charcot foot were included. Classification and grading of Charcot foot was done using Eichenholtz and Frykberg systems. Details on risk factors and level of amputations were recorded.

Results: Five amputations were observed; two with deformity and ulceration in midfoot underwent below knee amputation and three with rearfoot deformity and osteomyelitis underwent above knee amputation. Risk of amputation was significantly higher in association with location and complexity/stage of Charcot neuroarthropathy.

Conclusion: The risk of amputation increases with increasing severity and location of the deformity, as per Roger’s Charcot foot classification system.
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Old 11th January 2013, 12:11 AM
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Default Re: Ten years of Charcot: what have we learned?

Recurrence of Acute Charcot Neuropathic Osteoarthropathy After Conservative Treatment
Georg Osterhoff, Thomas Böni, Martin Berli
Foot & Ankle International January 10, 2013 1071100712464957
Quote:
Background: Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive-destructive process affecting the feet of patients with sensory neuropathy. Data on CN recurrence are underrepresented in the literature. The aim of the present study was to evaluate the rate of CN recurrence after its treatment and to find predisposing factors.

Methods: Fifty-two patients (age 59 ± 11 years, 16 female) with acute CN with 57 affected feet were enrolled. Comorbidities, localization, and stage of disease at first diagnosis as well as ulcerations, need for surgery, noncompliance, and subsequent treatment (orthopedic footwear or orthotic treatment) during the course of therapy were recorded. During follow-up, the incidence of recurrence of CN was observed. Mean follow-up was 47 ± 40 months.

Results: Diabetes was the most common reason for sensory neuropathy (79%). Recurrence of CN was seen in 13 feet (23%) with an interval of 27 ± 31 months (range, 3-102 months) after the end of initial immobilization. Patients with recurrence were immobilized for a shorter period of time and had a more advanced stage of CN at time of first diagnosis. Predictors of recurrence were noncompliance (odds ratio 19.7; confidence interval, 4.1-94.4; P < .001) and obesity (odds ratio 6.4; confidence interval, 1.6-25.9; P = .06).

Conclusions: Recurrence of osteoarthropathic activity is a possible complication after conservative treatment of CN. Obesity and noncompliance are strong predictors for the recurrence of CN.
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Old 20th February 2013, 06:41 PM
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Default Re: Ten years of Charcot: what have we learned?

Effect of immobilization, off-loading and zoledronic acid on bone mineral density in patients with acute Charcot neuroarthropathy: A prospective randomized trial
Toni-Karri Pakarinen, Heikki-Jussi Laine, Heikki Mäenpää, Mika Kähönen, Pentti Mattila, Jorma Lahtela
Foot and Ankle Surgery Available online 20 February 2013
Quote:
Backround
Bisphosphonates are commonly used as an adjuvant in the management of acute Charcot neuroarthropathy (CNA), although the clinical efficacy of the treatment is controversial. The aim of the present study is to investigate the effect of immobilization and zoledronic acid on bone mineral density (BMD) changes during the treatment of acute CNA.

Methods
Thirty-five patients with acute midfoot CNA were randomly assigned to treatment with either zolendronic acid or placebo. BMD of the lumbar spine and both hips was measured at baseline and after six months of treatment.

Results
Comparison between BMD at presentation and at 6 months demonstrated a significant fall in BMD in the placebo group at the CNA-affected femoral neck (−3.2%, p = 0.016) and in the CNA-free hip (−1.2%, p = 0.026). Conversely, a significant rise in BMD was observed in the zolendronic acid group at all measured areas of the CNA-free hip.

Discussion and conclusions
Immobilization and off-loading does not lead to marked disuse osteoporosis in patients with acute CNA after 6 months of treatment. Treatment with zoledronic acid led to a statistically significant increase in hip BMD compared to placebo.
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Old 23rd March 2013, 08:09 AM
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Default Re: Ten years of Charcot: what have we learned?

Recurrence of acute charcot neuropathic osteoarthropathy after conservative treatment.
Osterhoff G, Böni T, Berli M.
Foot Ankle Int. 2013 Mar;34(3):359-64.
Quote:
BACKGROUND:
Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive-destructive process affecting the feet of patients with sensory neuropathy. Data on CN recurrence are underrepresented in the literature. The aim of the present study was to evaluate the rate of CN recurrence after its treatment and to find predisposing factors.

METHODS:
Fifty-two patients (age 59 ± 11 years, 16 female) with acute CN with 57 affected feet were enrolled. Comorbidities, localization, and stage of disease at first diagnosis as well as ulcerations, need for surgery, noncompliance, and subsequent treatment (orthopedic footwear or orthotic treatment) during the course of therapy were recorded. During follow-up, the incidence of recurrence of CN was observed. Mean follow-up was 47 ± 40 months.

