Neuropathic Fractures Research Articles

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care.

The 1989 Saint Vincent Declaration established a goal of halving global diabetes-related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro-osteoarthropathy is more prevalent than previously thought. Most cases respond well to non-removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline-based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.

Amputation and infection are the greatest fears in patients with diabetes foot complications

AimsTo determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. Methods478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. ResultsOf the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8–4.5), major LEA (OR 2.8, 95 % CI 1.8–4.4), minor LEA (OR 2.3, 95 % CI 1.5–3.5), blindness (OR 2.0, 95 % CI 1.3–3.2), dialysis (OR 2.0, 95 % CI 1.1–3.3), and death (OR 2.4, 95 % CI 1.4–4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. ConclusionPatients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

IDF21-0442 Risk Categorization of Diabetic Foot in Patients with Type-II Diabetes and Influence of Various Risk Factors

Background: Diabetes Mellitus has been labelled as global epidemic with 463 million people have diabetes in 2019 and this number is projected to reach 700 million by 2045. Diabetes is the leading cause of nontraumatic amputation. Foot screening which detects and stratification of diabetics which are at the risk of developing diabetic foot ulcer is the simple and useful part of this model of care. Aim: Primary Aim is to stratify patients with type II diabetes into different risk categories of diabetic foot as per International Diabetic Federation guidelines. Secondary Aim is to determine the relationship of various risk factors with risk categories of diabetic foot. Method: Study Design: Cross sectional study. Place and Duration of Study: Department of Medicine, Liaquat University Hospital Jamshoro / Hyderabad from February 2019 to August 2020. Methodology: This study included 117 consecutive patients with confirmed diagnosis of Type-II diabetes of either sex aged ≥ 18 years. Patients fulfilling above criteria were included in study. Feet were thoroughly examined for neuropathy, peripheral vascular disease, infections, ulcers and osteoarthropathy. All the data was recorded on proforma. Patients having normal protective sensations were put in low risk (category 0), those having loss of protective sensations in moderate risk (category 1), those having loss of protective sensations with either high pressure or poor circulation or structural foot deformities or onychomycosis in high risk (category 2) and those having past history of ulceration, amputation or neuropathic fracture were put in very high risk (category 3). Data was analyzed by using SPSS version. 20. Results: Total 117 patients of diabetic foot ulcer were studied, their mean age was 52.28±9.26 years, diabetic duration 10.21±8.10 years and mean HbA1c level was 10.07±1.96 mmol/l. Male were 77(65.8 %). Ulceration history was in 18.8% cases, amputation history was in 7.7% cases, 46 patients (39.3%) had risk category 1. A strong relationship was found between risk categories and age, sex, duration of diabetes, HbA1c. This study revealed that 33 (28%) patients attending the diabetic clinic were at high risk of developing diabetic ulcer. Discussion: Diabetic foot ulcer (DFU) is a major source of morbidity and a leading cause of hospitalization in patients with diabetes. Among 117 diabetic patients 77 (65.8 %) were male and 40 (34.2%) were female in this study. Iqbal S et al. also found similar findings regarding gender as 52 (80%) were male and 13 (20%) female presenting with diabetic foot ulcer out of all 65 study cases. In another study which included 100 patients and risk stratification was done on the basis of American Diabetes Association (ADA) task force report for comprehensive foot examination. According to this classification 48 (48%) patients were in category 0, 33 (33%) in category 1, 19 (19%) in category 2. In a large prospective study comprising 3526 patients which was stratified according to Scottish risk stratification system. According to this system 2257 (64%) were in low risk, 811 (23%) in moderate risk and 458 (13%) high risk category.

A Curious Distal Tibiofibular Neuropathic Fracture: A Case Report.

Therapeutic, Level IV: Case report.

Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes.

Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality. The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality. Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use.

Oxidative stress parameters as biomarkers of risk factor for diabetic foot among the patients with type 2 diabetes

The aim of this study was to determine whether plasma levels of carbonylated proteins, total antioxidant capacity (TAC) and reduced protein thiols could be suitable biomarkers of risk factors for diabetic foot. Individuals with type 2 diabetes with normal protective sensation (normal foot group) vs. loss of protective sensation and/or signs of peripheral arterial disease and/or foot deformities and/or history of ulcers and/or neuropathic fractures and/or amputation (diabetic foot group) were compared. The diabetic foot group showed higher carbonylated protein levels (P = 0.0457) and lower levels of TAC (P = 0.0148) and reduced protein thiols (P = 0.0088), compared with the normal foot group. In general, several other parameters of risk of diabetes complication (blood levels of glycated hemoglobin, glucose and cholesterol, duration of diabetes, body mass index and waist circumference) showed a tendency of higher values in the diabetic foot group. The results suggest that the plasma levels of carbonylated proteins, TAC and reduced protein thiols could furnish information about the risk of diabetic foot, considering that the changes in these biomarkers were associated with the loss of sensitivity and foot ulcerations.

