Acute Charcot Neuroarthropathy Research Articles

Reconstruction of the ‘Foot at Risk’ during Acute Charcot Neuroarthropathy

Reconstruction of the ‘Foot at Risk’ during Acute Charcot Neuroarthropathy

Tibiotalocalcaneal Arthrodesis Using Hybrid Plate-Nail Constructs: A Novel Technique for Treatment of Unstable Ankle and Hindfoot Deformities.

Tibiotalocalcaneal (TTC) arthrodesis is a treatment option for several pathologies of the ankle and hindfoot, including acute trauma, posttraumatic arthritis, and Charcot neuroarthropathy. Traditional fixation options for TTC arthrodesis include intramedullary hindfoot nailing or internal fixation with plates and/or screws. In certain patients, either due to poor bone quality, impaired sensation, or concern for noncompliance, more robust fixation may be desired. In such patients, we have used a hybrid plate-nail construct with promising results. This article and the accompanying video demonstrate our technique for TTC arthrodesis using a plate-nail construct and review treatment decisions involved with management of these complex cases.

The Neuro-Ischaemic Charcot Foot: Prevalence, Characteristics and Severity of Peripheral Arterial Disease in Acute Charcot Neuro-Arthropathy.

The study aimed to evaluate the prevalence, characteristics and outcomes of patients affected by Charcot neuro-arthropathy (CN) and peripheral arterial disease (PAD) compared to CN without PAD. Consecutive patients presenting with an acute CN were included. The sample size was calculated by the power analysis by adopting the two-tailed tests of the null hypothesis with alfa = 0.05 and a value of beta = 0.10 as the second type error and, therefore, a test power equal to 90%. Seventy-six patients were identified. Twenty-four patients (31.6%) had neuro-ischaemic CN; they were older (66 vs. 57yrs), p = 0.03, had a longer diabetes duration (19 vs. 14yrs), p < 0.001, and more cases of end-stage-renal-disease (12.5 vs. 0%), p = 0.04 and ischaemic heart disease (58.3 vs. 15.4%), p < 0.0001 than neuropathic CN. Fifty patients (65.8%) had concomitant foot ulcers, 62.5% and 67.3% (p = 0.3), respectively, in CN with and without PAD. Neuro-ischaemic CN show arterial lesions of 2.9 vessels, and PAD was located predominantly below-the-knee (75%) but not below-the-ankle (16.7%). The outcomes for neuro-ischaemic and neuropathic CN patients were, respectively: wound healing (86.7 vs. 94.3%), p = 0.08; minor amputation (25 vs. 7.7%), p = 0.003; major amputation (8.3 vs. 1.9%), p = 0.001; hospitalization (75 vs. 23%), p = 0.0001. The study showed a frequent association between CN and PAD, leading to a neuro-ischaemic Charcot foot type. Neuro-ischaemic CN leaded to an increased risk of minor and major amputation and hospitalization, compared to neuropathic CN.

Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

BackgroundCharcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies.MethodsThis study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher’s exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated.ResultsMean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants.ConclusionsThe median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.

Investigating the Use of Denosumab in the Treatment of Acute Charcot Neuroarthropathy

Charcot neuroarthropathy is a devastating condition, most commonly affecting poorly controlled diabetic patients with peripheral neuropathy. Pharmacological options for the condition are currently limited. The purpose of this study was to investigate the potential of Prolia® (denosumab) as a safe and feasible option in the treatment of acute Charcot neuroarthropathy. A total of 7 consecutive subjects were enrolled and followed for 1 year. Subjects received a single one-time injection of denosumab 60 mg. Subjects also received standard of care treatment, which included total contact casting, restricted weightbearing status, and biweekly office visits until normalization of the skin temperature gradient. Overall, the pharmaceutical treatment was generally well-tolerated. One subject developed a diabetic foot infection with cellulitis of the contralateral lower extremity, which occurred following the 6-month follow-up visit and which resolved with oral antibiotics One subject identified transient muscle pain in the same upper extremity which received the injection. Subjects were found to exit the acute phase of the condition at an average of 52.00 ± 17.89 days after their injection, which was defined by normalization of skin temperature to within 2°C of the contralateral foot. Treatment of acute Charcot neuroarthropathy with denosumab was well-tolerated in this open-label, pilot study. The clinical outcomes suggest that the medication may be efficacious, though a larger sample size would be needed to confirm these preliminary results. An adequately-powered, randomized, controlled study may be an appropriate follow-up.

