Charcot Neuroarthropathy Research Articles

Diabetic Charcot neuroarthropathy: A threat to both limb and life.

Diabetic Charcot neuroarthropathy (DCN), first described in 1936, occurs in less than 1% of diabetic patients, but in those diabetic subjects with distal symmetrical polyneuropathy, the overall incidence increases to 30% and the risk is even greater in those with type 1 diabetes. Factors that precipitate DCN are trauma, ischaemia due to arterio-venous shunting, increased osteoclastic activity and inflammation. DCN usually presents with a painless swollen foot and/or ankle which is 'hot to the touch'. These clinical findings are soon followed by characteristic magnetic resonance imaging (MRI) abnormalities and later X-ray changes. The joints that are most typically involved in chronological order are the tarsometatarsals followed by the naviculocuniform, sub-tarsal, talonavicular and metatarsal and tarsophalangeal. The cornerstone of therapy is prolonged (3-12 months) offloading with immobilization. Bisphosphonates may possibly accelerate recovery, whereas other unproven possible therapies include rhPTH, 1-34, calcitonin and methylprednisolone, which are not only ineffective but in some cases may also prolong the time to healing. Denosumab is potentially an efficacious, if unproven, therapy to accelerate healing. The risk of amputation is high and increases in the presence of a foot ulcer. DCN is associated with manifestations of autonomic neuropathy, including cardiac denervation, so that the risks of a cardiac event and heart failure are increased with DCN. Mortality is also increased with DCN, especially in the presence of a foot ulcer. To avoid the recurrence of DCN and especially to lower the risk of the recurrence of a foot ulcer recurrence reconstructive, surgery may be needed.

Pedal Vessel Calcification and Risk of Major Adverse Foot Events in the Diabetic Neuropathic, Nephropathic Foot.

We aimed to determine the relative risk of pedal vessel calcification (PVC) on major adverse foot events (MAFEs) and chronic kidney disease (CKD) stage in patients with diabetes mellitus (DM) and peripheral neuropathy (PN). Retrospective electronic medical record review of 152 patients with diagnoses of DM, PN, and CKD stages 1-5 who had at least one foot x-ray obtained. PVC was scored (from 0-4) based on foot anatomic location and radiology reported MAFEs, which includes foot fracture, Charcot neuroarthropathy, foot ulcer, osteomyelitis, or minor amputation. Risk ratios (RR) with 95% confidence intervals (95% CI) and Poisson regressions were performed assessing the risk of sustaining MAFEs with number of PVCs and stage of CKD. The risk of any MAFE increased as PVC score increased (RR = 1.23); the risk of any MAFE increased as CKD stage increased (RR = 1.35); and risk of any PVC increased as CKD stage increased (RR = 1.71). Pedal vessel calcification (PVC) on a foot radiograph increases the risk of any MAFE and increases with progressive stage of CKD. PVC may serve as a gateway to prompt investigation, treatment, or referral for at-risk diabetic neuropathic, nephropathic patients.

Locally obtained autologous bone grafts are effective for achieving arthrodesis while managing foot and ankle charcot’s neuroarthropathy: short to mid-term results from a specialized north African foot and ankle surgery unit

PurposeWe aimed to report the union rate after only utilizing a locally obtained autologous bone graft while correcting the deformity and performing joint arthrodesis in patients with foot and ankle Charcot neuropathy (CN) and to report on the radiographic, functional, complications incidence outcomes at a minimum of two years of follow up.MethodsWe included 24 patients having a mean age of 55.4 ± 10.1 years diagnosed with CN of the foot, ankle, or both. Seven (29.2%) cases were classified as Brodsky type 1, 11 (45.8%) as type 3 A, and six (25%) were type 4. Hindfoot and Midfoot bi-columnar arthrodesis was performed in 70.8% and 29.2% of the patients, respectively. Eight (33.3%) cases had preoperative ulcers. Functional outcomes were evaluated using a modified AOFAS score. Arthrodesis site union was assessed clinically and radiographically. All patients were available for a mean follow up of 35.7 ± 9.5 (24–54) months.ResultsArthrodesis site union was achieved in 23 (95.8%) cases after a mean of 4 ± 1.7 (2-7.5) months. The mean modified AOFAS score was 72.4 ± 10.41 (46–83) points; 79.2% achieved excellent and good scores. Ulcers healed in 87.5% of the patients. Twenty-two (91.7%) patients were satisfied with their functional results. Infection incidence was 12.5%, and no patients required revision or amputation.ConclusionFoot and ankle Charcot neuroarthropathy deformity correction by arthrodesis of the affected joint as a salvage management option resulted in acceptable clinical and radiological outcomes. To enhance the local environment for arthrodesis consolidation, locally obtained autografts led to higher union rates and avoided the drawbacks of using other graft types.

