Charcot Arthropathy Research Articles

Establishment of a Neurodegenerative Charcot Mouse Model.

This study aimed to mimic the changes from Charcot neuropathic arthropathy in humans by examining the effects of exposing diet-induced obese (DIO) mice to neurotrauma through a regimented running protocol. Forty-eight male wild-type C57BL/6J mice were obtained at age 6 weeks and separated into 2 groups for diet assignment. After a 1-week acclimation period, half of the mice consumed a high-fat diet (60% fat by kcal) ad libitum to facilitate neuropathic diet-induced obesity whereas the other half were control mice and consumed an age-matched standard low-fat control diet (10% fat by kcal). At age 12 weeks, half of the animals from each group were subjected to a high-intensity inclined treadmill running protocol, which has been previously demonstrated to induce neurotrauma. Sensory testing and radiographic analyses were periodically performed. Histopathologic analyses were performed post killing. DIO mice had significantly higher bodyweights, higher body fat percentages, and lower bone mineral density than wildtype control mice that were fed a normal diet throughout the experiment (P < .001 for each). DIO mice displayed significantly reduced sensory function in week 1 (P = .005) and this worsened over time, requiring 20.6% more force for paw withdrawal by week 10 (P < .001). DIO mice that ran demonstrated greater midfoot subluxation and tarsal instability over all time points compared with normal-diet mice that ran (P < .001). Histopathologic analyses revealed that DIO mice that ran demonstrated significant changes compared with controls that ran (P < .001 for each parameter). Changes akin to the earliest changes observed in or before joint destruction identified in diabetic Charcot neuropathic arthropathy in humans were observed. There is currently no standard of treatment for patients with Charcot neuropathic arthropathy. This study establishes a protocol for an animal model that can be used to study and compare interventions to treat this disease.

Altered Gait in Charcot Neuropathic Mice: A Kinematic Analysis

Category: Diabetes; Hindfoot Introduction/Purpose: Charcot arthropathy is known to cause neurodegenerative as well as physical skeletal changes that can affect gait. A verified model of inducing Charcot arthropathy in mouse hindlegs exists, but clinical data has yet to be gathered from this model. This is a pilot study with the purpose of gathering clinical data on mouse gait and joint reactive forces that occur over time as a result of Charcot arthropathy utilizing MatLab software. Methods: Eleven wild-type 25-week-old C57BL/6J were included in this study. Group A (n= 6) was fed a high-fat 60% kcal diet starting at the age of 6 weeks and underwent a verified running protocol to induce microtrauma leading to hind-paw Charcot-type arthropathy. Sensory testing and fasting blood glucose levels confirmed the presence of hyperglycemia and neuropathy in Group A. Group B (n= 5) was fed a normal diet and did not complete a running protocol. At week 0 and week 16 of the study, brightly colored dots were placed on mice hindlimbs to mark the hip, knee, ankle, and tarsal joints. The mice were placed on the treadmill at a constant speed of 10 m/sec and were recorded in slow motion for 2-3 full gait cycles. MATLAB was used to measure gait angles and coordinates in space by following the corresponding colored dot for each joint on the mouse (Figure 1). Results: The control mice did not have significant changes in range of motion of the knee, ankle, or midfoot while walking between weeks 0 and 16. In contrast, the mice fed a high-fat diet had statistically significant differences in ankle range of motion (p=0.0275), nearly significant differences in knee range of motion (p=0.0991), and insignificant differences in midfoot range of motion between weeks 0 and 16. In addition, the differences between range of motion of the knee of the control vs. C57BL/6J mice were significantly different between groups at both weeks 0 (p=0.0016) and 16 (p=0.0201). In the ankle, the difference was statistically significant at week 0 (p=0.0275) but not week 16 (p=0.7066), presumably due to a large standard deviation in ankle range of motion. Conclusion: Results of this gait analysis indicate that mice with Charcot-like arthropathic changes demonstrated gait differences that affected the range of motion of the knees and ankles of the mice, but not the midfoot. These changes could be due to the neuropathic abnormalities induced in mouse feet that would cause gait changes. Future studies will include a larger sample size of mice with gait analysis done at intermediate time points to further quantify how gait changes over time with Charcot arthropathy.

Trends in Utilization of Charcot Reconstruction

Category: Ankle; Diabetes Introduction/Purpose: Charcot arthropathy of the foot and ankle is a challenging complication of peripheral neuropathy with a 0.1% and 5.0% incidence in the diabetic population. The purpose of this study is to assess rates of foot or ankle reconstructions (fusions) for Charcot arthropathy, describe the associated patient demographics and hospital settings, and project the volume of Charcot reconstructions anticipated to be performed in 2030. Methods: The National Inpatient Sample database was queried from 2016-2019 using International Classification of Diseases (ICD) codes for foot or ankle fusion (midfoot, hindfoot, or ankle) and a diagnosis of Charcot arthropathy, ultimately identifying 1,343 patients undergoing surgical procedures. Patient information collected included age, sex, race, primary payer status, year of surgery, length of hospital stays, and median household income quartile. Hospital information included bed size, census region, teaching status, and ownership. Results: Between 2016-2019, there were approximately 1,343 patients treated surgically with midfoot, hindfoot, or ankle arthrodesis for Charcot arthropathy, and the number of cases increased by 12.11% annually. Between 2019-2030, there is projected to be a 121.41% increase in the frequency of Charcot reconstruction procedures from 383 to 848 total annual cases. Patients undergoing these procedures are predominantly white, male, and in their 50s. The most common payers were Medicare and private insurance. The mean hospital length of stay was 5.80 days. The procedures performed were predominantly large, urban teaching hospitals in the south with a private, non-profit ownership structure. Conclusion: Surgical reconstruction of Charcot arthropathy of the foot and ankle is steadily increasing in prevalence. These patients are predominantly white, male, and in their 50s. It is important for orthopaedic foot and ankle surgeons to be trained in the surgical management and reconstruction of Charcot arthropathy to meet the expected growing surgical need, which is projected to be 848 procedures annually by 2030.

