Fracture of the Bone Inducing Its Necrosis as the End Point in the Evolution of Untreated Neuroarthropathy

We describe here the case of a female patient with type I diabetes who developed active Charcot neuroarthropathy in the foot. Due to therapeutic noncompliance, talus necrosis was discovered 2 years after the presentation of neuroarthropathy. The impact of untreated neuroarthropathy on the bone is commonly described as fracture and joint dislocation, but we describe the complete disappearance of the bony structure and its necrosis associated with active neuroarthropathy in a patient who refused offloading.

Management of Ankle Charcot Neuroarthropathy: A Systematic Review

Background: Charcot neuroarthropathy is a non-infective, destructive process occurring in patients rendered insensate by peripheral neuropathy, which is caused mainly by diabetes. Repetitive trauma from standing and walking provides a neuro-traumatic stimulus that leads to dislocation, or peri-articular fracture, or both, within the ankle. This review concentrates on the management protocols regarding the ankle only. Methods: A Pubmed search for clinical trials performed to manage ankle Charcot neuroarthropathy and a systematic review of these articles were undertaken. Results: Twenty papers met the inclusion criteria: four of them describe non-surgical management, while the rest show different surgical management options of ankle Charcot neuroarthropathy. Conclusions: Surgical algorithms for the treatment of CN of the ankle are based almost entirely on level four. There is inconclusive evidence concerning the timing of treatment and the use of different fixation methods. Instability and ulceration are the main precursors for surgical interventions. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.

The Charcot Foot: An Emerging Public Health Problem for African Diabetes Patients

Background: Although the awareness, diagnosis, management of the complications associated with diabetes have improved in African countries over the past decade, surveillance activities in Tanzania and anecdotal reports from other African countries have suggested an increased prevalence of Charcot Neuroarthropathy (CN) over the past few years. Aim: To characterize the epidemiology and the clinical burden of CN in a large diabetes population in Tanzania, and to evaluate outcomes of persons with the condition. Methods: This was a prospective analytic cohort study conducted between January 2013 through December 2015. Following informed consent, patients were followed at the outpatient clinic. Detailed clinical assessments and documented presence of diabetic peripheral neuropathy (DPN), macrovascular disease and microvascular disease were recorded. Education and counseling were part of the follow-up program. Results: 3271 ulcerations were presented at the clinic during the 3-year study period. 571 (18%) met the case definition for CN; all patients had Type 2 diabetes. The prevalence for each of the years 2013, 2014, and 2015 was 19/1192 (1.6%), 209/1044 (20%), and 343/1035 (34%), respectively; the increases in the slope of the trendline was statistically significant ( P < .001). Conclusion: The prevalence of CN is increasing in the Tanzanian diabetes patient population, and is strongly associated with neuropathy. CN can lead to severe deformity, disability, and amputation. Due to the risk of limb amputation, patients with diabetes must seek immediate care if signs or symptoms appear and avoid delay in seeking medical attention. Early diagnosis of CN by caregivers is extremely important for successful outcomes.

Differential Diagnosis of Charcot Neuroarthropathy in Subacute and Chronic Phases: Unusual Diseases

Charcot Neuroarthropaty (CN) is a complication of diabetes with devastating consequences as it produces severe deformities in the foot developing in recurrent ulcers that rise the probability of amputation. There are several diseases mentioned in the literature that have to be considered for the differential diagnosis of CN, often related to the acute phase (gout, ankle sprain, inflammatory arthritis, cellulitis, venous thrombosis) but there is paucity of information related to the differential diagnosis in later stages (coalescence, remodeling) when there is deformity of the foot. Clinicians and diabetologists are not familiarized with orthopedic pathology and do not have in mind certain diseases that could mimic CN in the subacute or chronic phases and this can develop in a wrong diagnosis. It is important to make a correct diagnosis in patients with suspected CN not only in the acute phase but also in the chronic phase to establish an accurate treatment. This article is a review of the differential diagnosis of CN in subacute and chronic phases showing similarities and differences that can help clinicians and diabetologists to make an accurate diagnosis and treatment. We describe unusual diseases like tendon and muscles disorders, Frieberg's disease, complex pain regional syndrome, transient regional osteoporosis and osteomyelitis superimposed to CN and the main features of each one that could help in making a differential diagnosis

Long-term foot outcomes following differential abatement of inflammation and osteoclastogenesis for active Charcot neuroarthropathy in diabetes mellitus

Aims Inflammatory osteolysis is sine-qua-non of active Charcot neuroarthropathy (CN) causing decreased foot bone mineral density (BMD) and fractures. We aimed to explore the effect of anti-inflammatory or anti-resorptive agents for effect on foot bone mineral content (BMC) and consequent long-term outcomes of foot deformities, fractures and amputation. Methods Forty-three patients with active CN (temperature difference >2°C from normal foot) were evaluated. Patients were off-loaded with total contact cast and randomized to receive either methylprednisolone (1gm) (group A), zoledronate (5mg) (group B) or placebo (100ml normal saline) (group C) once monthly infusion for three consecutive months. Change in foot BMC was assessed at 6 months or at remission and followed subsequently up to 4 years for the incidence of new-onset fracture, deformities, or CN recurrence. Results Thirty-six participants (24 male, 12 female) were randomized (11 in group A, 12 group B, 13 group C). The mean age was 57.7± 9.9 years, duration of diabetes 12.3± 5.8 years and symptom duration 6.5± 2.8 weeks. BMC increased by 36% with zoledronate (p = 0.02) but reduced by 13% with methylprednisolone (p = 0.03) and 9% (p = 0.09) with placebo at remission. There were no incident foot fractures, however, two patients sustained ulcers, and 3 had new-onset or worsening deformities and none required amputation during 3.36 ± 0.89 years of follow-up. Conclusion Bisphosphonate for active CN is associated with an increase in foot bone mineral content as compared to decrease with steroids or total contact cast but long-term outcomes of foot deformities, ulceration and amputation are similar. Trial registration ClinicalTrials.gov: NCT03289338.