Impact of Charcot neuroarthropathy on metatarsal bone mineral density and geometric strength indices

Charcot neuroarthropathy (CN), an inflammatory condition characterized by rapid and progressive destruction of pedal bones and joints, often leads to deformity and ulceration in individuals with diabetes mellitus (DM) and peripheral neuropathy (PN). Repetitive, unperceived joint trauma may trigger initial CN damage, causing a proinflammatory cascade that can result in osteolysis and contribute to subsequent neuropathic fracture. We aimed to characterize osteolytic changes related to development and progression of CN by measuring bone mineral density (BMD) and geometric strength indices using volumetric quantitative computed tomography. Twenty individuals with DM+PN were compared to twenty age-, sex-, and race-matched individuals with DM+PN and acute CN. We hypothesized that individuals with acute CN would have decreased BMD and decreased total area, cortical area, minimum section modulus, and cortical thickness in the diaphysis of the second and fifth metatarsals. Results showed BMD was lower in both involved and uninvolved feet of CN participants compared to DM+PN participants, with greater reductions in involved CN feet compared to uninvolved CN feet. There was a non-significant increase in total area and cortical area in the CN metatarsals, which helps explain the finding of similar minimum section modulus in DM+PN and CN subjects despite the CN group's significantly lower BMD. Larger cortical area and section modulus are typically considered signs of greater bone strength due to higher resistance to compressive and bending loads, respectively. In CN metatarsals, however, these findings may reflect periosteal woven bone apposition, i.e., a hypertrophic response to injury rather than increased fracture resistance. Future research using these techniques will aid further understanding of the inflammation-mediated bony changes associated with development and progression of CN and other diseases.

Neuropathic ankle fractures

A 65-year-old diabetic female presented with a 3-week history of a left swollen foot after a minor inversion injury and was found to have a minimally displaced fibular fracture. Despite casting and strict instructions to remain non-weight bearing, the patient continued to bear weight and later developed a significantly more displaced fracture with a draining ulcer. This injury eventually required a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail. Neuropathy and neuropathic fractures can be devastating complications of diabetes and thus require early diagnosis and intervention because they may result in significant morbidity for the patient. Thorough assessment involving imaging, a complete history and physical examination, and tools such as a 129 Hz tuning fork and the 10 g Semmes-Weinstein monofilament are paramount to establishing an accurate initial diagnosis. These tactics aid in future follow-up of the patient's injury and can be employed in both the clinic and the emergency department. Although management remains controversial for neuropathic ankle fractures because both conservative and surgical treatment regimens have high complication rates, open reduction and internal fixation continues to be the treatment of choice once closed reduction has been attempted and fails. Education is essential because diabetic patients have compromised pain and pressure sensation, which can lead to injuries and subsequent complications of which they are simply unaware. Physicians must be diligent when evaluating the diabetic foot and be explicit when providing instructions to these patients because preventing these injuries and their complications is the best patient care available.

Inflammatory Osteolysis in Diabetic Neuropathic (Charcot) Arthropathies of the Foot

Osteolysis and low bone mineral density (BMD) are underappreciated consequences of several chronic diseases that may elevate the risk for fracture. The purpose of this study was to assess tarsal BMD associated with acute inflammation (ie, inflammatory osteolysis) in individuals with chronic diabetes mellitus (DM), peripheral neuropathy (PN), and recent-onset neuropathic (Charcot) arthropathy (NCA) of the foot. This was a case-control study of 32 people (11 men, 21 women) with DM, PN, and NCA of the foot or ankle. The subjects with DM, PN, and NCA were compared with 64 age-, sex-, and race-matched control subjects (24 men, 40 women) without DM, PN or NCA. Within the first 3 weeks of cast immobilization, BMD was estimated in both calcanei using quantitative ultrasonometry. Acute inflammation was confirmed by comparing skin temperature differences between the feet of the subjects with DM, PN, and NCA and the feet of the control subjects. Skin temperature differences averaged 6.7 degrees F (SD=4.0 degrees F) (involved foot minus noninvolved foot) in the feet of the subjects with DM, PN, and NCA compared with 0.0 degrees F (SD=1.3 degrees F) in the feet of the control subjects. Calcaneal BMD averaged 384 mg/cm(2) (SD=110) in the involved feet and 467 mg/cm(2) (SD=123) in the noninvolved feet of the subjects with DM, PN, and NCA and 545 mg/cm(2) (SD=121) in combined right and left feet of the control subjects. Inflammation in individuals with DM, PN, and NCA may contribute to or exacerbate a rapid loss of BMD. Inflammatory osteolysis may be a prominent factor responsible for both the spontaneous onset of neuropathic fracture and the insidious and progressive foot deformity that is the hallmark of the chronic Charcot foot.