Charcot Arthropathy of the Digit

Case: Charcot arthropathy (CA) is a progressive degenerative joint disease typically affecting lower extremity weight-bearing joints, with only a few cases reported in the fingers. We present 2 cases of interphalangeal joint CA: the long finger distal interphalangeal joint in a 73-year-old man with severe carpal tunnel syndrome and the ring finger proximal interphalangeal joint of a 71-year-old woman with diabetic neuropathy. Conclusion: Two cases of CA of the digits were treated with splinting with resolution of symptoms and no wound complications.

If You Give a Mouse a Cookie: Quantification of Metabolic and Neurologic Changes in Murine Model for Charcot Arthropathy

Category: Basic Sciences/Biologics; Diabetes Introduction/Purpose: Charcot arthropathy (Charcot) is a significant complication of diabetes mellitus thought to occur as a result of repetitive microtrauma to the insensate foot. We previously developed a murine model of diet-induced obese mice with peripheral neuropathy which underwent a high-intensity treadmill protocol designed to induce metabolic, neurologic, radiographic, and histopathologic features similar to Charcot in humans. Using this model, we aimed to further characterize the metabolic and sensory changes that occur in these diet-induced obese mice subjected to various high-intensity exercise protocols designed to induce repetitive microtrauma to the hind paws similar to Charcot. Methods: Forty-nine wild-type C57BL/6J mice were randomized to receive either a standard or high-fat diet and exposed to a high-intensity treadmill running protocol for various lengths of time as described in Figure 1A. Group 1 received a standard low-fat (10% kcal from fat) mouse diet and did not participate in the treadmill protocol. Groups 2, 3, 4, and 5 were fed a high-fat (60% kcal from fat) diet ad libidum to facilitate diet-induced obesity (DIO) and completed the treadmill protocol for various lengths of time. Initial body weights, DEXA scans, hind-paw Von-Frey filament sensory testing, and hot plate sensory testing following the previously published murine model were performed prior to the start of the running protocol and repeated at weeks 4, 8, 12, and 16. Plantar temperatures were measured initially and at 16 weeks. Paired-t-Test and one-way ANOVA were utilized to determine the significance of observed results. Results: Bodyweights are represented in Figure 1B. Plantar temperature was not significantly different between treadmill running groups at week 0 or 16 (Figure 1C). Hot plate testing demonstrated no significant difference in the number of responses between groups at week 0. By week 16, groups 3 and 5 demonstrated decreased hind-paw sensitivity to hot plate testing, suggestive of decreased sensation. Von Frey sensory testing also showed more force was required to induce a positive response, indicating decreased hind-paw sensation in high-fat diet groups (Figure 1D). By weeks 12 and 16, high-fat diet groups had significantly higher fasting blood glucose levels than group 1(Figure 1E). Additionally, high-fat diet groups demonstrated a significantly higher body fat percentage and lower bone mineral density (BMD) at weeks 0 and 16. Conclusion: Decreased sensitivity to hot plate and Von Frey testing demonstrate decreased sensation in the hind paws of DIO mice fed a high-fat diet. DIO mice also have significantly higher fasting blood glucose levels than mice fed a regular diet indicating impaired glucose tolerance. These metabolic and sensory changes suggest this is a reliable murine model of diabetic neuropathy. This model of diabetic neuropathy provides an avenue to study the radiographic and histologic changes that occur in these mice when exposed to repetitive exercise-induced microtrauma similar to Charcot arthropathy in humans.

Normal Variation of the Lisfranc Joint: Tridimensional Analysis using Weight-Bearing Computed Tomography Imaging