RESULTS:
Diabetes was the most common reason for sensory neuropathy (79%). Recurrence of CN was seen in 13 feet (23%) with an interval of 27 ± 31 months (range, 3-102 months) after the end of initial immobilization. Patients with recurrence were immobilized for a shorter period of time and had a more advanced stage of CN at time of first diagnosis. Predictors of recurrence were noncompliance (odds ratio 19.7; confidence interval, 4.1-94.4; P < .001) and obesity (odds ratio 6.4; confidence interval, 1.6-25.9; P = .06).

CONCLUSIONS:
Recurrence of osteoarthropathic activity is a possible complication after conservative treatment of CN. Obesity and noncompliance are strong predictors for the recurrence of CN.
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Old 28th March 2013, 04:25 PM
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Default Re: Ten years of Charcot: what have we learned?

Neuropathic midfoot deformity: associations with ankle and subtalar joint motion.
Sinacore DR, Gutekunst DJ, Hastings MK, Strube MJ, Bohnert KL, Prior FW, Johnson JE.
J Foot Ankle Res. 2013 Mar 25;6(1):11.

Quote:
BACKGROUND:
Neuropathic deformities impair foot and ankle joint mobility, often leading to abnormal stresses and impact forces. The purpose of our study was to determine differences in radiographic measures of hind foot alignment and ankle joint and subtalar joint motion in participants with and without neuropathic midfoot deformities and to determine the relationships between radiographic measures of hind foot alignment to ankle and subtalar joint motion in participants with and without neuropathic midfoot deformities.

METHODS:
Sixty participants were studied in three groups. Forty participants had diabetes mellitus (DM) and peripheral neuropathy (PN) with 20 participants having neuropathic midfoot deformity due to Charcot neuroarthropathy (CN), while 20 participants did not have deformity. Participants with diabetes and neuropathy with and without deformity were compared to 20 young control participants without DM, PN or deformity. Talar declination and calcaneal inclination angles were assessed on lateral view weight bearing radiograph. Ankle dorsiflexion, plantar flexion and subtalar inversion and eversion were assessed by goniometry.

RESULTS:
Talar declination angle averaged 34+/-9, 26+/-4 and 23+/-3 degrees in participants with deformity, without deformity and young control participants, respectively (p< 0.010). Calcaneal inclination angle averaged 11+/-10, 18+/-9 and 21+/-4 degrees, respectively (p< 0.010). Ankle plantar flexion motion averaged 23+/-11, 38+/-10 and 47+/-7 degrees (p<0.010). The association between talar declination and calcaneal inclination angles with ankle plantar flexion range of motion is strongest in participants with neuropathic midfoot deformity. Participants with talonavicular and calcaneocuboid dislocations result in the most severe restrictions in ankle joint plantar flexion and subtalar joint inversion motions.

CONCLUSIONS:
An increasing talar declination angle and decreasing calcaneal inclination angle is associated with decreases in ankle joint plantar flexion motion in individuals with neuropathic midfoot deformity due to CN that may contribute to excessive stresses and ultimately plantar ulceration of the midfoot.
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Old 21st May 2013, 03:06 PM
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Default Re: Ten years of Charcot: what have we learned?

Pressure pain perception in the diabetic Charcot foot: facts and hypotheses
Ernst A. Chantelau, Tobias Wienemann
Diabetic Foot & Ankle 2013, 4: 20981
Quote:
Background: Reduced traumatic and posttraumatic (nociceptive) pain is a key feature of diabetic neuropathy. Underlying condition is a gradual degeneration of endings of pain nerves (A-delta fibers and C-fibers), which operate as receivers of noxious stimuli (nociceptors). Hence, the absence of A-delta fiber mediated sharp pain (‘‘first’’ pain), and of C-fiber mediated dull pain (‘‘second’’ pain). However, patients with diabetic neuropathy and acute Charcot foot often experience deep dull aching in the Charcot foot while walking on it.

Aim: To create a unifying hypothesis on the kind of pain in an acute Charcot foot. Result: Absence of punctuate (pinprick) pain perception at the sole of a Charcot foot, as was shown recently, likely corresponds to vanished intraepidermal A-delta fiber endings. C-fiber nociceptors are reduced, according to histopathology studies. Both types of fibers contribute to posttraumatic hyperalgesia at the skin level, as studies show. Their deficiencies likely impact on posttraumatic hyperalgesia at the skin level and, probably, also at the skeletal level.

