Lepromatous Leprosy and Charcot Neuroarthropathy of Insensate Feet: A Case Report.

Leprosy is a chronic infection of the skin, eyes, and peripheral nerves due to the slow-growing, acid-fast bacillus Mycobacterium leprae. Devastating complications include Charcot neuroarthropathy and insensate hands and feet. We present the case of an 81-year-old female with rheumatoid arthritis and 50 years of polar lepromatous leprosy who suffered from bilateral collapsed arches, flat feet, and bone deformities of Charcot feet.

Clinical outcomes of primary total knee arthroplasty in non-syphilitic neuroarthropathy of the knee.

PURPOSE: Total knee arthroplasty (TKA) in syphilitic neuroarthropathy using earlier implant designs was associated with poorer outcomes. Literature on TKA for non-syphilitic neuroarthropathy using modern contemporary prosthesis is scarce. We aim to analyse the clinical and radiological outcomes of TKA in neuropathic joints. METHODS: A final cohort of 17 patients (21 knees) with the diagnosis of neuropathic joint undergoing primary TKA between January 2013 to January 2019 were included in the study. The preoperative ambulatory status, range of motion, type of prosthesis, level of constraint and any augmentation used were retrieved from medical records. Radiological evaluation includes Koshino's staging, the magnitude of deformity defined by the Hip-Knee-Ankle (HKA) angle, and any progressive loosening. Pre and postoperative functional scores were obtained by the Knee Society (KSS) and Knee Society Functional Score (KSS-F). Any complications or reoperation were noted till the final follow-up. Preoperative and follow-up functional scores, HKA and range of motion were compared using the paired Samples test. RESULTS: The mean follow-up was 40.2 months (range, 15 to 75 months). Preoperatively, according to the Koshino staging, five knees were in stage 3 (23.8%). The mean HKA angle in valgus knees was 23.60 (range, 11.10 to 42.50) and for the varus knees was 19.30 (range, 4.90 to 39.60). The prosthesis used were posterior stabilized in 7 knees (33.3%), varus-valgus constrained in five knees (23.8%) and a rotating hinge was required in nine knees (42.8%). Metaphyseal sleeves were used along with hinge prosthesis in six knees (28.6%). The mean arc of motion improved from 102.4 ± 22.7 degrees to 105.7 ± 15.5 degrees postoperatively (p = 0.27). The knee society and knee society functional scores improved from 23.3 ± 9.3 and 28.3 ± 12.2 preoperatively to 81.1 ± 5.4 and 80.4 ± 8.5 during the follow up respectively (p < 0.001). There were no progressive radiolucent lines in any knees at the final follow-up. One patient had intraoperative bony medial collateral ligament injury, one patient had deep vein thrombosis after five days from the index surgery and another had postoperative periprosthetic tibial shaft fracture. CONCLUSION: According to our study, the clinical outcomes of TKA for neuroarthropathy show significant improvement with the diagnosis of non-syphilitic neuroarthropathy, utilization of modern constrained prostheses, and early rehabilitation, at medium-term follow-up. Tibial and femoral stems are preferred for equal stress distribution and to prevent early loosening.

Comparing Clinical Characteristics and Short-Term Outcomes Between Adult and Geriatric Patients Undergoing Charcot Reconstruction.

Maintaining an acceptable quality of life following a lifetime of chronic diseases and resulting physiologic effects poses a challenge when treating an aging population. In those with Charcot neuroarthropathy, wounds, and infection complicate decision making when considering limb preservation versus amputation. The purpose of this investigation is to describe the clinical characteristics and short-term outcomes of geriatric patients undergoing Charcot reconstruction. A retrospective chart review of patients who underwent Charcot reconstruction from 2016 to 2022 was conducted. Demographics, medical history, deformity type, surgical intervention, discharge planning, and short-term complications were collected. Descriptive statistics were calculated, and clinical characteristics and short-term outcomes were compared between the non-geriatric, adult (A) and geriatric (G) cohorts using Student's t-test or chi-squared test. Overall, 125 patients were reviewed for final analysis. Charcot deformity type, prevalence of wounds, osteomyelitis, and fixation construct did not significantly differ between groups. While the proportion of those experiencing a prolonged admission did not significantly differ between cohorts, the geriatric group showed age-related pathology including delirium and urinary tract infections. While discharge to nursing facilities did differ between groups (G 43% versus A 19%), baseline function did not. The 30-day unplanned readmission and mortality rates did differ between groups, though this difference was not statistically significant. Prior to geriatric Charcot reconstruction, consideration should be given to age-related comorbidities. Specifically, with a greater incidence of age-related complications unrelated to the surgery as well as mortality in the geriatric group, complications should be discussed at length.

Surgical Outcomes in Charcot Arthropathy.