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Untreated Lisfranc injuries can lead to chronic pain, midfoot arthritis, and functional disability 1,2,5. Approximately 20% of Lisfranc injuries are misdiagnosed or completely missed on initial evaluation, which can be attributed to a lack of parameters of what is within normal limits for subjects without injury in the Lisfranc complex3,4. The purpose of this study is to identify anatomic variations of unidimensional, bidimensional, and tridimensional (1D, 2D, 3D) measurements of the Lisfranc complex of normal individuals using weight-bearing computed tomography (WBCT) imaging. Our hypothesis is that there is some variation among individuals with a difference between right and left of the same individual of less than 10%. Methods: A total of 191 subjects with bilateral WBCT scans of the foot were collected from three tertiary medical centers from 2019-2022. Exclusion criteria included: history of Lisfranc injury, first to fourth metatarsal base fractures, Charcot arthropathy, midfoot arthritis, cuneiform fractures, and forefoot surgery proximal to the metatarsal neck region. The following Lisfranc joint measurements were collected6 bilaterally: joint volume (3D), area of the joint on a consistent axial slice (2D), and distance between the second metatarsal and medial cuneiform (1D). Foot alignment was assessed using lateral talar-first metatarsal angle (Meary’s Angle). Patient demographics (age, sex, weight, height, BMI) were also collected. Descriptive statistics were calculated for quantitative variables. Percent difference was used to assess volume, area, and distance variation between sides.7 Correlation between demographic data and Lisfranc measurements was assessed using Pearson Correlation tests. A T-test was used for categorical variables. A p-value &lt; 0.05 was considered statistically significant. Results: The cohort included 61% female and 39% male with an average age of 45.2±17.3 years. The mean volume, area, and distance measurements of the Lisfranc joint for both left and right sides are shown in Figure 1. Overall, the mean percent difference between left and right sides were 11.9%, 14.9% and 13.9% for volume, area and diastasis, respectively (Figure 1). No association was found between age, BMI, or weight and the volume, area or distance measurements. A correlation (r=0.48, p= &lt; 0.001) was found between height and left Lisfranc joint volume, but no other measurements. Significant difference between sex in volume (p &lt; 0.001) and area (p &lt; 0.001) measurements were found. Foot alignment did not have a correlation with a variation of the Lisfranc complex measurements. Conclusion: This study provides an objective characterizing of the anatomic variations of the Lisfranc joint amongst healthy individuals. Differences in the measurements and the large standard deviation in absolute measurements of volume, area, and distance suggests that percent difference with the contralateral side may be a better metric to use to diagnose Lisfranc instability. Our results showed that the difference between bilateral sides in a patient is less than 15% for volume, area, and diastasis. The results of this study can set the foundation for future studies to determine the cut-off value for the diagnosis of Lisfranc instability using WBCT imaging.

The Accuracy of 3D Measurements in Weightbearing Computed Tomography to Diagnose Lisfranc Instability

Category: Midfoot/Forefoot; Other Introduction/Purpose: Up to one-third of Lisfranc injuries are missed on initial evaluation, resulting in significant morbidity. Prompt diagnosis of Lisfranc injuries is, therefore, critical in optimizing outcomes, and yet there remains a lack of consensus on diagnostic criteria to identify Lisfranc instability using anatomic measurements. Prior studies have underscored the utility of weight-bearing computed tomography (WBCT) in diagnosing Lisfranc instability, which allows for bilateral three-dimensional (3D) evaluation under physiologic load. The aim of this study was to quantify appropriate cutoff values using 3D anatomic measurements of Lisfranc instability under physiologic load and as compared to the uninjured extremity. Methods: A total of 234 adult patients with bilateral WBCT scans of the foot were included: 43 patients with Lisfranc instability &amp; 191 patients without a history of midfoot injuries. Lisfranc instability was confirmed intraoperatively or by clinical evaluation by the surgeon. Patients with prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, or significantly displaced fracture of the cuneiforms or 1st, 2nd, or 3rd metatarsal bases were excluded. Lisfranc joint measurements were conducted bilaterally, including C1-M2 diastasis, C1-M2 area and 3D WBCT volume. Patient demographics were collected. Descriptive statistics were calculated for quantitative variables. Percent difference as compared to the contralateral side was calculated for volume, area, and diastasis. Mann Whitney U tests were utilized to determine differences in measurements between patients in the Lisfranc cohort and patients in the uninjured cohort (p-value &lt; 0.05). Diagnostic cutoffs for Lisfranc instability were determined with minimum distance to the corner analysis on ROC curves. Results: The distribution of patients with Lisfranc instability was 58% female with an average age of 38.5±17.6 years. Of the Lisfranc injuries, 36% were purely ligamentous, 18% demonstrated an avulsion injury, and 43% involved a metatarsal base fracture. In the Lisfranc cohort, the median percent difference between injured and uninjured feet was 28.2% (IQR: 20.9%) for volume, 36.3% (IQR: 31.1%) for C1-M2 area, and 40.0% (IQR: 23.3%) for C1-M2 diastasis. Mann-Whitney testing was significant for percent difference between left and right feet for Lisfranc patients versus patients with an uninjured midfoot (p &lt; 0.001). The area under the curve and associated diagnostic cutoffs for Lisfranc instability, were 0.81 and 18% for volume, 0.84 and 20% for area, and 0.91 and 28% for diastasis (Figure 1). Conclusion: Diastasis (1D), area (2D), and volume (3D) measurements are effective measurements to diagnose Lisfranc instability on WBCT. With current diagnostic algorithms, however, 1D measurements afford superior diagnostic sensitivity as compared to 2D and 3D measurements when using WBCT, suggesting Lisfranc instability may be best appreciated in the axial plane. Additional studies are necessary to expand the sample population to assess for corroboration with the current results, especially for subtle Lisfranc instability.

