Lee C. Rogers

The Charcot Foot in Diabetes

The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.

The charcot foot in diabetes

The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.

Digital Planimetry Results in More Accurate Wound Measurements: A Comparison to Standard Ruler Measurements

Background: Cutaneous wound measurements are important to track the healing of a wound and direct appropriate therapy. The most commonly used method to calculate wound area is an estimation by multiplying the longest length by the widest width. Other devices can provide an accurate and precise measurement of the true area (TA). This study aim was to compare wound areas calculated by computerized planimetry with standard area estimation by multiplying the longest length by the widest width (l × w). Methods: We reviewed the wound records of 10 patients with circular or oval wounds and estimated the area with the l × w method. We compared this with the TA obtained by a specialized planimetric camera. Results: Average wound size was 4.3 cm2 by l × w estimation and 3 cm2 by TA calculation. We found the l × w method overestimated wound area an average of 41%. Conclusions: Standard, manual (l × w) measurement of cutaneous wounds inaccurately overestimates wound area by roughly 40%.

The Right to Bear Legs—An Amendment to Healthcare: How Preventing Amputations Can Save Billions for the US Health-care System

Charcots arthropathy is a destructive arthritis that can occur in patients with peripheral neuropathies of various etiologies. This report describes a rare case of Charcots arthropathy attributable to the distal sensory polyneuropathy associated with HIV infection. As treatments for HIV/AIDS advance and life expectancy increases, cases of end-organ sequelae, such as Charcot foot, may become more common.

The use of marrow-derived stem cells to accelerate healing in chronic wounds.

Adult bone marrow‐derived stem cells may aid the healing of chronic lower extremity wounds by transplanting a population of progenitor cells locally into the wound. We present results from three cases in which bone marrow aspirate containing marrow‐derived cells was applied/injected locally into complex lower extremity chronic wounds of differing aetiologies. Our case series suggest that bone marrow aspirate, applied topically and injected into the wound periphery, may be a useful and potentially safe adjunct to wound simplification and ultimate closure.

The Charcot Foot

The diabetic Charcot foot is rare, but a life-changing event affecting quality of life, and it risks amputation of the limb. There is no high quality evidence base governing treatment, causing clinicians to rely on low-quality, underpowered studies and expert opinion. However, CN is a treatable condition and, with lifestyle modifications and proper footwear, it does not shorten the life span of those afflicted.

Surgical Management of Charcot Midfoot Deformities

Diagnosing Charcot neuroarthropathy requires a heightened index of suspicion. Early recognition and intervention can limit deformity. Aggressive conservative management should be initiated early in the treatment plan to minimize the devastating effects often seen with this condition. Any delay in therapy can result in severe foot and ankle deformity in which traditional nonoperative methods alone may be inadequate. These deformities may lead to ulcerations and ultimately progress to amputation of the lower extremity. Surgical correction and stabilization is an effective method to prevent further deformity and ulcer recurrence. If performed in the appropriate setting and for the right indications, Charcot foot reconstruction is a better alternative to lower limb amputation.

Imaging of the Charcot foot.

Charcot foot is a serious problem that causes considerable morbidity and may lead to limb loss. Arriving at a definitive diagnosis can be challenging. Given the progressive, destructive nature of Charcots arthropathy, this delay can result advancing deformity, ulceration, infection, and place the limb at risk for amputation. Although clinical signs and symptoms and historical information are crucial, this article focuses on the imaging modalities that can aid practitioners in arriving at an early diagnosis, and how to differentiate Charcots arthropathy from osteomyelitis of the feet.

The Diagnosis of Charcot Foot

Charcot foot is a rapidly progressive disease process occurring in those with peripheral neuropathy. The disease is frequently misdiagnosed resulting in a delay of appropriate treatment, worsening the outcome. We present the hallmarks for diagnosis of Charcot foot based on the clinical examination and imaging studies. We provide a simple algorithm based on evidence and experience for the investigation of the foot when Charcot arthropathy is suspected. Additionally, we propose a new classification that accounts for the degree of complications in the Charcot joint. This new system considers deformity, ulceration, and osteomyelitis, which may help to predict amputation.

Can we predict outcome of surgical reconstruction of Charcot neuroarthropathy by dynamic plantar pressure assessment?--A proof of concept study.

The joint deformity that arises as a result of Charcot neuroarthropathy, leads to gait modification. Ulceration risk associated with the deformity is generally assessed by measuring plantar pressure magnitude (PPM). However, as PPM is partially dependent on gait speed and treatment interventions may impact speed, the use of PPM to validate treatment is not ideal. This study suggests a novel assessment protocol, which is speed independent and can objectively (1) characterize abnormality in dynamic plantar loading in patients with foot Charcot neuroarthropathy and (2) screen improvement in dynamic plantar loading after foot reconstruction surgery. To examine whether the plantar pressure distribution (PPD) measured using EMED platform, was normal, a customized normal distribution curve was created for each trial. Then the original PPD was fitted to the customized normal distribution curve. This technique yields a regression factor (RF), which represents the similarity of the actual pressure distribution with a normal distribution. RF values may range from negative 1 to positive 1 and as the value increases positively so does the similarity between the actual and normalized pressure distributions. We tested this novel score on the plantar pressure pattern of healthy subjects (N=15), Charcot patients pre-operation (N=4) and a Charcot patient post-foot reconstruction (N=1). In healthy subjects, the RF was 0.46+/-0.1. When subjects increased their gait speed by 29%, PPM was increased by 8% (p<10(-5)), while RF was not changed (p=0.55), suggesting that RF value is independent of gait speed. In preoperative Charcot patients, the RF<0, however, RF increased post-surgery (RF=0.42), indicating a transition to normal plantar distribution after Charcot reconstruction.