Charcot foot syndrome

Abstract

Charcot foot syndrome is an uncommon complication of diabetes but is potentially devastating in its consequences. Outcome is made worse by widespread professional ignorance leading to delayed diagnosis, but it is also hampered by lack of understanding of its causes and lack of treatments with proven effectiveness, other than offloading. There remains a desperate need for studies into its causes as well as comparative audit and trials designed to determine the best treatment for this difficult condition. Such work can probably only be effectively carried out through the establishment of multicentre networks. Nevertheless, improved understanding in recent years of the likely role of inflammatory pathways has raised awareness of the multiple ways in which the effects of neuropathy may be manifest in the development of the Charcot foot. This awareness is also leading to the realization that similar processes may conceivably contribute to the refractoriness of other foot diseases in diabetes, including both chronic unhealing ulcers and osteomyelitis.

Corneal confocal microscopy detects severe small fiber neuropathy in diabetic patients with Charcot neuroarthropathy

“…Diagnosis is based on the history and clinical examination and timely imaging of the foot6. The pathogenesis of CN remains unclear.…”

A study of extracellular vesicle concentration in active diabetic Charcot neuroarthropathy

“…While several biochemical mechanisms have been suggested to contribute to its development, the etiology of CN remains enigmatic . It is currently believed that CN occurs as a consequence of an imbalance of activity of two types of cells: osteoblasts and osteoclasts (Jeffcoate, 2015). This imbalance leads to enhanced bone lysis and fracture and is driven by inflammation .…”

“…Increased concentrations of TNF- and IL-6 were found also in sera of patients with CN (Petrova et al, 2015). CN has been associated with an increase in advanced glycation end products (AGEs) in blood that is often caused by poorly controlled diabetes and/or inflammation due to hyperglycemia and oxidative stress (Jeffcoate, 2015). It was found that AGEs stimulate apoptosis of human mesenchymal stem cells (Kume et al, 2005) and osteoblasts (Alikhani et al, 2007) by binding to receptor for AGE (RAGE) on their membranes (Witzke et al, 2011).…”

Vanishing bone disease: a manifestation of diabetic Charcot’s neuropathic osteoarthropathy

“…Once a temperature difference of <2°C compared with the contralateral foot was achieved, he was provided with a custom-made ankle–foot orthosis with a modified shoe and was ambulatory after 15 months. DCN has an incidence of 0.1% per year in patients with diabetes mellitus and is not commonly seen in day-to-day practice by primary care physicians 1 2. It may not be considered among the differentials for unilateral erythematous foot swelling in a patient with diabetes mellitus and peripheral neuropathy and is often misdiagnosed as osteomyelitis, cellulitis, gouty arthritis or venous thrombosis.…”

“…MRI is a sensitive modality for early acute Charcot's neuropathic osteoarthropathy and is helpful in distinguishing DCN from osteomyelitis 3. The treatment for DCN is different from that for common inflammatory conditions, and involves immobilisation in an irremovable TCC followed by use of modified shoes 1 2. A wrong or significantly delayed diagnosis may culminate in foot deformity, non-healing ulceration and limb amputation 4…”