Midfoot and Hindfoot Charcot Deformity Correction is Well Maintained with Beam Fixation

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot arthropathy is a neurotraumatic foot disorder seen in patients with peripheral neuropathy. Surgical reconstruction via medial column arthrodesis with beams can restore plantigrade foot anatomy with decreased soft tissue dissection and improved bony compression. Methods: We identified 12 patients with midfoot (n=7) or hindfoot (n=5) Charcot who underwent medial column beaming arthrodesis between 2015 and 2021 b y one of two fellowship-trained foot and ankle surgeons at an academic medical center. Data collected from patient charts included demographics, medical history, complications, and reoperation rate. Meary’s angle was measured on lateral weightbearing radiographs preoperatively and up to two years postoperatively. Mean follow-up time was 2.50 (range, 1.04-6.98) years. Statistical analysis included correlation, two-tailed Student t-test, and Chi-squared test. Results: Meary’s angle was recorded preoperatively for 12 patients (19.3° ± 6.7°) and postoperatively at three months for 12 patients (4.0° ± 6.7°), at six months for 12 patients (7.1° ± 9.7°), at one year for 11 patients (6.1° ± 9.4°), and at two years for five patients (10.2° ± 6.4°). However, two (16.7%) patients showed a loss of deformity correction, which was demonstrated by a Meary’s angle that was greater at final follow-up than preoperatively. Overall complication, infection, reoperation rates were 50.0%, 41.7%, and 58.3%, respectively. Finally, dependent on preoperative ulceration, those with and without an ulcer did not differ in Meary’s angle at any time point, overall complication, infection, nor reoperation rate. Conclusion: Although the results showed a relatively high complication rate, the use of beaming arthrodesis was generally able to maintain a plantigrade foot and overall alignment, while decreasing the recurrence of plantar ulceration.

Preliminary Results and a Treatment Algorithm for Osteomyelitis of the Distal Tibia and Talus

Category: Hindfoot; Ankle Introduction/Purpose: Management of hindfoot osteomyelitis involves eradication of infection, deformity correction, and bony stabilization in the setting of bone loss and poor bone quality. This case series of 20 patients presents a two-stage technique: debridement, deformity correction, joint surface preparation, intramedullary reaming with antibiotic-impregnated polymethyl methacrylate rod and ring external fixation, followed by a second stage of external fixator removal and exchange of antibiotic rod for definitive hindfoot fusion rod. The purpose of the study is to highlight techniques and preliminary results that can improve the success of obtaining stable fixation, remission of infection and ultimately fusion. Techniques highlighted are ring fixator placement, antibiotic rod formulation, intramedullary canal preparation, rod exchange and use of blocking screws to enhance compression and axial loading of the fusion. Methods: Twenty patients were treated with this two-stage protocol. The most common indication was post-traumatic osteomyelitis followed by neuropathic (Charcot) joint. All were treated with an initial debridement of nonviable tissue including osteomyelitic bone. The tibiotalar and talocalcaneal joint surfaces were prepared for fusion at the initial debridement. Provisional stabilization and compression were obtained using a ring external fixator for patients without rotational stability. The polymethyl methacrylate-antibiotic impregnated rod (PMMA with gentamycin and vancomycin) was introduced through the calcaneus, talus, and the intramedullary space of the tibia. The patients were kept in the fixator until the skin was healed and all incisions were dry. At this point, the fixator was removed, and the antibiotic rod was exchanged for the definitive hindfoot fusion rod. Results: Cultures were positive for Staphylococcal or Streptococcal species in 60% of cases, Fingeoldia magna 10%, Cutibacterium Acnes 2%, and Gram-negative organisms in 30%. On average patients spent 80 days in the fixator while wounds were healing, and were receiving systemic antibiotics. One patient died while in the frame. There have been no amputations in the series. Of the patients that have completed the protocol, all have gone on to either bony fusion or stable fibrous union. All are able to walk unaided and 25% used an AFO to control and protect the foot and equalize leg length. Secondary procedures are described. Conclusion: This technique of staged fusion for hindfoot osteomyelitis offers the following advantages. The first stage involves thorough debridement and deformity correction. Oftentimes, there is extensive scarring, and the soft tissue envelope is not conducive to internal fixation. This technique allows the soft tissues to heal before placing the definitive internal fixation. It also allows for graduated compression at the fusion site with the ring fixator. The antibiotic rod not only delivers high concentration of local antibiotics, but it prevents deformity recurrence during the compression phase. The definitive rod provides support of pathologic bone and maintains deformity correction.

Evaluating the Quality and Usability of Artificial Intelligence-Generated Responses to Common Patient Questions in Foot and Ankle Surgery.

Artificial intelligence (AI) platforms, such as ChatGPT, have become increasingly popular outlets for the consumption and distribution of health care-related advice. Because of a lack of regulation and oversight, the reliability of health care-related responses has become a topic of controversy in the medical community. To date, no study has explored the quality of AI-derived information as it relates to common foot and ankle pathologies. This study aims to assess the quality and educational benefit of ChatGPT responses to common foot and ankle-related questions. ChatGPT was asked a series of 5 questions, including "What is the optimal treatment for ankle arthritis?" "How should I decide on ankle arthroplasty versus ankle arthrodesis?" "Do I need surgery for Jones fracture?" "How can I prevent Charcot arthropathy?" and "Do I need to see a doctor for my ankle sprain?" Five responses (1 per each question) were included after applying the exclusion criteria. The content was graded using DISCERN (a well-validated informational analysis tool) and AIRM (a self-designed tool for exercise evaluation). Health care professionals graded the ChatGPT-generated responses as bottom tier 4.5% of the time, middle tier 27.3% of the time, and top tier 68.2% of the time. Although ChatGPT and other related AI platforms have become a popular means for medical information distribution, the educational value of the AI-generated responses related to foot and ankle pathologies was variable. With 4.5% of responses receiving a bottom-tier rating, 27.3% of responses receiving a middle-tier rating, and 68.2% of responses receiving a top-tier rating, health care professionals should be aware of the high viewership of variable-quality content easily accessible on ChatGPT. Level III, cross sectional study.