Conclusion: It is hypothesised that deep dull aching in an acute diabetic Charcot foot may represent faulty posttraumatic hyperalgesia involving cutaneous and skeletal tissues.
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Old 15th June 2013, 06:15 AM
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Default Re: Ten years of Charcot: what have we learned?

Who was first to diagnose and report neuropathic arthropathy of the foot and ankle: Jean-Martin Charcot or Herbert William Page?
Sanders LJ, Edmonds ME, Jeffcoate WJ.
Diabetologia. 2013 Jun 14.
Quote:
In November 1883, Jean-Martin Charcot and Charles Féré reported on bone and joint disease of the foot in cases of tabes dorsalis, and referred to the condition as 'pied tabétique'-a disabling neuropathic osteoarthropathy that we usually now refer to as the Charcot foot. Charcot had originally described neuropathic osteoarthropathy in more proximal joints in 1868, and in his 1883 paper with Féré stated that involvement of the short bones and small joints of the foot had not yet been described. They emphasised in the paper that one of their cases was the first ever observed, two years earlier, in 1881. It is relevant, however, that it was in this same year that involvement of the foot by tabetic arthropathy was presented to the International Medical Congress in London by an English surgeon, Herbert William Page. We believe that Page was the first to diagnose and to report a case of tabetic neuropathic osteoarthropathy in which the bones of the foot and ankle were involved. He was also the first to propose a link between the tabetic foot and disease of the peripheral nerves, as opposed to the central nervous system.
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Old 16th July 2013, 02:53 PM
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Default Re: Ten years of Charcot: what have we learned?

Recurrence of acute Charcot neuropathic osteoarthropathy after conservative treatment.
Osterhoff G, Böni T, Berli M.
Foot Ankle Int. 2013 Mar;34(3):359-64.
Quote:
BACKGROUND:
Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive-destructive process affecting the feet of patients with sensory neuropathy. Data on CN recurrence are underrepresented in the literature. The aim of the present study was to evaluate the rate of CN recurrence after its treatment and to find predisposing factors.
METHODS:
Fifty-two patients (age 59 ± 11 years, 16 female) with acute CN with 57 affected feet were enrolled. Comorbidities, localization, and stage of disease at first diagnosis as well as ulcerations, need for surgery, noncompliance, and subsequent treatment (orthopedic footwear or orthotic treatment) during the course of therapy were recorded. During follow-up, the incidence of recurrence of CN was observed. Mean follow-up was 47 ± 40 months.
RESULTS:
Diabetes was the most common reason for sensory neuropathy (79%). Recurrence of CN was seen in 13 feet (23%) with an interval of 27 ± 31 months (range, 3-102 months) after the end of initial immobilization. Patients with recurrence were immobilized for a shorter period of time and had a more advanced stage of CN at time of first diagnosis. Predictors of recurrence were noncompliance (odds ratio 19.7; confidence interval, 4.1-94.4; P < .001) and obesity (odds ratio 6.4; confidence interval, 1.6-25.9; P = .06).
CONCLUSIONS:
Recurrence of osteoarthropathic activity is a possible complication after conservative treatment of CN. Obesity and noncompliance are strong predictors for the recurrence of CN.
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Old 31st July 2013, 12:50 PM
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Default Re: Ten years of Charcot: what have we learned?

The acute diabetic Charcot foot managed on the basis of magnetic resonance imaging - a review of 71 cases.
Chantelau E, Richter A.
Swiss Med Wkly. 2013 Jul 29;143:0.
Quote:
BACKGROUND:
Acute Charcot foot (ACF) is a skeletal breakdown associated with inflammatory swelling of a foot in patients with pain insensitivity, such as diabetic neuropathy. In ACF stage 0, skeletal pathology (e.g. osseous oedema) is visible on magnetic resonance imaging (MRI), but not on plain radiographs. Continued unprotected walking invariably causes stage 1 (complex cortical fractures). Treatment by total contact cast (TCC) is of limited benefit if X-ray-based. The benefits of MRI-based TCC treatment are unknown.
AIM:
To assess the impact of MRI, all cases of ACF diagnosed by MRI between 2000 and 2012 were reviewed.
METHOD:
Audit of medical charts of a single outpatient diabetic foot clinic.
RESULTS:
Seventy-one cases (59 patients) were retrieved. Diagnosis of stage 0 (n = 27 cases) and stage 1 (n = 44 cases) was established one and two months (medians) after symptom onset, respectively. Unremarkable radiographs, that were not cross-checked by MRI (n = 13 cases), misled primary care physicians to postpone referral until five months after symptom onset, when cortical fractures had already occurred in 12 cases. Midfoot (Chopart- and Lisfranc-) lesions healed better in stage 0 versus stage 1 (69% versus 7% without deformities, p = 0.0012), while forefoot (metatarsal) lesions healed well in either stage (100% versus 75% without deformities). TCC-treatment lasted four to six months.
CONCLUSION:
Healing of ACF was more efficient in stage 0 than in stage 1. Expeditious MR imaging was indispensable to diagnose stage 0 in a swollen foot of a neuropathic patient, while unremarkable X-rays often led to a missed diagnosis.
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Old 8th August 2013, 04:51 PM
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Default Re: Ten years of Charcot: what have we learned?

