4Department of Medicine, University of Manchester, Manchester, U. 5Diabetic Foot Clinic, King’schwartz principles of surgery pdf College Hospital, London, U. 7Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, U. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners.
The Charcot foot in diabetes poses many clinical challenges in its diagnosis and management. Despite the time that has passed since the first publication on pedal osteoarthropathy in 1883, we have much to learn about the pathophysiology, and little evidence exists on treatments of this disorder. Charcot foot, is a condition affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase. The typical appearance of a later-stage Charcot foot with a rocker-bottom deformity. Existing classifications do not provide prognostic value or direct treatment. Active or inactive should be used to describe an inflamed or stable CN, respectively. Acute and chronic can also be used in this regard, but there is no accepted measure that defines the transition point.
PATHOGENESISThere is no singular cause for the development of the Charcot foot, but there are factors that predispose to its development, as well as a number of likely precipitating events. The current belief is that once the disease is triggered in a susceptible individual, it is mediated through a process of uncontrolled inflammation in the foot. Osteoclasts generated in vitro in the presence of macrophage colony-stimulating factor and RANKL from patients with active CN have been shown to be more aggressive and exhibit an increase in their resorptive activity compared with control subjects. Despite these observations, it should be noted that the syndrome might also occur in patients with a spectrum of unrelated diseases complicated by nerve damage. Finally, it is possible that peptides normally secreted from nerve terminals are also important in the underlying pathophysiology.
Hence, any reduction of CGRP through nerve damage will result in an increase in RANKL expression. Because it is not possible to identify those most likely to develop the Charcot syndrome, it is impossible to determine with any degree of confidence whether preexisting osteopenia is a significant predisposing factor. Although the Charcot syndrome may occur in a variety of conditions, diabetes is ostensibly the most common worldwide. Diabetes may predispose to its occurrence through a number of mechanisms. Other cases may be triggered by different causes of local inflammation, including previous ulceration, infection, or recent foot surgery. In this respect the occurrence of an acute Charcot foot as a complication of osteomyelitis is increasingly recognized in people with diabetes.
DIAGNOSISThe initial manifestations of the Charcot foot are frequently mild in nature, but can become much more pronounced with unperceived repetitive trauma. Diagnostic clinical findings include components of neurological, vascular, musculoskeletal, and radiographic abnormalities. There have been no reported cases of CN developing in the absence of neuropathy. Easily available and inexpensive, they provide information on bone structure, alignment, and mineralization.
X-rays may be normal or show subtle fractures and dislocations or later show more overt fractures and subluxations. CN when X-rays could still be normal. MRI primarily images protons in fat and water and can depict anatomy and pathology in both soft tissue and bone in great detail. Nuclear medicine includes a number of exams based on the use of radioisotopic tracers. However, diminished circulation can result in false-negative exams and, perhaps more importantly, uptake is not specific for osteoarthropathy. Evaluation of bone density may be useful in those with diabetes to assess onset of CN as well as fracture risk.
BMD can be assessed using dual-energy X-ray absorptiometry or calcaneal ultrasound. However, a negative result obviously should not offer any confidence regarding lack of disease. Diagnostic recommendations for active CNThe diagnosis of active Charcot foot is primarily based on history and clinical findings but should be confirmed by imaging. Inflammation plays a key role in the pathophysiology of the Charcot foot and is the earliest clinical finding. CN because of the inflammatory process of bone healing, even in the absence of deformity. X-rays should be the initial imaging performed, and one should look for subtle fractures or subluxations if no obvious pathology is visible.
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