Neuropathic osteoarthropathy: diagnostic dilemmas and differential diagnosis.

The purpose of this pictorial essay is to illustrate the radiologic spectrum of imaging findings of neuropathic osteoarthropathy. Typical findings include joint destruction, disorganization, and effusion with osseous debris. A variety of other imaging findings related to neuropathic osteoarthropathy such as resorption of the ends of tubular bones and neuropathic fracture are shown. The two prevailing theories for the pathophysiology of neuropathic bone and joint disease, the neurovascular and neurotraumatic theories, are briefly described. Examples of osteoarthropathy from diverse causes are presented including syringomyelia, spinal cord injury, meningomyelocele, diabetes mellitus, congenital insensitivity to pain, steroid injections, syphilis, leprosy, and others. The discussion focuses on key imaging features with emphasis on disease patterns and differential diagnosis, which vary by skeletal location.

Management of neuropathic fractures in the foot and ankle.

Neuroarthropathy, a rapid, painless destructive process, has become increasingly prevalent among long-lived diabetic patients. It is characterized by warm, swollen joints with a grossly disorganized radiographic appearance, in spite of which the patient is often pain-free. Neglect of this condition results in progressive deformity or instability, often complicated by ulceration and infection, which can ultimately result in loss of independent mobility, loss of the affected limb, and even death. In most cases, a plantigrade, stable, and functional foot can be achieved with simple nonoperative techniques, such as the use of a total-contact cast or shoe modification. A few patients in whom uncontrolled instability or major osseous prominences cause recurrent ulceration will require reconstructive surgery (either exostectomy or osteotomy/arthrodesis). Although some patients will have an improvement in function, ongoing vigilance is necessary.

Charcot neuroarthropathy of the foot and ankle.

The goal of this study was to characterize Charcot neuroarthropathy of the foot and ankle by specific sites of involvement (ankle, hindfoot, midfoot, and forefoot), modes of presentation, methods of management, and outcome. A summary of treatment and results for 50 ankles, 22 hindfeet, 131 midfeet, and 18 forefeet is presented. Nondisplaced neuropathic ankle fractures typically healed uneventfully with casting and bracing. For displaced ankle fractures, closed reduction and casting generally resulted in loss of reduction and progressive deterioration; better results were obtained with open reduction and internal fixation, using supplemental Kirschner wires and screws. Ankles with Charcot neuroarthropathy and preexisting arthritis typically required arthrodesis. Of the ankles with neuropathic avascular talar necrosis, approximately 1/3 did well with nonoperative intervention and 2/3 required surgery. Chronic, unstable, malaligned Charcot ankles often required arthrodesis. Neuropathic calcaneal fractures were managed successfully nonoperatively. For feet with transverse tarsal joint involvement (Schon Type IV), management was more complex. Nonoperative treatment was successful for less than 1/2. Two thirds of the feet with midtarsus involvement (Schon Types I, II, and III) were managed successfully nonoperatively; 1/3 required surgery for recurrent ulceration, instability, or osteomyelitis. Half of the feet with forefoot neuroarthropathy required surgery for malalignment, ulceration, and/or difficulty with shoewear or braces. This review has established patterns of Charcot involvement of the foot and ankle with corresponding methods of treatment and subsequent responses. From this extensive clinical experience with 221 neuropathic fractures or Charcot joints, recommendations were derived to assist in selecting appropriate management options.

Neuropathic Calcaneal Tuberosity Avulsion Fractures

Avulsion of a calcaneal tuberosity can be the initial presentation of a neuropathic fracture. Neuropathic fracture should be investigated in patients who appear without a history of significant indirect or direct trauma. Neuropathic fractures should always be considered in patients with diabetes mellitus. The diagnosis of neuropathic calcaneal tuberosity avulsion fracture alters the prognosis and treatment of this injury. Two cases of bilateral fracture avulsions are reported to emphasize problems in diagnosis and treatment.

Risk factors in the diabetic foot. Recognition and management.

The most frequently reported diabetic foot complication is plantar ulceration. Neuropathic fractures occur less often than plantar ulcers but usually result in major structural deformities of the feet. The primary risk factors for plantar ulceration are believed to be loss of protective sensation and the presence of high plantar pressures. Principal etiologic factors in the development of neuropathic fractures are hypothesized to be loss of protective sensation and bone demineralization. Major diabetic foot injuries are preventable by the use of comprehensive screening examinations and patient education. Patients at highest risk of injury should be seen more frequently and receive more extensive therapy. Successful management of plantar ulcerations is dependent on reduction of pressures under the foot and control of infection. Neuropathic fractures require long-term immobilization to promote healing followed by careful monitoring after removal of casts to prevent reinjury. Future research needs include prospective studies on risk factors and validation of treatment techniques.

