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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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Re: Ten years of Charcot: what have we learned?
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