Diabetic Foot. Part 2: Charcot Neuroarthropathy / Pé diabético. Parte 2: Neuroartropatia de Charcot

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.

Resumo A neuropatia de Charcot (NC) é uma complicação lamentável e comum de pacientes com diabetes, provavelmente resutlante de uma falta de entendimento adequado dessa condição, que leva ao diagnóstico tardio.A confusão diagnóstica com quadro infeccioso contribui para que o tratamento inicialmente indicado seja equivocado ao prescrever medicação antibiótica ou, eventualmente, drenagem cirúrgica. Não é infrequente que a drenagem inadvertida do suposto abcesso revele que na verdade seu conteúdo é formado apenas de partículas provenientes da destruição osteoarticular. A educação adequada, tanto dos pacientes diabéticos quanto dos médicos responsáveis por prestar atendimento primário a estes pacientes, é fundamental para a correta compreensão das principais características relacionadas ao desenvolvimento da NC. O ortopedista geral é quem, na maioria das vezes, recebe no pronto atendimento os pacientes que se encontram na fase aguda inicial da doença. Por esta razão, esses profissionais devem estar extremamente alertas e serem capazes de identificar os primeiros sinais que permitem diagnosticar precocemente a NC. Em tese, isto possibilitaria reduzir a morbidade desta afecção na medida em que o tratamento adequado venha a ser precocemente instituído.

Artropatia de charcot do mediopé no paciente diabético: complicação de uma doença epidêmica / Mid-foot charcot arthropathy in diabetic patients: complication of an epidemic disease

OBJETIVOS: Traçar o perfil epidemiológico dos pacientes diabéticos portadores de artropatia de Charcot acometendo exclusivamente o mediopé ou estendendo-se do mediopé ao retropé. Avaliar, a médio prazo, o resultado do tratamento a que esses pacientes são submetidos seguindo um protocolo preestabelecido. MÉTODOS: Avaliamos, retrospectivamente, 88 pacientes (110 extremidades) portadores de artropatia de Charcot do mediopé, com seguimento mínimo de 12 meses. Incluímos os pacientes portadores de artropatia de Charcot acometendo as articulações tarsometatársicas, 45 pacientes (51%); as articulações talonavicular, calcaneocuboide e subtalar, 20 pacientes (23%); e aqueles com envolvimento do mediopé e retropé, 23 pacientes (26%), segundo Brodsky e Trepman. Definimos como sucesso a preservação de um pé funcional e insucesso como amputação do pé. RESULTADOS: O tratamento da artropatia de Charcot envolvendo primariamente o mediopé foram satisfatórios em 75 pacientes (85%) tratados seguindo nosso protocolo. Nos pacientes com lesões graves, acometendo tanto o mediopé quanto o retropé, foi necessário maior número de cirurgias complexas do tipo artrodese para se obter o mesmo índice global de resultados satisfatórios. A lesão osteoarticular originada no mediopé provavelmente estende-se progressivamente ao retropé devido à demora no diagnóstico no início do tratamento adequado. CONCLUSÃO: Foi possível preservar uma extremidade funcional em 85% dos pacientes. Lesões graves envolvendo o mediopé e estendendo-se ao retropé necessitaram maior número de cirurgias para o tratamento.

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.

Artropatía de Charcot secundaria a tabes dorsal: reporte de un caso / Charcot`s arthropathy due to tabes dorsalis: case report

El Tabes Dorsal (TD) es una enfermedad toxico degenerativa donde hay afectación de las raíces, los ganglios y los cordones posteriores de la médula espinal por la espiroqueta de la sífilis, como manifestación tardía de la enfermedad. La TD es muy rara en nuestro medio. El 5 a 10 % de los pacientes presentan una Osteoartropatía Neuropática, que afecta de forma predominante a las articulaciones de las extremidades inferiores. Se presenta el caso de un paciente masculino de 29 años de edad, con diagnóstico clínico y de laboratorio de sífilis, el cual inicia su enfermedad actual en febrero de 2003 con trastornos de la marcha, acompañado de artralgias progresivas y espasticidad en miembros inferiores. Al examen físico se encontró marcha con aumento de la base de sustentación, signo de Romberg positivo, arreflexia rotuliana y aquílea. Los estudios radiológicos de ambas rodillas muestran signos importantes de destrucción articular. Se realizó una Artroplastia Total de Rodilla (ATR) izquierda. La ATR se puede ofrecer a un selecto grupo de pacientes con OAN en estadíos finales