Clinical Comparison of Internal Fixation Constructs in Midfoot Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot can lead to instability, deformity and ultimately ulceration that can be limb threatening. Previous authors have described a variety of surgical stabilization techniques and constructs including intramedullary fixation (“beaming”) across the midfoot in varying orientations. More recently, intramedullary compression nails (“IM nail”) have been introduced. In contrast with static screws, these devices provide compression across the joints of the midfoot by engaging a compression mechanism against a fixed interlock screw. To our knowledge no clinical comparison between traditional beaming techniques and modern compression nails for midfoot Charcot has been reported. We hypothesize that using IM nails will result in a higher union rate, and lower reoperation and hardware failure rates. Methods: Our electronic medical record was queried to identify patients from 2016-2021 who underwent midfoot reconstruction. Only patients with midfoot Charcot who underwent extended intramedullary fixation were included. Patients with active ulceration at the time of surgery, Charcot that included the ankle, or external fixation as part of the construct were excluded. IM nails were used exclusively for medial column constructs. Basic demographic information was collected. Radiographs and operative notes were evaluated and construct type and implants used were noted. Radiographs at final follow-up were evaluated for union and hardware complication. Clinical notes were evaluated for weightbearing status, plantigrade foot position, ulceration, and wound care requirements. Finally, all complications and reoperations were recorded. Chi-squared or Fisher’s Exact tests were used as appropriate to compare categorical variables and t-tests were used to compare numerical variables. Results: 48 feet (47 patients) with a median age of 58 years (IQR 50, 64) were included. Diabetes was the Charcot etiology in 34/48 (70.8%) feet. There were 19 beaming and 29 IM nail constructs. Basic demographics and Brodsky classification were equally distributed (p&gt;0.05). Median follow-up time was 1.3 years (IQR 0.8, 2.9). Combined medial and lateral column fixation was performed in 39/48 (81.3%) patients. 52% (25/48) included subtalar arthrodesis. Beaming constructs had higher re-operation rates (57.9% versus 27.6%, p &lt; 0.05), and higher hardware failure rates (57% versus 6.9%, p&lt; 0.001). IM nail group had higher union rates (75.9% versus 31.6%, p = 0.001), and higher rates of full weight-bearing at final follow up (86.2% versus 68%, p &lt; 0.05). Two (4.2%) patients required amputation. Conclusion: In a cohort of 48 feet undergoing midfoot Charcot reconstruction, the use of medial column IM nails was associated with lower reoperation rates, lower rates of hardware failure, higher union rates, and higher rates of full weightbearing at final follow-up compared with traditional screw fixation. Surgeons who treat midfoot Charcot may consider these results when planning their stabilization constructs in this high-risk patient population.

Charcot arthropathy and acro-osteolysis in a 5-year-old girl with hereditary sensory and autonomic neuropathy type II: A case report

Charcot neuropathic arthropathy is a destructive process that can occur in patients with neuropathy associated with medical diseases such as diabetes. A rare cause of neuropathic arthropathy is congenital insensitivity to pain (CIP) which includes varying degrees of sensory loss and lack of pain perception contributing to absent withdrawal responses. The clinical manifestations of CIP include delayed diagnosis of fractures, joint dislocations, acro-osteolysis, avascular necrosis, osteomyelitis, heterotopic ossification, and Charcot arthropathy. We herein report a case of Charcot arthropathy of ankle joints in a 5-year-old girl with CIP due to underlying hereditary sensory and autonomic neuropathy who had recurrent upper and lower limb fractures with acro-osteolysis. She had an inability to perceive pain from the first year of her life. She also had mild developmental delay. Family history was unremarkable. Blood count, liver and thyroid function tests, erythrocyte sedimentation rate, C-reactive protein, blood electrolytes, blood sugar and other laboratory tests were normal. Charcot neuropathic arthropathy in children is rare and can be a part of congenital diseases like CIP. A high degree of suspicion may lead to early detection and can prevent joint and bone destruction and deformities.