Syringomyelia-induced wrist Charcot neuroarthropathy.

We present a rare case of wrist Charcot neuroarthropathy secondary to post-tuberculosis syringomyelia.Level of evidence: V.

Operative management of Charcot neuropathy of the foot and ankle: A retrospective cohort study of long-term outcomes

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the main treatment, but surgical intervention has gained interest to improve poor long-term outcomes. Few long-term outcome studies exist on operative management of CN. A retrospective chart review was performed to analyze demographics, comorbidities, complications, and outcomes of operative management of CN. Patients were divided into two cohorts for analysis: limited surgical intervention (LSI) and reconstructive surgery (RS). Fifty-eight patients with CN treated surgically over 11 years were identified. Average follow-up was 46 months (range, 1 to 173 months). The mean age was 60.2 (range, 29 to 81) years, and the average body mass index was 34.3. Diabetes caused CN in 72.4 % (42/58) of patients. The LSI cohort (n = 32) had significantly higher rates of presenting infection (59.4 %; 19/32) and ulceration (87.5 %; 28/32) compared with the RS cohort (n = 26; 23.1 % [6/26] and 50 % [13/26], respectively). Rates of postoperative infection and ulceration were lower in the LSI group (25 % [8/32] and 34.4 % [11/32], respectively) than the RS group (42.3 % [11/26] and 42.3 % [11/26], respectively). The amputation rate for the LSI cohort was 21.9 % (7/32) compared with 23.1 % (6/26) for RS. This large, single-center study of operatively treated CN patients showed no significant difference between LSI and RS. This study provides data to help surgeons counsel patients on expected outcomes.

Single-stage management of Charcot neuroarthropathy and osteomyelitis in diabetic patients

Objective: Describe our experience treating Charcot neuroarthropathy (CN) coexisting with concurrent bone infection in a single step, treated with external fixation, and report the mid-term radiographic and functional outcomes. Methods: Retrospective case series of patients diagnosed with CN and osteomyelitis treated with a single-step approach consisting of necrotic bone debridement and fusion extended over the affected joints using a circular external fixator with a minimum of 18 months of follow-up. Results: Six patients were evaluated, and three patients achieved excellent results and were able to walk outside their homes. One of them required a below-the-knee amputation due to persistent infection. Two patients had good results according to the Pinzur proposed evaluation scheme. All patients agreed that they would choose the reconstruction process for their deformity over an infrapatellar amputation. Conclusion: We believe the results from our case series apply to the previously published literature on this therapeutic modality. Level of evidence IV; Case series.

Charcot reconstruction using a novel intramedullary nail along the medial column: 3-5 year follow-up results

Charcot neuroarthropathy is a destructive, chronic disease of the bone structure and joints, and is identified in patients experiencing peripheral neuropathy, frequently associated with diabetes. The foot and ankle are most impacted by Charcot neuroarthropathy; whereas the goal of management is to stabilize the joint to avoid pedal collapse, infection, and foot amputation. Novel surgical approaches and hardware have shown promise in achieving these goals, allowing patients to return to ambulation, while avoiding late-stage complications. This multicenter, retrospective, consecutive case series reviewed individuals with midfoot Charcot neuroarthropathy who underwent surgical reconstruction using a novel locking intramedullary nail (LIN) in the medial column with at least 36 months of follow-up. Patients were treated between 2019 and 2021.This report presents data and outcomes on 30 patients with Charcot disease treated with a LIN to achieve stability and fusion along the medial column of the reconstruction, with 36-60 months of follow-up data. Of these patients, 93.3% (n = 28) demonstrated complete (multiple joint) fusion along the medial column while there were zero nonunions. Overall, the mean time to fusion was 14.1 weeks (range 10-18 weeks) and 18.1 weeks mean time to functional braced-weightbearing (range 12-28 weeks). Overall, this retrospective review investigated the long-term use of a novel LIN in Charcot neuroarthropathy patients. The success of this LIN was demonstrated by the rate of fusion and time to functional braced-weightbearing, and safety was demonstrated by the low incidence of adverse events. Overall, these results indicate that use of a LIN within the medial column to be successful in the surgical reconstruction of an unstable midfoot Charcot deformity.