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.

Polymethylmethacrylate (PMMA) Augmentation Enhances the Mechanical Characteristics of Midfoot Beam Constructs in Charcot Neuroarthropathy Cadaver Model.

BACKGROUND: Even with the best conservative care, patients with Charcot neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has been associated with risk of recurrent ulceration, potentially due to poor bone quality prone to recurrent deformity and ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation. METHODS: A protocol was developed to create characteristic CN midfoot fragmentation both visually and fluoroscopically in each of 12 matched-pair cadaveric feet. Afterward, the pairs were divided into 2 groups: (1) midfoot beam fusion surgery alone, and (2) midfoot beam fusion surgery augmented with PMMA. A solid 7.0-mm beam was placed into the medial column and a solid 5.5-mm beam was placed across the lateral column. In the PMMA group, 8 to 10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded. RESULTS: One specimen in the beam alone group failed before reaching the 1800th cycle and was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared with the PMMA group, P < .05. The maximum force (N), stiffness (N/mm), and toughness (Nmm) were all significantly greater in the group augmented with PMMA, P < .05. CONCLUSION: In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared with midfoot beams alone. CLINICAL RELEVANCE: The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct. This increased mechanical toughness may help reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.

What is New on Diabetic Neuropathy? Insights from the 2023 ADA and EASD Conferences.

Diabetic neuropathy is a common complication of diabetes; yet its pathophysiology is still incompletely understood and until today, there is no specific treatment against it. In the two 2023 large congresses on diabetes (American Diabetes Association, ADA, European Association for the Study of Diabetes, EASD), several high-level studies have been presented. They have attempted to delineate the pathophysiology of DN, the characteristics of affected patients, and future potential treatments. We herein review the presented studies on diabetic neuropathy at these diabetes congresses and discuss the needs for future research on this topic.

The Differentiation Between Infection and Acute Charcot.

The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.

Intraoperative Radiation Exposure During Midfoot Charcot Reconstruction.

While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ .05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5 ± 5.39 mGy and 256.64 ± 130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p = .32) or fluoroscopy times (p = .71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p = .01) body mass index (p = .03) and number of stages (p = .04). Similarly, a relationship existed between fluoroscopy time with weight (p = .02), body mass index (p = .03), and number of beams/screws (p = .003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.

Prevalence of Ankle Charcot Neuroarthropathy Presenting in a Tertiary Care Center.

Charcot neuroarthropathy's (CN) anatomic classification was originally formulated by the Brodsky article and the Trepman et al modification, including midfoot (type 1), rearfoot (type 2), ankle (type 3a), calcaneus (type 3b), multiarticular (type 4), and forefoot (type 5). In these classic studies, ankle joint and multijoint CN are reported as 9% and 6% to 9%, respectively, but we believe ankle CN to be more common than that in a tertiary setting. We retrospectively reviewed patients presenting initially or as referral between 2004 and 2020. Initial presentation radiographs were reviewed and classified by 3 authors based on Brodsky's model with Trepman and colleagues' modification, and any discrepancies were reviewed by the fourth author. A total of 175 patients (205 feet) were assessed. This revealed 80 cases classified as type 1 (39.0%), 23 cases type 2 (11.2%), 17 cases type 3a (8.3%), 2 cases type 3b (1.0%), and 83 cases type 4 (40.5%). After subdividing type 4, total prevalence included 150 with type 1 anatomic location (73.2%), 103 type 2 (50.2%), 44 type 3a (21.5%), and still 2 type 3b (1.0%). This study revealed a similar prevalence of isolated ankle CN (8.5%) compared to the Trepman et al article (9%), however, in total, ankle CN (21.5%) occurred 2.4-times more than the original 9%. Our study also found there to be a higher prevalence of ankle CN in the setting of multiarticular CN, which has not been evaluated in past studies. The prevalence of multiarticular CN was found to be 4.5-fold greater than the Trepman article (6%-9%).

Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research.

Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review.

BACKGROUND: There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin. METHODS: We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted. RESULTS: We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission. CONCLUSIONS: There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease.

Comprehensive Rehabilitation of Charcot Foot With Equinovarus Deformity: A Case Report.