Is an increase in skin temperature predictive of neuropathic foot ulceration in people with diabetes? A systematic review and meta-analysis
Houghton VJ, Bower VM and Chant DC
Journal of Foot and Ankle Research 2013, 6:31 (7 August 2013)
Quote:
Introduction
The aim of this systematic review was to evaluate the strength of the existing research to answer the question: Is an increase in skin temperature predictive of neuropathic foot ulceration in people with diabetes?

Methods
This study is a systematic review and meta-analysis of temperature-monitoring in the prediction and prevention of diabetic foot ulceration. Two investigators conducted a literature search for all relevant articles from the 1960 until July 2011. During this process the following data bases were searched: MEDLINE, Science Direct, AMED, Australian Medical Index, APAIS-Health, ATSIhealth, EMBASE, Web of Science and OneSearch. Keywords used in this search included diabetes, foot complications, ulceration, temperature-monitoring, prediction and prevention.

Results
Results of the meta-analysis support the theory that an increase in skin temperature is predictive of foot ulceration when compared with the same site on the contralateral limb. The theory that there is a mean norm foot temperature which can be used as a benchmark to monitor pathological change was unsupported by this meta-analysis.

Conclusions
The conclusions derived from this review are based on the best available scientific evidence in this field. It is intended that the results of this study will improve clinical decision-making and encourage the appropriate measures used to predict and prevent ulceration in people with diabetes at high risk of foot complications. Based on quality studies in this area, the results of this review have indicated that the use of temperature-monitoring is an effective way to predict, and thus prevent, diabetic foot ulceration.
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Old 5th September 2013, 12:38 PM
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Default Re: Ten years of Charcot: what have we learned?

Charcot neuroarthropathy in simultaneous kidney-pancreas transplantation: report of two cases.
Del Vecchio JJ, Raimondi N, Rivarola H, Autorino C.
Diabet Foot Ankle. 2013 Aug 29;4
Quote:
Charcot neuroarthropathy (CN) is considered a major complication in diabetes mellitus (DM), and it is estimated that 1% of diabetic patients may develop this complication. Simultaneous kidney-pancreas transplantation (SKPT) is one of the most effective therapies for patients with type 1 DM and end-stage diabetic nephropathy. Some cases with a Charcot-modified clinical presentation during the postoperative convalescence period after SKPT have been described. The clinical presentation may condition severe destructive lesions, and good practices include systematic follow-up. Based on the cases described, SKPT is one more entity that might lead to CN 'foot-at-risk'. The aim of this article is to describe two cases of neuropathic arthropathy with rapid progression in the short term after SKPT.
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Old 16th September 2013, 04:25 PM
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Default Re: Ten years of Charcot: what have we learned?

Pedal Bone Density, Strength, Orientation, and Plantar Loads Preceding Incipient Metatarsal Fracture After Charcot Neuroarthropathy: 2 Case Reports
David J. Gutekunst, David R. Sinacore
J Orthop Sports Phys Ther, Epub 9 September 2013. doi:10.2519/jospt.2013.4443
Quote:
Background Charcot neuroarthropathy (CN) is a progressive, non-infective, inflammatory destruction of bones and joints leading to foot deformities and plantar ulceration. Though individuals with CN typically have low areal bone mineral density (aBMD), little is known regarding changes in volumetric bone mineral density (vBMD), bone geometry, joint mal-alignment, and biomechanical loads preceding fracture.

Case Description Two females, aged 45 and 54 years at the onset of an acute non-fracture CN event, received regular physical therapy with wound care and total contact casting. Both enrolled in a larger research study that included plantar pressure assessment and quantitative computed tomography (QCT) at enrollment and 3, 6, and 12 months later. The women sustained mid-diaphyseal fifth metatarsal fracture 10–11 months after enrollment. QCT image analysis techniques were used to measure vBMD; bone geometric indices reflecting strength in compression, bending, and cortical buckling; and 3-dimensional bone-to-bone orientation angles reflecting foot deformity.