Magnetic Resonance Imaging and 99Tc WBC-SPECT/CT Scanning in Differential Diagnosis between Osteomyelitis and Charcot Neuroarthropathy: A Case Series.

Distinguishing between Charcot Neuroarthropathy (CN), osteomyelitis (OM), and CN complicated with superimposed OM in diabetic patients is crucial for the treatment choice. Given that current diagnostic methods lack specificity, advanced techniques, e.g., magnetic resonance imaging (MRI) and 99mTc-HMPAO-WBC Single Photon Emission Computed Tomography (SPECT/CT), are needed. This study addresses the challenges in distinguishing OM and CN. We included diabetic patients with CN and soft tissue ulceration. MRI and 99mTc-HMPAO-WBC SPECT/CT were used for the diagnosis. The patients were classified into three probability levels for OM (i.e., Definite, Probable, and Unlikely) according to the Consensus Criteria for Diabetic Foot Osteomyelitis (CC-DFO). Eight patients met the eligibility criteria. MRI, supported by SPECT-CT and CC-DFO, showed consistency with the OM diagnosis in three cases. The key diagnostic features included the location of signal abnormalities and secondary features such as skin ulcers, sinus tracts, and abscesses. Notably, cases with inconclusive MRI were clarified by SPECT/CT, emphasizing its efficacy in challenging scenarios. The primary objective of this study was to compare the results of MRI and 99mTc-HMPAO-WBC SPECT/CT with the CC-DFO score in the diabetic foot with CN and suspected OM. Advanced imaging offers a complementary approach to distinguish between CN and OM. This can help delineate the limits of the disease for presurgical planning. While MRI is valuable, 99mTc-HMPAO-WBC SPECT/CT provides additional clarity, especially in challenging cases or when metallic implants affect MRI accuracy.

Reconstruction of unstable ankle charcot deformity using a 3-D printed titanium porous block and hindfoot nail – A case report

Charcot neuroarthropathy (CN) of the ankle joint can cause marked bone resorption of the talus resulting in severe deformity and instability. The utilisation of a 3-D printed bespoke titanium porous block that allows the use of an intramedullary calcaneo-tibial nail is an attractive option in such cases that has been reported for use in post-trauma deformities, following tumour resections, in avascular necrosis of talus and for revision of failed total ankle replacements, however has not previously been reported for Charcot ankle reconstructions. We present a novel case and surgical technique illustrating the use of a 3-D printed titanium porous block and hindfoot nail for reconstruction of a deformed and unstable Charcot hindfoot.

Exploring the psychosocial burden of foot complications in diabetes: A cross-sectional survey and qualitative interview study in a United Kingdom coastal community.