Bone Defect Replacement in Diabetic Neuropathic Osteoarthropathy (Charcot Foot): Review

Background. The number of patients with diabetes mellitus, including those with its severe complications such as Charcot neuropathic osteoarthropathy, is increasing worldwide. Restoration of weight bearing ability and creation of conditions for ulcer healing is challenging for trauma and orthopedic surgeons, especially because of the need to restore bone tissue defects.&#x0D; Aim of the review to compare modern methods of replacement of large bone tissue defects of the distal segment of the lower limb in patients with Charcot neuropathic osteoarthropathy.&#x0D; Methods. The articles were searched in PubMed/MEDLINE, Google Scholar, Scopus, eLIBRARY, CyberLeninka databases. The search was performed using the following keywords and word combinations: Charcot foot, diabetic neuropathic osteoarthropathy and bone grafting. Full-text articles in Russian and English were selected. The search was carried out without chronological limitations due to the small number of published studies and specific subject of research.&#x0D; Results. The possibilities of bone defect replacement in Charcot foot are poorly described in the world literature. The narrow specificity and relative infrequency of this pathology is the probable reason for the small number of publications and the lack of studies with a high level of evidence.&#x0D; Conclusion. Bone autografting for lesions of the medial or lateral midfoot column and Ilizarov tibial lengthening to compensate for limb shortening after reconstructive surgeries at the level of the hindfoot and ankle joint are the most commonly used methods of bone defect replacement in patients with Charcot foot. Free bone autografting (possibly with demineralized bone matrix) is the method of choice for small defects of the lateral or medial column of the midfoot.

Diabetes Mellitus: A Review and Update

Diabetes mellitus is a group of metabolic diseases which are typified by the development of hyperglycaemia which do emanate from defects in insulin secretion, insulin action, or both. The chronic hyperglycaemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. Various types of diabetes mellitus exist which have been discussed in the main part of this article. Many pathogenic processes are involved in the development of diabetes mellitus. These pathogenic processes range from autoimmune destruction of the beta-cells of the pancreas with consequent insulin deficiency to abnormalities which result in resistance to insulin action. The basis of the abnormalities in carbohydrate, fat, and protein metabolism in diabetes is deficient action of insulin on target tissues. Deficient insulin action ensues inadequate insulin secretion and / or diminished tissue responses to insulin at one or more points within the complex pathways of hormone action. Impairment of insulin secretion and defects in insulin action frequently coexist in the same patient, and it is often unclear which abnormality, if either alone, is the primary cause of the hyperglycaemia. The manifestations of marked hyperglycaemia do include: polyuria, polydipsia, weight loss, sometimes with polyphagia, and blurred vision. Impairment of growth and susceptibility to certain infections may also ensue chronic hyperglycaemia. Acute, life-threatening consequences of diabetes mellitus include: hyperglycaemia with ketoacidosis or the nonketotic hyperosmolar syndrome. Long-term complications of diabetes mellitus do include: diabetic retinopathy with potential loss of vision; diabetic nephropathy which leads to kidney (renal) failure; peripheral neuropathy with risk of foot ulcers, amputation, and Charcot joints; as well as autonomic neuropathy which cause gastrointestinal, genitourinary, as well as cardiovascular symptoms and sexual dysfunction. Glycation of tissue proteins and other macromolecules and excess production of polyol compounds from glucose are among the mechanisms that had been postulated to produce tissue damage from chronic hyperglycaemia. Patients who have diabetes mellitus do have an increased incidence of atherosclerotic cardiovascular, peripheral vascular, and cerebrovascular disease. Hypertension, abnormalities of lipoprotein metabolism, and periodontal disease are often found in people who have diabetes mellitus. The emotional and social impact of diabetes mellitus as well as the demands of treatment of diabetes and its complications could cause significant psychosocial dysfunction in patients who have diabetes mellitus as well as their families. Even though there are many types of diabetes mellitus, the vast majority of cases of diabetes mellitus do fall into two broad etiopathogenetic categories which have been extensively discussed in the ensuing article below that has been divided into (a) Overview and (b) miscellaneous narrations. In one category of diabetes mellitus type 1 diabetes mellitus, the cause is an absolute deficiency of insulin secretion. Individuals at increased risk of developing this type of diabetes could often be identified by serological evidence of an autoimmune pathological process that occur within the pancreatic islets and by genetic markers. In the other type of diabetes mellitus, which is the much more prevalent category that is referred to as type 2 diabetes mellitus, the cause of the disease is a combination of resistance to insulin action and an inadequate compensatory insulin secretory response. In the latter category, a degree of hyperglycaemia sufficient to cause pathological and functional changes in various target tissues, but without clinical symptoms, could be present for a long period of time before diabetes mellitus is diagnosed. During this asymptomatic period, it is possible to demonstrate an abnormality in carbohydrate metabolism by measurement of plasma glucose in the fasting state or after a challenge with an oral glucose load. Considering that diabetes mellitus is common as well as the symptoms of diabetes mellitus are non-specific symptoms that may simulate diabetes mellitus, a number of individuals who are afflicted by diabetes mellitus do not know they have diabetes mellitus, there is need for a global educational program on the manifestations and approach that is needed for early diagnosis of the disease so that all clinicians and the entire global population would have a high index of suspicion of the disease. There also a global life style education including regular exercise that would delay onset of or reduce the severity of type 2 diabetes and to improve the quality of life of patients who have diabetes mellitus. It is important to dedicate time to read the article carefully which contains documentations related to the World Health Organization’s global effort to reduce the incidence and severity of diabetes mellitus and all individuals globally should follow carefully recommendations of the World Health organization as well as recommendations of other organizations in the world that have devoted their time to health education on diabetes mellitus. and a number of people

Features of organotopic remodeling of bone tissue and implanted osteoplastic material in Charcot neuro/osteoarthropathy