Outcomes Fifth metatarsal mid-diaphyseal vBMD decreased during off-loading treatment from 0 to 3 months, then increased to above baseline levels by 6 months. All geometric strength indices improved from baseline through 6 months. Plantar loading in the lateral midfoot increased preceding fracture, concomitant with alterations in bone orientation angles which suggest progressive development of metatarsus adductus and equinovarus foot deformity.

Discussion Fractures may occur when bone strength decreases or when biomechanical loading increases. Incipient fracture was preceded by increased loading in the lateral midfoot, but not by reductions in vBMD or geometric strength indices, suggesting that loading played a greater role in fracture. Moreover, the progression of foot deformities may be causally linked to the increased plantar loading.
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Old 25th October 2013, 07:22 PM
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Default Re: Ten years of Charcot: what have we learned?

The effect of diabetic neuropathy on foot bones: a systematic review and meta-analysis.
Barwick AL, Janse de Jonge XA, Tessier JW, Ho A, Chuter VH.
Diabet Med. 2013 Oct 23
Quote:
AIMS:
It is proposed that diabetic neuropathy may affect peripheral bone. Direct innervation of bone as well as neural control over its vascular supply and muscular influences may be affected by diabetes-induced peripheral neuropathies. Associated changes to bone may contribute to the occurrence of foot bone pathology in this population. This systematic review aims to examine the literature related to the effect of diabetic neuropathy on foot bones.
METHODS:
Studies examining relationships between neuropathy and indicators of bone health (e.g. bone mineral density) in populations with diabetes were sought. Relevant publications were obtained from searches in MEDLINE, CINAHL and Embase in the period up to March 2013. Meta-analysis was performed using a random effects model in the statistical package Stata version 12.1.
RESULTS:
Ten studies met the inclusion criteria and were included in the narrative synthesis. All studies were cross-sectional or case-control in design. Four of the 10 included studies found results indicating poorer bone health in those with diabetes and neuropathy compared with those with diabetes without neuropathy. Seven of the 10 studies were able to be included in a meta-analysis. The mean pooled effect was -0.36 (95% CI -0.76 to 0.04; P = 0.08), indicating a non-significant trend towards poorer bone health in those with diabetic neuropathy.
CONCLUSIONS:
We did not find a significant relationship between presence of neuropathy in those with diabetes and poorer peripheral bone health. However, methodological limitations of the included studies mean further research is required to investigate this theoretical relationship. This article is protected by copyright. All rights reserved.
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Old 29th October 2013, 12:25 PM
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Default Re: Ten years of Charcot: what have we learned?

Radiographic and functional results in the treatment of early stages of Charcot neuroarthropathy with a walker boot and immediate weight bearing
Maria Candida Ribeiro Parisi, Alexandre Leme Godoy-Santos, Rafael Trevisan Ortiz, Rafael Barban Sposeto, Marcos Hideyo Sakaki, Marcia Nery, Tulio Diniz Fernandes
Diabetic Foot & Ankle 2013, 4: 22487
Quote:
Background: One of the most common gold standards for the treatment of Charcot neuroarthropathy (CN) in the early Eichenholtz stages I and II is immobilization with the total contact casting and lower limb offloading. However, the total amount of offloading is still debatable.

Objectives: This study evaluates the clinical and radiographic findings in the treatment of early stages of CN (Eichenholtz stages I and II) with a walker boot and immediate total weight-bearing status.

Methods: Twenty-two patients with type 2 diabetes mellitus (DM) and CN of Eichenholtz stages I and II were selected for non-operative treatment. All patients were educated about their condition, and full weight bearing was allowed as tolerated. Patients were monitored on a fortnightly basis in the earlier stages, with clinical examination, temperature measurement, and standardized weight-bearing radiographs. Their American Orthopedic Foot and Ankle Society (AOFAS) scores were determined before and after the treatment protocol.

Results: No cutaneous ulcerations or infections were observed in the evaluated cases. The mean measured angles at the beginning and end of the study, although showing relative increase, did not present a statistically significant difference (p>0.05). Mean AOFAS scores showed a statistically significant improvement by the end of the study (p<0.005).

Conclusion: The treatment of early stages of CN (Eichenholtz stages I and II) with emphasis on walker boot and immediate weight bearing has shown a good functional outcome, non-progressive deformity on radiographic assessment, and promising results as a safe treatment option.
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