The onset of acute Charcot neuroarthropathy during pregnancy in patients with type 1 diabetes.

SummaryWe report the onset of acute Charcot neuroarthropathy during pregnancy in two patients with type 1 diabetes using retrospective review of case notes. We describe for the first time the onset of acute Charcot neuroarthropathy during pregnancy in two patients with type 1 diabetes. Pregnancy may promote the onset and worsening of a number of diabetic complications. A link between pregnancy and the onset of acute Charcot neuroarthropathy is demonstrated for the first time in this report.Learning points:Patients with already diagnosed sensitive neuropathy can develop an active phase of Charcot neuroarthropathy during pregnancy.The rapid correction of hyperglycaemia may induce an active phase of Charcot neuroarthropathy during pregnancy.

Systematic review of techniques to monitor remission of acute Charcot neuroarthropathy in people with diabetes.

The management of acute Charcot neuroarthropathy relies on off-loading which is costly and time-consuming. Published studies have used monitoring techniques with unknown diagnostic precision to detect remission. We performed a systematic review of techniques for monitoring response to offloading in acute Charcot neuroarthropathy. We included studies of off-loading which evaluated or described monitoring techniques in acute Charcot neuroarthropathy. PubMed, EMBASE, CINAHL and Cochrane databases were searched (January1993-July 2018). We extracted data from papers including study design, setting, population, monitoring techniques and treatment outcomes. We also extracted information on the cost, clinical applicability, sensitivity and specificity, safety and participant acceptability of the monitoring techniques. We screened 1205 titles, 140 abstracts and 45 full-texts, and included 29 studies. All studies were of low quality and at high risk of bias. In seven studies, the primary aim was to evaluate monitoring techniques: three evaluated magnetic resonance imaging, two thermography monitoring, one three-phase bone scanning and one Doppler spectrum analysis. The remaining 22 observational studies reported treatment outcomes and described the monitoring techniques used to assess the Charcot neuroarthropathy. Heterogeneity prevented the pooling of data. Very few studies included data on cost, clinical applicability, sensitivity and specificity, safety and patient acceptability of the monitoring techniques used. Multiple techniques have been used to evaluate remission in acute Charcot neuroathropathy but uncertainty remains about their effectiveness. We recommend further research into the influences of different monitoring techniques on treatment outcomes.

Ultrasonographic features of acute Charcot neuroarthropathy of the foot: a pilot study.

Our aim was to characterize the ultrasonographic features of patients with acute Charcot neuroarthropathy (CN) of the foot. In this prospective study, 26 patients with CN of the foot proved by MRI were enrolled. All patients were in early stage of CN with normal radiography (grade 0 modified Eichenholtz classification system). Ultrasonographic examination of mid-tarsal and ankle joints was performed with a 7-15MHz linear probe. Ages of our patients ranged from 38 to 67years (57.3 ± 6.4). About 96.2% of our patients (25 patients) had diabetes mellitus. Ultrasonographic findings were as follows: effusion/synovitis (100%) with high Doppler activity (92.3%) in the mid-tarsal joints, and effusion/synovitis (92.3%) and high Doppler activity (84.6%) in the ankle joints. Bone erosions were present in the distal fibula in 23 patients (79.3%), while in distal tibia in 9 patients (34.6%). Tendonitis was found in tibialis posterior tendons in 23 patients (88.4%), and in peroneal tendons in 22 patients (84.6%). A combination of active synovitis (in mid-tarsal joints and ankle joints), active tendonitis (of tibialis posterior and peroneal tendons), and erosions in the distal end of fibula was present in 21 patients (80.8%). Ultrasonography is able to detect soft tissue inflammation and pre-radiographic bony changes in early stages of CN. Key Points •Ultrasound is a useful diagnostic tool for pre-radiographic stages of Charcot joint. •High-grade synovitis, high-grade tenosynovitis, and bony erosions are highly suggestive of Charcot arthropathy.

What Is the Best Method to Differentiate Acute Charcot Foot From Acute Infection?