The Tabes Dorsalis (TD) are a degenerative toxic disease where there is roots, ganglia and posterior cords affectation of the spinal marrow by the syphili´s spiroquette, as delayed manifestation of the disease. TD is very rare in our means. 5 to 10% of these patients development a Neuropathic osteoarthropathy (NOA), that affects the joints of the lower extremities. We present the case of a 29 years old masculine patient, with clinical and laboratory diagnosis of syphilis, which initiates his disease in February 2003 with march upheavals, accompanied by progressive arthralgias and lower limbs spasticity. To the initial physical examination, there was march with sustenation base increased, lower extremity osteotendonous areflexia and positive Romberg's sign. The radiological studies of both knees show important signs of articular destruction. A left Total Knee Arthroplasty (TKA) was made. TKA can be offered to a select group of patients with NOA in final stages

Artrodesis tibiotalocalcánea con placa humeral bloqueada / Tibiotalocalcaneal arthrodesis with humeral locking plate

Diversos tipos de fijación han sido utilizados para la artrodesis Tibiotalocalcánea. El propósito de este estudio es analizar retrospectivamente el uso de la placa bloqueada de humero proximal para la fijación de esta artrodesis. Entre Julio 2007 y Julio 2010 se realizaron 12 artrodesis tibiotalocalcánea en 12 pacientes con placa bloqueada de húmero proximal a través de un abordaje lateral extendido previa resección del Peroné distal. Los pacientes presentaban como diagnóstico preoperatorio: artrítis reumatoidea, artropatía de Charcot y osteoartrosis postraumática. Los pacientes fueron seguidos por un periodo de 7 meses y 3 años (media de 19 meses). Todos los pacientes obtuvieron fusión de sus artrodesis en un periodo de 3 a 6 meses. Este estudio demuestra que el uso de placa humeral bloqueada para la fijación de artrodesis tibiotalocalcánea es una excelente opción por la alta incidencia de fusión de la artrodesis y facilidad la lograr correcta alineación del retropié por su forma

There are many options for Tibiotalocalcaneal arthrodesis. The aim of this study is to retrospectively review the role of the inverted proximal humeral locking plate to fix this arthrodesis. Between July 2007 and July 2010, 12 tibiotalocalcaneal arthrodesis were performed in 12 patients with the inverted proximal humeral locking plate thru an extended lateral ankle approach resecting the distal fibula. Patients preoperative diagnosis were : rheumathoid arthritis, Charcot arthropaty and posttraumatic osteoarthrosis. Patients were followed for a period between 7 months and 3 years (19 months). All the patients fused they arthrodesis in a period of 3 to 6 months. This study showed that the inverted proximal humeral locking plate is an excellent option for tibiotalocalcaneal arthrodesis because of the high fusion rate and the facility for correct hindfoot alignment because of the plate shape

Imaging findings of Charcot joint / 中华放射学杂志

Objective To analyze the MRI characters of Charcot joint, and to evaluate the diagnostic value of X-ray, CT, and MRI on Charcot joint. Methods Eight patients with 8 Charcot joints underwent X-ray, CT, and MR examinations. 6 of them had syringomyelia, 1 patient had injury of the spinal cord, and 1 case had diabetes. All 8 patients had sensory reduction or deficit in the sick extremities. Results There were two types of Charcot joint, hypertrophic and atrophic. Radiographic and CT features of hypertrophic joint (n=3) showed hyperostotic osteosclerosis and mammoth osteophytes in the sick bones, periarticular ossification,and articular disorganization. Radiographic and CT features of atrophic joint (n=5) showed extensive bone resorption (destruction), periarticular debris, and articular disorganization. Main MRI features of Charcot joint included hydrarthrosis within joint capsule, thickened, loose, and elongated joint capsule with para-joint, peri-diaphysis, and inter-muscular extension in a pseudopodia pattern. The irregular joint capsule wall was presented as mild hypointensity on T 1WI, slight hyper-intensity on T 2WI, and was markedly enhanced after Gd-DTPA was administrated, which was considered as a characteristic manifestation of the lesion. Soft tissue mass containing hypo-intense stripes on both T 1WI and T 2WI was commonly noted adjacent to the involved joint. Conclusion X-rays plain film is the first choice for the diagnosis of Charcot joint, and MRI is pretty useful in the diagnosis of Charcot joint.