Hip Replacement in a Charcot Joint

A 61-year-old woman with a neuropathic joint was treated by total hip arthroplasty. Histologically, the absence of any osseous repair process in this hip is consistent with reports that neuropathic fractures of the femoral neck generally fail to unite. The fragments of necrotic bone found in the synovium are characteristic of the pathologic process. The above-described patient is typical of the preataxic stage. The seven-year successful result of total hip arthroplasty is most likely explained by the fact that the patient was not ataxic. Because of the unpredictability of neurosyphilis, seven years should not be considered the touchstone of success. From this experience there is no recommendation or even a suggestion that hip arthroplasty should be performed on ataxic patients.

Post-operative neuropathic fractures in patients with myelomeningocele.

Neuropathic fractures are common after major surgical procedures to stabilize the hip or spine in patients with myelomeningocele. Complications resulting from such fractures are frequently observed. The fractures occur particularly in the more severely involved children and are associated with prolonged immobilization after surgery. The authors advise that all necessary surgery be done within the shortest possible time, and urge that prolonged immobilization be avoided if possible.

Neuropathic Fractures and Joint Injuries

Current concepts of the treatment of neuropathic joints are reviewed and a number of questions are raised. Selected cases are reviewed which illustrate the role of fractures, the varied clinical picture, and the natural course of the condition. The mode of onset is discussed with reference to obvious and occult trauma, stress fractures, and ligament damage. The local pathological changes are briefly reviewed with emphasis on their variety and their relationship to the stage of development of the process. The various stages and clinical course of the condition are described and the interrelationship of different clinical stages is shown. Animal experiments showed no demonstrable intrinsic weakness of denervated bones and joints, and the subsequent Charcot-like fractures and joint injuries were felt to be purely traumatic. A rational form of treatment is described based on an understanding of the pathogenesis of the condition. Emphasis is placed on preventive therapy.

Spina bifida and epiphysial displacement. Report of two cases.

The Journal of Bone and Joint Surgery. British volumeVol. 44-B, No. 1 Clinical StudiesFree AccessSPINA BIFIDA AND EPIPHYSIAL DISPLACEMENTFelicity E. SoutterFelicity E. SoutterSearch for more papers by this authorPublished Online:1 Feb 1962https://doi.org/10.1302/0301-620X.44B1.106AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited ByEpiphyseal Growth Plate Fracture-Separations20 December 2015Neural4 October 2011Fractures in myelomeningocele19 August 2010 | Journal of Orthopaedics and Traumatology, Vol. 11, No. 3Lower Extremity InjuriesEpiphyseal separations in spastic cerebral palsyJournal of Pediatric Orthopaedics B, Vol. 16, No. 3Epiphyseal Growth Plate Fracture–SeparationsChronic Physeal Fractures in Myelodysplasia: Magnetic Resonance Analysis, Histologic Description, Treatment, and OutcomeJournal of Pediatric Orthopaedics, Vol. 17, No. 5Physeal injuries in myelomeningocele patientsSpinal Cord, Vol. 30, No. 11Radiographic appearance of healed extremity fractures in children with spinal cord lesionsSkeletal Radiology, Vol. 18, No. 3Some miscellaneous joint diseasesSeminars in Roentgenology, Vol. 17, No. 1Post-operative Neuropathic Fractures in Patients with Myelomeningocele12 November 2008 | Developmental Medicine & Child Neurology, Vol. 23, No. 2Spina bifida and unilateral focal destruction of the distal femoral epiphysisSkeletal Radiology, Vol. 6, No. 2Die Lenden-KreuzbeingegendFractures in Children with Myelomeningocele: Report of 15 Cases and a Review of the Literature8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 45, No. 6Die pathologischen Frakturen bei Spina bifidaArchiv f�r Orthop�dische und Unfall-Chirurgie, Vol. 68, No. 2The Incidence of Vitamin-C Deficiency in Meningomyelocele12 November 2008 | Developmental Medicine & Child Neurology, Vol. 9, No. 3Fracture in childhood paraplegiaSpinal Cord, Vol. 3, No. 3Epiphyseal Injuries of the Lower ExtremitySurgical Clinics of North America, Vol. 45, No. 1 Vol. 44-B, No. 1 Metrics Downloaded 102 times History Published online 1 February 1962 Published in print 1 February 1962 InformationCopyright © 1962, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download