Differentiation between acute Charcot neuroarthropathy (CN) and acute infection/osteomyelitis is complex and requires multiple (>1) diagnostic criteria. These criteria include an emphasis on the presence of neuropathy, history, and physical examination. The absence of skin wounds and resolution of swelling/erythema with elevation makes the likelihood of infection very low. In unclear cases, laboratory testing, histologic examination and culturing of bone specimens, scintigraphy, and imaging, especially magnetic resonance imaging (MRI), may be of benefit. Moderate. Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Clinical features, radiological characteristics and offloading modalities in stage 0 Acute Charcot's neuroarthropathy - A single centre experience from South India

AimsStage 0 Acute Charcot's Neuroarthropathy (ACN)in Type 2 Diabetes patients is a challenging diagnosis with subtle clinical features and normal appearing plain radiographs of the affected foot. Delay in diagnosis can lead to progression of disease and irreversible deformities. There is a paucity of data on Stage 0 ACN from India. The aim of this study was to assess clinical and radiological characteristics and treatment outcomes in Indian Type 2 Diabetes patients with Stage 0 ACN. Materials and methodsA comparative, case-control study was carried out amongst patients attending the Integrated Diabetes Foot Clinic at a tertiary care South Indian hospital. During the 3-year study period, a total of 1811 patients with Type 2 Diabetes Mellitus were screened. Of these, n = 10 patients with stage 0 ACN Charcot's arthropathy were identified based on clinical features and MRI imaging of the foot for confirmation of diagnosis. These were compared with an age and duration of diabetes-matched group of n = 50 patients without ACN as controls. ResultsOur study identified 10 patients (0.5%) with Stage 0 Acute charcot neuroarthropathy (ACN) in the study population. Those with ACN had higher BMI, poorer glycaemic control and greater degree of peripheral neuropathy (p < 0.05). Clinically relative lack of pain and infrared thermometric temperature difference >2 °C in the affected foot were the most significant findings, while MRI foot was useful in early detection of active and severe stage 0 disease. Total contact cast was the preferred initial offloading modality, with delay in initiating complete immobilization leading to worse outcomes. ConclusionsThis is the first study to highlight the characteristic features of Stage 0 ACN in Indian Type 2 Diabetes patients. Thorough clinical evaluation, infrared thermometry and radiological findigs on MRI foot leads to early disease detection. Complete offloading, preferably with total contact casts can prevent disease progression and chronic deformities.

Varied presentations and outcomes of Charcot neuroarthropathy in patients with diabetes mellitus

Charcot neuroarthropathy (CN) of the foot is uncommon and CN of atypical sites like wrist is sparingly described. CN is grossly under-diagnosed or misdiagnosed by primary care physicians. CN may present in acute phase with classical signs of inflammation or with deformities in chronic phase. The present study describes varied presentations, diagnostic dilemmas, and outcomes of CN in patients with diabetes. Data from the electronic repository of patients with diabetes and foot complications was obtained. The repository has a pre-designed structured format for information pertaining to the patients’ anthropometry, presentation, neurological, vascular and foot examination details, treatment offered, and outcomes on follow-up. In addition, literature search for prior reported cases of atypical site (wrist) of CN was conducted. Data of 206 subjects with foot CN and two cases of atypical joint amongst 1297 patients with diabetes mellitus was screened. The particulars of patients with varied presentation viz. acute phase (case 1), stable foot deformities in chronic phase (case 2), and unstable foot with destruction of ankle joint in hindfoot CN (case 3) are presented along with the differential diagnosis and their outcomes on follow-up at 36 months of presentation. A literature search for atypical site of CN revealed only nine cases of wrist CN. The diagnosis of wrist CN was not initially considered and misdiagnosed. Patient with CN may present in active phase or more commonly with deformities and destroyed joints. The acute CN is misdiagnosed as cellulitis and inadvertently treated with antibiotics. Wrist and MCP joint CN is extremely rare and the diagnosis of CN requires a high index of suspicion supported by radiography findings.

