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      Diabetic Foot. Part 2: Charcot Neuroarthropathy *

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          Abstract

          Charcot neuroarthropathy (CN) is an unfortunate and common complication of patients with diabetes, most likely resulting from a lack of proper understanding of the disease, which leads to late diagnosis. It is commonly misdiagnosed as infection and treated with antibiotics and a frustrated attempt of surgical drainage, which will reveal only debris of the osteoarticular destruction. Proper education of diabetic patients and of the health care professionals involved in their treatment is essential for the recognition of the initial signs of CN. The general orthopedic surgeon is usually the first to treat these patients in the early stages of the disease and must be aware of the signs of CN in order to establish an accurate diagnosis and ensure proper treatment. In theory, this would make it possible to decrease the morbidity of this condition, as long as proper treatment is instituted early.

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          The Charcot Foot in Diabetes

          Lee C Rogers, Robert G. Frykberg, David Armstrong … (2011)
          The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
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            Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study.

            Tore J. Larsson, M Löndahl, P Nyberg … (2009)
            We sought to identify factors related to short-term outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1-5, below ankle) (n = 2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31. The characteristics of the remaining 2,480 patients were: 1,465 men, age 68 +/- 15 years (range 18-96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. The healing rate without major amputation in surviving patients was 90.6% (n = 1,867). Sixty-five per cent (n = 1,617) were healed primarily, 9% (n = 250) after minor amputation and 8% after major amputation; 17% (n = 420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to co-morbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.
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              Chapter V: Diabetic foot.

              M Lepäntalo, J. Apelqvist, C. Setacci … (2011)
              Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade. Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology. Published by Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Rev Bras Ortop (Sao Paulo)
                Journal ID (iso-abbrev): Rev Bras Ortop (Sao Paulo)
                Journal ID (doi): 10.1055/s-00042410
                Title: Revista Brasileira de Ortopedia
                Publisher: Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revinter Publicações Ltda (Rio de Janeiro, Brazil )
                ISSN (Print): 0102-3616
                ISSN (Electronic): 1982-4378
                Publication date (Print): August 2020
                Publication date (Electronic): 27 April 2020
                Volume: 55
                Issue: 4
                Pages: 397-403
                Affiliations
                [1 ]Grupo de Cirurgia do Pé e Tornozelo, Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
                Author notes
                Endereço para correspondência Ricardo Cardenuto Ferreira, MD Rua Barata Ribeiro, 380, Cj 64, 6°. Andar, Bela Vista, São Paulo SP, 01308-000Brasil ricardocardenuto@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-9886-5082
                Article
                Publisher ID: 190100pt
                DOI: 10.1055/s-0039-3402460
                PMC ID: 7458761
                PubMed ID: 32904836
                SO-VID: 68b521ad-2a09-478d-a57b-86d48ed93107
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

                History
                Date received : 28 June 2019
                Date accepted : 13 September 2019
                Categories
                Subject: Artigo de Atualização
                Subject: Tornozelo e Pé

                Keywords: diabetes,foot,arthropathy, neurogenic/complications,amputation,pé,artropatia neurogênica/complicações,amputação
                Data availability:
                Keywords: diabetes, foot, arthropathy, neurogenic/complications, amputation, pé, artropatia neurogênica/complicações, amputação

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