Midfoot Charcot Arthropathy in Diabetic Patients: Complication of an Epidemic Disease

Abstract

Objectives: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. Methods: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. Results: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. Conclusion: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

Pé diabético. Parte 2: Neuroartropatia de Charcot

“…19 Local foot trauma, whose magnitude and intensity may vary, appears to be involved in the beginning of the destructive process. 4,5,20 Eventually, CN can be triggered by repetitive trauma that causes stress fractures in previously osteopenic bones (neurotrauma theory). 21 In contrast, peripheral arterial vasodilation, due to paralysis of the smooth muscle of the blood vessel wall (autosympathectomy), is directly responsible for the reduction in blood flow velocity, and, apparently, it is involved in the increase in bone resorption rate, thus contributing to the installation of the destructive process of CN (neurovascular theory).…”

“…The vast majority of patients with CN present symptoms related to pain in the midfoot, as well as edema and erythema. 20,21 However, as in the early acute phase of the disease no noticeable deformity is present yet, many patients are misdiagnosed as having cellulitis, gout, or tenosynovitis. 23 Due to misdiagnosis, many patients are mistakenly treated with antibiotics, corticosteroids or even with surgery indicated for "abscess drainage".…”

“…21 In most cases, only when the acute condition subsides and the edema disappears, can the patient, and often the doctor himself, be able to detect the presence of residual deformities already installed in the sequela phase of the disease. 20,21 As many of these deformities are of minor magnitude, it is possible to accommodate the feet in therapeutic shoes suitable for insensitive feet together with specially made insoles. 20,21 Some patients, whose protective foot sensitivity is more seriously compromised due to peripheral neuropathy, continue to walk leaning on the foot affected by the destructive process of CN, and this further accelerates osteoarticular deformation.…”

“…20,21 As many of these deformities are of minor magnitude, it is possible to accommodate the feet in therapeutic shoes suitable for insensitive feet together with specially made insoles. 20,21 Some patients, whose protective foot sensitivity is more seriously compromised due to peripheral neuropathy, continue to walk leaning on the foot affected by the destructive process of CN, and this further accelerates osteoarticular deformation. [20][21][22] Approximately 40% of patients with CN arrive at the first medical care already presenting plantar ulcer located under the bony prominence on the midfoot, especially when it is affected, and there is collapse of the lateral plantar arch.…”

“…20,21 Some patients, whose protective foot sensitivity is more seriously compromised due to peripheral neuropathy, continue to walk leaning on the foot affected by the destructive process of CN, and this further accelerates osteoarticular deformation. [20][21][22] Approximately 40% of patients with CN arrive at the first medical care already presenting plantar ulcer located under the bony prominence on the midfoot, especially when it is affected, and there is collapse of the lateral plantar arch. 24 The presence of an ulcer is a poor prognostic factor regarding the risk of extremity amputation, since it increases in six times the chance of this occurrence in diabetic patients with CN.…”