Charcot neuroarthropathy is the destruction of the bones and joints caused by underlying neuropathy, trauma, and disturbances in bone metabolism. Modern health care and surgical options now include limb salvage. An acquired or congenital foot deformity is the equinovarus deformity, also known as clubfoot or talipes equinovarus. The foot is fixed in plantarflexion (equinus), deviates toward its center (varus), and is rotated upward so that it rests on its outside (supination) in this condition. In another way, the foot turns axially outward while pointing downward and inward. Charcot neuroarthropathy generally occurs due to diabetes, but in this case, it occurs due to trauma and leads to a traumatic congenital talipes equinovarus deformity. A 38-year-old male patient complained of right foot pain and an inability to walk. Two years ago, he was involved in an accident that left him with a right leg injury. He was eventually diagnosed with a mid-shaft tibia-fibula fracture and underwent surgery with nailing. But one month ago, he again met with an accident and was diagnosed with Charcot's foot and equinovarus deformity. He returned to Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi, Wardha, Maharashtra, for further management. K-wire was applied for the fixation of Charcot foot with equinovarus deformity. Further on, rehabilitation was started to restore mobility, regain full range of motion and develop muscle strength.

Case Report: Supramalleolar osteotomy to preserve joint function and delay the development of Charcot neuroarthropathy of the ankle.

Background: Charcot neuroarthropathy (CN) is a severe disease that primarily affects the foot and ankle. Conservative treatment with total contact casts is suitable for early stages, but surgery is necessary for complications such as ulceration, malalignment, infection, or severe pain. The ankle instability caused by excessive axial load may require arthrodesis. However, preserving joint function in young patient can significantly enhance the quality of life. Case report: A 33-year-old woman underwent open reduction and internal fixation after the right tibia and fibula fractures following a fall while walking. She developed severe pain and deformity in her right ankle after full weightbearing. After further evaluation, she was diagnosed with Charcot neuroarthropathy (CN) of the right ankle. The patient declined arthrodesis and opted for a supramalleolar osteotomy (SMO) instead 18 months after the initial surgery. The SMO procedure involved correcting the hindfoot malalignment through osteotomy and fixation. Although she experienced skin necrosis, the patient eventually achieved satisfactory outcomes with improvements in pain, deformity, and functionality of the ankle. Radiographic measurements showed positive realignment, and the patient reported a significant improvement in her quality of life at the final follow-up. Conclusions: The SMO procedure could potentially be considered as an option to preserve ankle function and delay the disease development of CN for young patients. The restored foot stability and hindfoot alignment can help improve patients' quality of life.

[Progress in clinical diagnosis and treatment of diabetic Charcot neuroarthropathy of foot and ankle].

Objective: To summarize the progress of clinical diagnosis and treatment of diabetic Charcot neuroarthropathy (CNO) of foot and ankle to provide reference for clinical treatment. Methods: The research literature on diabetic CNO of foot and ankle at home and abroad was widely reviewed, and the stages and classification criteria of CNO were summarized, and the treatment methods at different stages of the disease course were summarized. Results: CNO is a rapidly destructive disease of bone and joint caused by peripheral neuropathy, which leads to the formation of local deformities and stress ulcers due to bone and joint destruction and protective sensory loss, which eventually leads to disability and even life-threatening. At present, the modified Eichenholtz stage is a commonly used staging criteria for CNO of foot and ankle, which is divided into 4 stages by clinical and imaging manifestations. The classification mainly adopts the modified Brodsky classification, which is divided into 6 types according to the anatomical structure. The treatment of diabetic CNO of foot and ankle needs to be considered in combination with disease stage, blood glucose, comorbidities, local soft tissue conditions, degree of bone and joint destruction, and whether ulcers and infections are present. Conservative treatment is mainly used in the active phase and surgery in the stable phase. Conclusion: The formulation of individualized and stepped treatment regimens can help improve the effectiveness of diabetic CNO of foot and ankle. However, there is still a lack of definitive clinical evidence to guide the treatment of active and stable phases, and further research is needed.

Managing Cavovarus Feet in Diabetic Patients.

A cavovarus foot is characterized by exacerbated medial longitudinal arch (cavus), hindfoot varus, plantar flexed first ray, forefoot pronation (apparent supination), forefoot adduction, and claw toe deformities. It can be broadly divided as flexible and rigid and further classified based on the neurological and non-neurological causes. Diabetes associated peripheral neuropathy complicates individual bony deformities associated with cavovarus foot with early callus which can breakdown to ulceration rapidly. Based on the disease progression in neurological and non-neurological causes of cavovarus feet in patients with diabetic neuropathy, 3 stages of the disease and its management is described.

Establishment of a Neurodegenerative Charcot Mouse Model.

