The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic

Abstract

The aim of this longitudinal study was to report on the clinical characteristics and treatment course of acute Charcot's arthropathy at a tertiary care diabetic foot clinic. Fifty-five diabetic subjects, with a mean age of 58.6 +/- 8.5 years, were studied. All patients were treated with serial total contact casting until quiescence. Following casting and before transfer to prescription footwear, patients were eased into unprotected weightbearing via a removable cast walker. This cohort was followed for their entire treatment course and for a mean 92.6 +/- 33.7 weeks following return to shoes. Pain was the most frequent presenting complaint in these otherwise insensate patients (76%). The mean duration of casting was 18.5 +/- 10.6 weeks. Patients returned to footwear in a mean 28.3 +/- 14.5 weeks. Nine per cent of the population had bilateral arthropathy. These subjects were casted significantly longer than the unilateral group (p < 0.02). Surgery was performed on 25% of patients, with approximately two-thirds of these procedures involving plantar exostectomies and one-third fusions of affected joints. Patients receiving surgery remained casted significantly longer than non-surgical patients (p < 0.05). Additionally, men were casted longer than women (p < 0.008). Acute Charcot's arthropathy requires prompt, uncompromising reduction in weightbearing stress. Our data show that the ambulatory total contact cast is very effective for this. Regardless of the specific treatment method instituted, it is imperative that appropriate and aggressive treatment be undertaken immediately following diagnosis to help prevent progression to a profoundly debilitating, limb-threatening deformity.

Update on charcot neuroarthropathy

“…Sensory neuropathy is sine qua non for the development of CNA, and in 101 cases of CNA all cases had distal symmetrical sensory neuropathy in one series [9]; this was similarly observed in two other published series [10,11]. However, although these patients have severe neuropathy, pain is usually preserved and is in fact the most common presenting symptom in these patients, along with discomfort in the foot [10,12•].…”

Charcot neuroarthropathy in diabetes mellitus

“…There is no particular sex preponderance and it could be bilateral. Although CN was bilateral in only 9% [32], others have reported a higher level of bilateral involvement, even up to in 75% of cases [33]. Similarly, another study found bilateral changes when the feet were examined by computerised tomography (CT) in 75% of 22 patients [34].…”

“…Both neuropathy and increased blood flow appear to be important, and the abnormality of collagen structure could be involved due to the lack of associated pain. A study showed that 73% of patients did not recall any precipitating event, 22% recalled a specific traumatic episode within one month before the onset of symptoms and 4% of patients with CN had recent foot surgery [32].…”

“…This is often achieved using plaster casting [93]. A recent study reported that, on average, 18 weeks of nonweight bearing is required [32] for the acute phase to subside. Another study found that ambulation in a total-contact cast resulted in a mean healing time of 86 days, with the most rapid healing occurring in forefoot CN rather than CN at other parts in the foot [96].…”

Percutaneous injection of bone marrow mesenchymal stem cells for ankle non-unions decreases complications in patients with diabetes

“…Co-morbidities [12][13][14][15][16][17] were considered present if reported in the patient's history or records from other services available at the time of the injury. Specifically, sensory deficits identified on follow-up examinations were noted for the purposes of this study.…”