Foot complications in diabetes are common and destructive, resulting in substantial healthcare costs and high rates of morbidity. Coastal areas have a significantly higher burden of disease. People with diabetes experience disproportionately high rates of psychological health issues, including anxiety, depression and diabetes distress. These can affect self-management and concordance with preventive measures and treatments of foot complications, negatively impacting on outcomes. Access to psychological health services is variable across the United Kingdom and there is a paucity of high-quality evidence for the effectiveness of treatments for diabetes distress. This study aimed to explore experiences of psychosocial burden and perceptions and experiences of psychosocial support, among patients with diabetes and foot complications living in a coastal area. Patients were eligible to participate if they had experienced diabetes-related foot complications (amputation, ulceration and/or Charcot neuroarthropathy) within the last 5years and scored positive for diabetes distress on a validated screening tool (DDS2). Eligible patients completed cross-sectional questionnaires describing symptoms of diabetes distress (DDS17), anxiety (GAD-7) and depression (PHQ-9) and to take part in a face-to-face, semi-structured interview. Questionnaires were analysed using frequencies and interviews were analysed using reflexive thematic analysis. A total of 183 patients completed the DDS2 screening questionnaire. Of these, 56 (30.6%) screened positive for diabetes distress. Twenty-seven patients completed DDS17, GAD-7 and PHQ-9 questionnaires. Eleven (40.7%) participants indicated high levels of diabetes distress and four (14.8%) indicated moderate distress. Seventeen participants (age range 52-81years; 12 men) took part in an interview. Four key themes were identified: impact of living with foot problems; emotional consequences of foot problems; experiences and perceptions of psychological support; and strategies to cope with the emotional impact of foot problems. Diabetes distress was prevalent among patients with diabetes-related foot complications. Foot problems impacted on participants' daily activities, social lives and ability to work. Despite expressing feelings of ongoing fear, worry and depression relating to their foot problems, only one participant had accessed formal psychological support. Many participants relied on talking to podiatrists at routine appointments and described developing various strategies to cope. The psychosocial burden of living with foot complications in diabetes must not be overlooked by health professionals. Findings from this study can inform the design of future services and interventions.

The diabetic sausage toe: Prevalence, presentation and outcomes.

Osteomyelitis (OM) in diabetic foot infection could have many presentations such as an infected ulcer spreading to the bone or superimposed to Charcot neuroarthropathy. However, the sausage toe as a diabetic OM presentation was very rarely investigated; therefore, this study aims to assess the prevalence and signs of this presentation along with treatment modalities and outcomes. This is a retrospective series of patients presenting a sausage toe on admission. Several methods were conducted to diagnose OM, and three treatment modalities were applied. Two groups were compared: acute and chronic sausage toes. Outcomes were defined as sausage toe prevalence, ulcer location, OM prevalence, and comparative treatment results. Out of 82 diabetic toe infection cases, 24 (30%) presented as 'sausage toe'. The side of the proximal interphalangeal joint of the lateral toes was the most frequent ulcer location (50%), mostly on the dorsal aspect followed by the side aspect. There were 15 (62.5%) acute cases and 9 (37.5%) chronic cases. MRI showed signs of OM in 21 (87.5%) cases and signs of septic arthritis in 3 (12.5%) cases. At the final follow-up, a successful treatment was recorded in five (20%) cases with antibiotics alone. Out of the 19 (42%) procedures, conservative surgery was performed successfully in 8 (58%) cases while amputation was needed in 11 (45.8%) cases. There was no significant difference in amputation frequency between acute and chronic groups. This is the first study documenting the sausage toe as a prevalent presentation of diabetic toe infection. The deformity is conclusive of deep infection with a very high osteomyelitis frequency. Surgery is often required for infection control and healing, mainly for chronic cases, and treatment outcomes did not differ between acute and chronic sausage toe groups. It could be beneficial to include this entity in the diabetic wound classification systems.

Calcaneotalotibial arthrodesis by retrograde intramedullary nailing for Charcot osteo-neuroarthropathy of the foot and ankle

Background The Charcot’s foot and ankle presents a significant and complex clinical challenge for foot and ankle surgeons. Neuropathic arthropathy of the foot and ankle is a degenerative deformity that gradually worsens over time. It is most frequently observed in individuals with diabetic neuropathy. Aim and objectives To evaluate the efficacy, advantages, and disadvantages of calcaneotalotibial arthrodesis by retrograde intramedullary nailing for Charcot osteo-neuroarthropathy of the ankle. Patients and methods This prospective research was done on 20 cases with Charcot osteoarthropathy of the ankle using calcaneotalotibial interlocking nails at Helwan University Hospital, Al Helal Hospital, Boulak El Dakror General Hospital, and Kasr Al Ainy Hospital during the period between January 2021 and January 2022. Results Patients had both types of diabetes mellitus. As regard complications, they occurred in seven (35%) patients as follows: one patient had an intraoperative distal tibial crack during nail introduction, two patients had loosening of proximal screws and infection, three patients had skin infection at the site of distal screws, and one patient had deep infection improved with parenteral antibiotics. There was a statistically significant improvement in the American Orthopedic Foot and Ankle Society score among the studied patients with a P value less than 0.001. Conclusion We observed a satisfactory result in the treatment of severe abnormalities of the ankle and hind foot in Charcot neuroarthropathy utilizing the retrograde intramedullary arthrodesis nail. The transcalcaneal retrograde intramedullary represents a safe and efficacious fixation option.