BACKGROUND: This study aimed to mimic the changes from Charcot neuropathic arthropathy in humans by examining the effects of exposing diet-induced obese (DIO) mice to neurotrauma through a regimented running protocol. METHODS: Forty-eight male wild-type C57BL/6J mice were obtained at age 6 weeks and separated into 2 groups for diet assignment. After a 1-week acclimation period, half of the mice consumed a high-fat diet (60% fat by kcal) ad libitum to facilitate neuropathic diet-induced obesity whereas the other half were control mice and consumed an age-matched standard low-fat control diet (10% fat by kcal). At age 12 weeks, half of the animals from each group were subjected to a high-intensity inclined treadmill running protocol, which has been previously demonstrated to induce neurotrauma. Sensory testing and radiographic analyses were periodically performed. Histopathologic analyses were performed post killing. RESULTS: DIO mice had significantly higher bodyweights, higher body fat percentages, and lower bone mineral density than wildtype control mice that were fed a normal diet throughout the experiment (P < .001 for each). DIO mice displayed significantly reduced sensory function in week 1 (P = .005) and this worsened over time, requiring 20.6% more force for paw withdrawal by week 10 (P < .001). DIO mice that ran demonstrated greater midfoot subluxation and tarsal instability over all time points compared with normal-diet mice that ran (P < .001). Histopathologic analyses revealed that DIO mice that ran demonstrated significant changes compared with controls that ran (P < .001 for each parameter). CONCLUSION: Changes akin to the earliest changes observed in or before joint destruction identified in diabetic Charcot neuropathic arthropathy in humans were observed. CLINICAL RELEVANCE: There is currently no standard of treatment for patients with Charcot neuropathic arthropathy. This study establishes a protocol for an animal model that can be used to study and compare interventions to treat this disease.

Management of Midfoot Charcot: Minimally Invasive Techniques and Improved Fixation.

The objective of this article is to review the etiology and pathophysiology of Charcot neuroarthropathy as it contributes to the breakdown of the midfoot. The article will also discuss the emerging techniques in minimally invasive surgery and how this is applied to Charcot reconstructive surgery as well as reflect on a newer thought processes to surgical intervention.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Charcot Neuroarthropathy of the Hip.

BACKGROUND: Historically, Charcot neuroarthropathy hip (CNH) was deemed a contraindication for total hip arthroplasty (THA). However, as implant design and surgical techniques advance, THA for CNH has been performed and documented in literature. Information regarding the outcomes of THA for CNH is limited. The objective of the study was to assess outcomes following THA in patients who have CNH. METHODS: Patients who have CNH underwent primary THA and had at least 2 years of follow-up were identified in a national insurance database. For comparison, a 1:10 matched control cohort of patients who did not have CNH was created based on age, sex, and relevant comorbidities. Eight hundred and ninety-five CNH patients who underwent primary THA were compared to 8,785 controls. Medical outcomes, emergency department visits, hospital readmissions, and surgical outcomes including revisions between cohorts were evaluated using multivariate logistic regressions. RESULTS: The CNH patients were found to have higher risks of 90-day wound complications (P = .014), periprosthetic joint infection (P = .013) (P = .021), dislocation (P < .001) (P < .001), aseptic loosening (P = .040) (P = .002), periprosthetic fracture (P = .003) (P < .001), and revision (P < .001) (P < .001) at 1-year and 2-year follow-up, respectively. CONCLUSION: While patients who have CNH are at a higher risk of wound and implant-related complications, they are comparatively lower than previously reported in literature. Orthopaedic surgeons should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

A Rare Charcot Neuro-Osteoarthropathy of Hip with an Uncommon Cause.

Neuro-osteoarthropathy often called as Charcot joint results from decreased sensory innervations of the involved joint resulting in severely damaged and disrupted joints and involvement of adjacent soft tissues. Charcot joint is characterized by the "6Ds," which are i) distended joints, ii) density increase, iii) debris production, iv) dislocation, v) disorganization, and vi) destruction. Hip joint involvement is very rare probably because of rich nerve supply compared with other peripheral joints. To minimize the joint deformity and loss of function, early diagnosis is of great importance in which radiological imaging plays a major role.

Therapeutics of Charcot neuroarthropathy and pharmacological mechanisms: A bone metabolism perspective.

Charcot neuroarthropathy (CN) is a chronic, destructive, and painless damage of the skeletal system that affects the life quality of patients. CN, with an unclear mechanism, is characterized with invasive destruction of bones and a serious abnormality of bone metabolism. Unfortunately, development of an effective prevention and treatment strategy for CN is still a great challenge. Of note, recent studies providing an insight into the molecular mechanisms of bone metabolism and homeostasis have propelled development of novel CN therapeutic strategies. Therefore, this review aims to shed light on the pathogenesis, diagnosis, and treatment of CN. In particular, we highlight the eminent role of the osteoprotegerin (OPG)-receptor activator of nuclear factor-κB (RANK)-RANK ligand (RANKL) system in the development of CN. Furthermore, we summarize and discuss the diagnostic biomarkers of CN as well as the potential pharmacological mechanisms of current treatment regimens from the perspective of bone metabolism. We believe that this review will enhance the current state of knowledge on the diagnosis, prevention, and therapeutic efficacy of CN.