Introduction Despite the recognition of MRI as the gold diagnostic standard for Charcot arthropathy, there is evidence in the literature that MSCT is more informative for objective qualitative and quantitative diagnosis of the condition, primarily of the bone skeleton of the Charcot foot, in comparison with standard radiography. The sensitivity and specificity of these methods are different.Purpose To reveal the features of organotopic remodeling of bone tissue and implanted osteoplastic material in the course of midfoot and hindfoot subtotal defects management in Charcot neuro-osteoarthropathy.Materials and methods The analysis of bone tissue and implanted osteoplastic material density was carried out in a case series that included 11 patients with Charcot neuro-osteoarthropathy who underwent a two-stage procedure for bone defects in the hindfoot and midfoot with the Ilizarov apparatus. We studied CT and MRI scans and measured bone regenerate density before treatment, at the stages of transosseous osteosynthesis, and 3, 6, and 12 months after surgery.Results In all patients, varying increase in the amount and volume of bone tissue was visualized due to intensive periosteal bone formation along with the formation of bone ankylosis in the joints along combined with a consistent increase in the optical density of bone regenerates. The formation of the new bone tissue ran without the signs of lysis or sequestration. The conducted studies indicate that the sizes and architectonics of bone fragments are more differentiated in CT than in MRI scans.Discussion It is known that the bone, despite its high mineralization, continuously rebuilds, restores and adapts itself to certain functional conditions. This constant dynamic process of adaptive remodeling depends mostly on optimal blood supply, metabolic activity and the coordinated work of bone cell elements. The data obtained show angiogenesis in the compromised tissues in patients with Charcot foot and consistent remodeling of the graft into the new bone tissue.Conclusion The allobone in the composition of the combined bone graft does not reduce the likelihood of complete remodeling of the newly formed bone tissue. Higher bone density by filling in a bone defect with a graft differs from distraction regenerate that initially has low bone density. CT and MRI are highly effective and informative diagnostic methods for surgical treatment. In reconstructive interventions in the patients with Charcot foot under the conditions of transosseous osteosynthesis, preference among radiological study methods should be given to CT.

Arthrodesis with the Ilizarov ring ffxator for severe ankle arthritis

Introduction End-stage ankle arthritis is a very painful and disabling pathology, associated with deformity. Infection, poor skin condition, chronic smoking, Charcot arthropathy may not only affect selection of treatment method but also union, leading to unfortunate amputation. Ankle arthrodesis is indicated in advanced ankle arthritis. A variety of fixation methods are available for arthrodesis ranging from internal to external fixation. The Ilizarov ring fixator is a dynamic versatile fixation method. It is a biomechanically stable and minimally invasive method which promotes bone union and has advantage of initiating early weight-bearing and simultaneous deformity correction. We describe our experience in Ilizarov ring fixator application for ankle arthrodesis in 5 patients with severe ankle arthritis and their functional outcome.Materials and Methods This retrospective study was conducted in 5 ankle arthrodesis cases using the Ilizarov ring fixator application from July 2021 to October 2022 in the department of orthopaedics, Jaipur national university, India. Average age of patient was 52 years (range, 40-65). Among included patients one patient had chronic osteomyelitis of the distal tibia and severe arthrosis of the ankle joint with a non-healing ulcer, two patients had post-traumatic arthrosis following talus and distal tibia plafond fracture, Charcot ankle arthropathy and tuberculosis of the ankle joint was detected in two patients respectively. Postoperative pain relief, deformity correction and radiological union at the fusion site were defined as success.Results Fusion was achieved in all patients (100%). Early post-operative ambulation and full weight-bearing was initiated in every case. Pin-tract infection was the commonest complication. Shortening due to arthrodesis was less than 2.5 cm so limb lengthening was not done. Frame removal time was 12 to 14 weeks (average time, 13 weeks). Visual analogue scale was used in all cases. It was in the range of 2 to 3 points preoperatively and 7 to 9 post-operatively after arthrodesis. Average follow-up period was 6 months and it is still underway. AOFAS score was used for functional assessment.Conclusion Ilizarov ring fixator application can be considered as versatile, biomechanically stable, minimally invasive method for ankle arthrodesis in severe ankle arthritis associated with poor soft tissue condition, post- traumatic arthritis, infection, deformity, bone loss, Charcot arthropathy.

Innovative techniques and concepts in surgical management of Charcot foot deformities

Abstract There is a growing interest in the surgical treatment of Charcot foot arthropathy following the increase in the prevalence of diabetes. The current gold standard of treatment is total contact casting for early deformity, but in recent years, surgery has been performed earlier in the disease process to create a clinically and radiographically plantigrade foot, with the aim of preventing or treating skin ulceration. This review article focused on types of surgical treatment and outcomes associated with each treatment option. Surgical correction consists of ostectomy, tendo-Achilles lengthening, soft tissue releases, and midfoot osteotomies. Arthrodesis can be performed with internal or external fixation or a combination of the two. The purpose of this review article is to review modern surgical techniques for the management of Charcot midfoot deformities. We searched PubMed, Embase, and the Cochrane Library databases using the following search terms: “Charcot arthropathy,” “neuroarthropathy,” “midfoot,” and “arthrodesis.” Articles were chosen based on relevancy to modern surgical treatment options for Charcot midfoot arthropathy. Internal fixation options include intramedullary column fixation, “beaming,” and superconstructs involving a combination of intramedullary fixation and plantar plating. An additional extramedullary construct is introduced, which involves placing large screws from the base of the metatarsal across the deformity, known as “rafting screws.” Complications of fixation methods are also discussed in detail.