Initial Diagnosis and Management for Acute Charcot Neuroarthropathy

Charcot neuroarthropathy, also known as Charcot foot, is a complication of diabetes mellitus where there is progressive degeneration of the joints, but it potentially is devastating in its consequences.1 It commonly affects the middle of the foot, hind-foot joints, the ankle, and forefoot joints, and it is believed to result from inflammation in the foot that becomes abnormally protracted due to the underlying neuropathy.2–8 The prevalence of Charcot neuroarthropathy is up to 13% in individuals with diabetes.9–11 Patients with Charcot neuroarthropathy encounter increased morbidity and decreased quality of life and mortality.2,4,5,12,13 If there is a delay in treatment, Charcot neuroarthropathy could result in ulceration and infection which can lead to amputation of the limb.12–16 These patients have a significant financial impact on the health care system through primary care, community care, outpatient costs, increased bed occupancy, and prolonged stays in hospital. Charcot neuroarthropathy poses many clinical challenges in its diagnosis and management. The often asymptomatic nature of the condition is very similar to ankle sprain, cellulitis, venous thrombosis, inflammatory arthritis, or gout in a healthy patient.5,16–22 Missed diagnosis is as high as 79% which ultimately leads to a delay in treatment for an average of 29 weeks.11,16,17,20,23–25 Charcot neuroarthropathy is caused by multiple factors, but essentially it is the result of peripheral neuropathy which is a complication associated with many diseases.2,4,5 The underlying peripheral neuropathy can skew the pain perception the patient experiences and can mislead the clinician on their differential diagnosis of an “inflamed foot”. A thorough neurological examination of the foot can uncover the underlying inflammatory and osteolytic disease process of Charcot neuroarthropathy.2,4,11,19,26–29 Early recognition and intervention is imperative to avoid the rapid progression toward permanent foot deformity, ulceration, and the possibility of limb loss.16,30,31 There are multiple review articles about Charcot neuroarthropathy2,11–13,16,23,25,28,32–34, but a lack of guidance on foot screen strategies for primary care and emergency room physicians. There is a need for a comprehensive guideline for initial diagnoses and management on foot care to advocate for increased awareness, thereby leading to earlier diagnosis and treatment by a multi-disciplinary team. In the current study, a thorough literature review of Charcot neuroarthropathy was conducted to evaluate efficacious methods of protocol design and potential barriers to implementation. The literature review also encompassed treatment goals for patients with Charcot neuroarthropathy. Based on the literature review, a foot screen strategies protocol for Charcot neuroarthropathy was devised by the authors and reported here. This protocol contains three parts: (1) pathophysiology of acute Charcot neuroarthropathy to highlight the relationship between the clinical findings and the development of the disease, (2) a comprehensive guideline on how to screen and evaluate Charcot neuroarthropathy, and (3) a brief overview on prevention of Charcot neuroarthropathy in patients with diabetes and other forms of peripheral neuropathy. Pathophysiology The underlying cause for Charcot neuroarthropathy is due to peripheral neuropathy, which is a loss of function of the nerves in the periphery of the body.2–4 The primary episode of inflammation can result from a number of factors, but ultimately leads to an increase in pro-inflammatory cytokines (interleukin-1β and tumor necrosis factor-α) which leads to receptor activator of the nuclear factor-κB ligand (RANKL-NFκB) pathway. Osteoclasts are activated leading to bone lysis followed by clearing of debris. In the presence of autonomic neuropathy, there is increased blood flow to the area, which acts to clear away bony material demineralizing the bone, cartilage, and soft tissue in the region.3 However, in the presence of diabetic neuropathy, the patient does not have the protective pain perception. Therefore, they continue to walk on the inflamed foot exacerbating the progressive pathway of osteolysis and osteopenia and weakening the pedal skeleton, leading to the high risk for dislocation and/or fracture.5–8,34,35

The Diabetic Foot Attack: "'Tis Too Late to Retreat!"

The "diabetic foot attack" is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of "time is tissue" and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.

A study of extracellular vesicle concentration in active diabetic Charcot neuroarthropathy

It was the aim of this work to determine whether the plasma concentration of extracellular vesicles (EVs) in active diabetic Charcot neuroarthropathy (CN) is connected to the inflammatory markers, temperature elevation in the affected foot and concentration of soluble receptor for advanced glycation end products (RAGE). EVs were isolated from peripheral blood of 35 patients with active CN. EVs were counted after repetitive centrifugation and washing of samples, by flow cytometry. Foot temperature was measured by infrared thermometer. Concentration of soluble receptor for advanced glycation end products (RAGE) was determined by enzyme-linked immunosorbent assay (ELISA). We found statistically significant correlations of EV concentration (but not soluble RAGE concentration) with C-Reactive Protein (CRP) and with temperature difference between the affected and the contralateral foot (r=0.40, p=0.032; r=0.89, p<10−8, respectively). We provide evidence that the concentration of EVs is related to elevation of markers of inflammation (CRP and foot temperature difference) in acute Diabetic CN. EV-based markers could be considered as a potential aid in early diagnosis of CN.

Expression of the receptor activator of nuclear factor-kB ligand in peripheral blood mononuclear cells in patients with acute Charcot neuroarthropathy.