Charcot neuroarthropathy in diabetic patients in Texas

AimsCharcot neuroarthropathy (CN) is a complex disease of the bone and joints that can lead to serious and life-threatening complications. This study investigates epidemiologic trends in diabetic CN in Texas and the impact of age on these values. MethodsA retrospective analysis was conducted using the Texas Department of State Health Services Hospital Discharge Data Public Use Data File. Using International Classification of Diseases, Ninth (ICD-9) and Tenth (ICD-10) Revision codes, we identified patients with diabetes and Charcot ankle or foot. Data extracted included diagnoses, race, and gender. Population rates were estimated using census data, calculated per 1000 population and standardized by age. ResultsOverall and age-standardized rates of CN increased each year from 2006 to 2016, except for a downward trend from 2014 to 2016. Poisson regression revealed significant increases in the incidence rate ratio compared to 2006 for each year from 2008 to 2016. When age group is included, all years except 2007 show a significant increase relative to 2006, and all age groups have increased rates relative to ages 18–44. Major and minor amputations in patients with CN have increased. ConclusionsThe increasing rates of CN and amputations highlight the need for further research and standardized strategies for diagnosis and management.

Painful Nonunion in Patients With Clinically Plantigrade Diabetes-Associated Charcot Foot Arthropathy.

It has been assumed that diabetic patients with peripheral neuropathy should not have pain associated with Charcot foot arthropathy. During a 19-year period, 14 diabetic patients (15 feet) presented for treatment with pain following resolution of the acute phases of midfoot Charcot foot arthropathy. All were clinically plantigrade with plain radiographic evidence of bony union without deformity. Pain did not resolve with the use of appropriate therapeutic footwear. When used, CT scans uniformly demonstrated nonunion. All 14 patients had resolution of their presenting pain following successful arthrodesis. Nonunion was confirmed at surgery in all of the patients. One patient developed a fatal pulmonary embolus following removal of the external fixator. Two required late exostectomy for bony overgrowth at the surgical site of fusion for nonunion. This small series of patients would suggest that nonunion of the Charcot neuroarthropathy process was responsible for complaints of pain not able to be managed with therapeutic footwear. Successful arthrodesis resolved the pain. CT imaging may help identify a treatable source of pain in this population.

CHARCOT NEUROARTHROPATHY: SURGICAL OUTCOMES FOLLOWING HIND- AND MIDFOOT RECONSTRUCTION. A MINIMUM 12-MONTH FOLLOW-UP FROM A TERTIARY HOSPITAL

BackgroundCorrective fusion of a deformed / unstable Charcot neuroarthropathy (CN)of the midfoot and hindfoot is performed with the aim to prevent ulcers and maintain patient mobility.MethodsBetween October 2007 and July 2018, 103 CN mid and hind foot corrections in 95 patients were performed. There were 34 hind-foot, 38 mid-foot and 31 combined hind and mid-foot surgeries. 83 feet had single stage corrections, whereas 20 required a staged operation.ResultsNinety-five patients were prospectively followed up. The mean patient age in our study was 57 years (21 – 85). Twenty-seven patients had type1 diabetes, 64 patients had type 2 and 4 patients had a neuropathy secondary to other conditions. Forty patients (42%) were offered a below knee amputation prior to attending our foot clinic. At a mean follow up of 56 months (12 – 140) we achieved 100% limb salvage with a 75% full bone fusion rate. There were 17 mortalities within our cohort at a mean period of 3 years. Ninety-seven percent (n=92) patients were mobilizing post-operatively in orthotic footwear. Fifty-two feet had pre-operative ulcers. Post-operatively 17 feet (16 patients) had persistent ulceration. Eight patients had ulcer resolution following further surgery and alteration of footwear, one patient has been listed for a below knee amputation for unstable non-union, whilst the remaining 7 patients have stable ulcers which are managed with dressings. Of the 26 feet (25 patients) with non-unions, 6 patients had revision fixation procedures whilst 8 patients required minor surgical procedures. The remaining 11 patients are stable non-unions who are asymptomatic and weight bearing. Other complications included a deep infection rate of 8% (n=7).ConclusionWe demonstrated a 100% limb salvage rate and an 83% success rate in ulcer resolution. We recommend this be done with the support of the multi-disciplinary team.