Three-Dimensional Patient-Specific Cut Guides for Correction of Charcot Midfoot Deformities

Charcot arthropathy of the foot and ankle is a challenging pathology that can require intensive surgical reconstruction. Most often the pathology involves breakdown of the midfoot. Osteotomies of the midfoot to resect and correct the deformity can be unpredictable and time-consuming. With the advent of 3D printing, we propose a new technique utilizing custom cut-guides for midfoot osteotomies in Charcot reconstruction.

H19 The bronze diabetic

Abstract Many works of art throughout the centuries have not only garnered intrigue, but also debate among physicians relating to a possible medical diagnosis depicted by the artist. Representation of both anatomy and disease with the use of votive offerings and forms of grotesque art is well recognized. Such work was particularly prevalent in pieces produced during the Hellenistic Age and includes statuettes, anatomical replicas, coins and other art work. Diseases such as acromegaly, Gorlin syndrome, lymphoedema, neurofibromatosis and ophthalmic disorders, among others, have been represented in such pieces. It had been thought by the suppliants that in presenting these offerings to the Gods, particularly Asclepius, the Greek god of medicine and son of Apollo, they could be cured from their ailments. An example of an artistic piece representing an individual with disease is that of a small bronze statuette described as a ‘Statue of an Emaciated Man’ and housed at the Dumbarton Oaks Research Library and Collection, Washington DC. It is a small bronze statue measuring at just 11.5 × 5 × 8.3 cm, and is thought to date from around the first century Bc to the first century Ad. It depicts a gaunt young man sitting atop a bench with his left hand held limply and an apparently swollen right foot. It has been suggested that this individual could have suffered from lead poisoning. However, lead neuropathy is typically symmetrical and emaciation is uncommon. A more common source of lead poisoning in ancient times was wine drinking, as lead was used both as a sweetener and preservative. In addition, occupational exposure was common as lead was used widely in pottery, painting, lead smelting and glass ceramics. A disease that could explain the three features of emaciation, wrist drop and a swollen foot is diabetes mellitus. Diabetes had been recognized in Egyptian manuscripts dating back to 1500 Bc commenting on ‘honey urine’. Diabetes has been well documented during the Hellenistic Age with Apollonius of Memphis in 250 Bc being credited for coining the term ‘diabetes’. Insulin insufficiency can cause emaciation mainly through ketosis. The neuropathy of diabetes mellitus can affect single nerves, and a radial nerve palsy resulting in a wrist drop has been recognized. The appearance of an apparent swollen foot could be due to a Charcot joint, which is a result of repetitive microtrauma-induced complications of polyneuropathy. In conclusion, we believe this statuette represents features consistent with diabetes mellitus and is a ‘bronze diabetic’.

1358-P: Disparities in Acute and Chronic Complications of Diabetes in Rural U.S.

Rural Americans are more likely than urban Americans to be diagnosed with diabetes, to have poorly controlled diabetes, and to die from diabetes-related complications; however, there is little published data about the rates of acute and chronic diabetes complications in rural as compared to urban areas. We examined the rates of acute and chronic diabetes complications across the spectrum of rurality among U.S. adults with diabetes using OptumLabs Data Warehouse, a de-identified dataset of commercially insured and Medicare Advantage beneficiaries: remote (population &amp;lt;2,500; N=75,077), town (population 2,500-50,000; N=409,152), and city (population &amp;gt;50,000; N=2,417,334). As compared to cities, small towns had greater incidence of severe hyperglycemia (HR=1.1; 95% CI: 1.06, 1.14), severe hypoglycemia (HR= 1.15; 95% CI: 1.12, 1.18), end-stage kidney disease (HR=1.06; 95% CI: 1.04, 1.08), heart failure (HR=1.08; 95% CI: 1.07, 1.1), myocardial infarction (HR=1.14; 95% CI: 1.12, 1.16), osteomyelitis (HR=1.06; 95% CI: 1.04, 1.08), and revascularization (HR=1.06; 1.05, 1.08). Compared to cities, remote areas had higher incidence of myocardial infarction (HR=1.09; 95% CI: 1.05, 1.13), osteomyelitis (HR=1.09; 95% CI: 1.04, 1.14), and revascularization (HR=1.05; 95% CI: 1.03, 1.07). Urban areas had lower incidence of stroke: (Remote: HR=0.93; 95% CI: 0.89, 0.96); (Town: HR=0.98; 95% CI: 0.96, 0.99). There were no significant differences between the groups in the development of atrial fibrillation, Charcot joint, retinopathy, or lower extremity ulcer. Overall, rural areas had greater incidence of diabetes complications (remote areas in 3 out of 12 complications and towns in 7 out of 12 complications); however, cities had decreased incidence of stroke. An important limitation of this study is that it measures treatment/diagnosis rates, necessitating health care utilization. We therefore likely underestimate the rate of complications in rural areas, where gaps in access to health care is widely recognized. Disclosure K.Steiger: None. J.Herrin: Consultant; Johnson &amp; Johnson Medical Devices Companies. K.Swarna: None. R.G.Mccoy: Consultant; Emmi. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)