Introduction. The receptor activator of nuclear factor-kB (RANK), ligand (RANK-L) and osteoprotegerin (OPG) are implicated in the pathogenesis of acute Charcot neuroarthropathy (CN).Materials and Methods. This study aimed to investigate the expression of RANK-L and OPG in peripheral blood mononuclear cells (PBMC) from patients with acute CN.Results. We found that the expression of RANK-L was lower in patients with acute CN as compared with diabetic control subjects and healthy control participants; whereas OPG expression was not detected in patients and in both control groups. RANK-L expression at the onset of disease was inversely correlated with the index of polyunsaturation (PUI), a bone marrow MRS-derived measurable index that allows evaluation of disease activity in acute CN, and recovery time. Finally, the expression of RANK-L increased at the time of healing compared with the values found during the acute phase.Conclusions. In conclusion, our preliminary data provide a first step in applying analysis of RANK-L expression in peripheral blood cells to the diagnosis of acute CN. Based on our data we also suggest that analysis of RANK-L expression could be a complementary tool that can be employed to obtain quantitative parameters that may help clinicians to monitor disease activity in patients with acute CN.

A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle.

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

The effect of anaemia and malnutrition on the healing of diabetic foot wound

Background: Anaemia is a common problem in surgical patient, and it is an independent risk factor for blood transfusion, peri-operative infection, mortality and a longer in-patient stay. Diabetic foot wound results from the interaction of several contributory factors, the most important of which is neuropathy. With respect to the management of acute Charcot neuroarthropathy in diabetics, patients with diabetic foot wounds suffer from chronic inflammation, repeated infection, often undergo several invasive or operative treatments, and can have a protracted hospital stay. We hypothesised that, for these reasons, many patients with diabetic foot wound may suffer anaemia, require blood transfusion and suffer from poor nutrition. Aim of the work: Anaemia and nutritional status assessment as they affect the healing in patients presenting with diabetic foot wounds. Patients and methods: Two observational studies were undertaken. Initially a retrospective series of 20 patients with diabetic foot wounds. Patient demographics, clinical details, transfusion status and in-patient laboratory haemoglobin values (Hb) were recorded. In a prospective series of 33 patients, laboratory markers and nutritional status were assessed. Infection was excluded and managed appropriately by antibiotics and surgically by wound debridement or amputation. Other factors affecting wound healing were excluded as peripheral arterial diseases or debilitating diseases as renal failure. Results: In the retrospective series, 17 patients (85%) were anaemic (100% females) with average haemoglobin of5g (SD 2.4) below the lower limit of normal for the sex ofthe patients. Ten patients (50%) were transfused. The average trigger haemoglobin index was 8.5 gldl (SD 0.8). Patients who were transfused had lower haemoglobin on admission (p = 0.0016). Overall, at discharge, most of the patients were anaemic (92%). In the prospective series on admission, 27 patients (82%) were anaemic, also anaemic patients had a higher CRP and lower albumin level. 17 patients (52%) had been scored to be undernourished. Clinical follow up with appropriate dressing ofthe wounds and calculating the healing rate was observed. Conclusion: Usually anaemia as well as poor nutrition is the normal event and affecting the healing of diabetic wounds. Multidisciplinary review should be undertaken in all patients.

Chapter 8 - Diabetic neuropathy and foot complications

Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.

A Surgeon's guide to advances in the pharmacological management of acute Charcot neuroarthropathy

Acute Charcot neuroarthropathy is a devastating condition and, its incidence is increasing. Currently, treatment consists of immobilisation and off-loading of the involved extremity. Outcomes are frequently poor and novel treatments are being sought urgently. This review aims to outline advances in the pharmacological treatment of this, condition. PubMed and the Cochrane Database of systematic reviews were searched. Relevant papers were cross referenced. Eleven original studies were identified. The limited data available suggest pamidronate, alendronate and calcitonin provide some clinical and biochemical improvements while zoledronic acid is deleterious and, increases off-loading times. However, the data is not robust enough to convincingly demonstrate clinically meaningful effects. The studies were predominantly low quality and heterogeneous. They differed markedly in study type, pharmacological agent used, dosing regimen, disease, aetiology/stage/location, concurrent off-loading regimen, outcomes and, follow-up. Few were rigorous in controlling for associated confounding variables and none investigated long term outcomes. The routine use of pharmacological treatment modalities for this condition is not recommended in the United States by the Food and Drug Administration or in the United Kingdom by the National Institute for Health and Clinical Excellence. Given the evidence available this is justified and further higher quality research is required.

Charcot Neuroarthropathy of the Foot and Ankle

Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.