Polymethylmethacrylate (PMMA) Augmentation Enhances the Mechanical Characteristics of Midfoot Beam Constructs in Charcot Neuroarthropathy Cadaver Model.

Even with the best conservative care, patients with Charcot neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has been associated with risk of recurrent ulceration, potentially due to poor bone quality prone to recurrent deformity and ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation. A protocol was developed to create characteristic CN midfoot fragmentation both visually and fluoroscopically in each of 12 matched-pair cadaveric feet. Afterward, the pairs were divided into 2 groups: (1) midfoot beam fusion surgery alone, and (2) midfoot beam fusion surgery augmented with PMMA. A solid 7.0-mm beam was placed into the medial column and a solid 5.5-mm beam was placed across the lateral column. In the PMMA group, 8 to 10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded. One specimen in the beam alone group failed before reaching the 1800th cycle and was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared with the PMMA group, P < .05. The maximum force (N), stiffness (N/mm), and toughness (Nmm) were all significantly greater in the group augmented with PMMA, P < .05. In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared with midfoot beams alone. The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct. This increased mechanical toughness may help reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.

Charcot foot: the unknown diagnosis and the unwilling treatment

A 55-year-old Caucasian female presented with one year old oedema of the right foot, flattened, and deformed with no scratch, wound or ulcer. There was no difference in temperature between the feet and it was not painful. The left foot had previously presented two episodes of diabetic ulcers which were treated successfully. The patient had a history of type 2 Diabetes mellitus with need of insulin therapy and associated organ damage. Foot radiography demonstrated and confirmed inactive consolidated Charcot neuroarthropathy. Comfortable custom-made footwear was advised by Orthopedics. No other follow-up was arranged. In Portugal, Charcot foot is not readily recognized, and its management is far from the recommended by the present literature. There are almost no published article about Portuguese Charcot neuroarthropathy cases. Therefore, it is important to showcase Charcot feet in order to make clinicians aware of its existence and their appropriate treatment.

Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone. Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA. Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068). Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain. Level III.

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot.

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Association of Anatomical Location of Neuroarthropathic (Charcot's) Destruction with Age-and Sex-Matched Bone Mineral Density Reduction.

It is well documented that diabetes has a systemic impact on bone mineral density. Recent literature has evaluated the relationship between the development of Charcot neuroarthropathy and reduced local bone mineral density; however, it is not clear if there is an association between osteoporosis/osteopenia and Charcot onset, or, even further, location of neuroarthropathic breakdown. We retrospectively identified and assessed 39 patients with 41 feet (4 bilateral) with a history of Charcot breakdown who underwent a bone mineral density scan over a 15-year period. Demographic, radiographic, and bone mineral density information was analyzed. The average patient age at the time of bone mineral density scan was 53.44 ± 8.09 years, and 52.77 ± 8.19 years at the time of Charcot diagnosis. Four feet were considered Sanders-Frykberg I (9.3%), 17 were Sanders-Frykberg II (39.5%), ten were Sanders-Frykberg III (23.3%), and 12 were Sanders-Frkyberg IV/V (27.9%). Neuroarthropathic breakdown of the rearfoot region (Sanders-Frykberg IV/V) was found to be associated and preceded by osteoporosis and osteopenia at the hip as demonstrated by a lower Z-score (P = 0.05). Charcot neuroarthropathy was not associated with poor bone health or loss of bone mineral density at the femoral neck, forearm, or lumbar spine. We believe that the present findings suggest a possible relationship between osteoporosis/osteopenia and the location of CN development. With these findings in mind, we conclude that patients with diabetic skeletal fragility may benefit from treatment of underlying poor bone mineral density to prevent the onset of Charcot neuroarthropathy.