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Aim: Diabetic Charcot neuro-osteoarthropathy carries a significant worldwide disease burden including diabetic foot infection, ulceration and amputation. The current accepted standard of treatment during the active phase of Charcot neuro-osteoarthropathy is offloading with total contact casting; however, controversy remains regarding weight-bearing status during this period., Methods: A systematic review was performed following PRISMA guidelines of Pubmed, EMBASE, MEDLINE and the Cochrane central register of controlled trials for clinical studies from inception until June 2024 investigating weight-bearing and non-weight-bearing total contact casting for active Charcot neuro-osteoarthropathy., Results: Four hundred ninety-three studies were identified in the search strategy of which 5 studies met the inclusion criteria comprising 158 patients. These studies found that allowing patients to weight-bear during total contact casting does not have a negative impact on the healing process. There were no comparative studies between weight-bearing and non-weight-bearing total contact casting., Conclusions: There is limited evidence to support current practice of non-weight bearing in a total contact casting for active Charcot neuro-osteoarthropathy. Allowing patients to weight bear carries advantages to patient independence and quality of life. Further investigation with randomised control trial should be considered to investigate if weight bearing is associated with negative outcomes., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. No conflicts in data handling., (© The Author(s) 2024.)

Charcot neuroarthropathy (CN) is a chronic progressive debilitating disease affecting joints, bone and soft tissue of an insensate limb, usually seen in patients with diabetes. CN of the great toe is rare or it may be associated with CN of other joints. Only a few cases have been reported on the CN of the great toe. Stabilization and offloading is the primary aim of the treatment of CN. The present case report highlights the presentation, diagnosis and management of CN of the great toe. A 56-year-old male patient with diabetes presented to our outpatient department with post-traumatic swelling of the great toe with blackish discoloration and scanty, purulent discharging sinus. Based on the clinical and radiological findings, it was diagnosed to be the CN of the great toe, which was stabilized with a Kirschner wire. Clinical improvement and new bone formation were seen and the great toe was stabilized in acceptable alignment. Diagnosing CN of the great toe is challenging and needs both clinical and radiological evaluation. Stabilization with a single Kirschner wire is a simple, low-cost procedure, which can be done under a digital block in a minor operation theatre. Immediate mobilization and weight-bearing are allowed with good radiological and functional outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Moonot et al.)

Background: Charcot neuroosteoarthropathy (CNO) is characterized with increased osteoclastic activity that can be curbed with antiresorptive agents. Chronic kidney disease (CKD) precludes bisphosphonates but anti-receptor activator of nuclear factor-B ligand (anti-RANKL) antibody, denosumab, can be contemplated in CKD. We investigated denosumab for active CNO of foot in CKD for CNO remission., Methods: During the study period, 446 persons of diabetes with unilateral, active CNO of foot and CKD were identified and 78 were finally enrolled. Patients received either 60 mg denosumab (single-dose, subcutaneous) along with standard of care (SoC) as total contact cast (TCC) (group A; n = 26) or SoC (group B; n = 52) only. Patients were followed every 4 weeks until CNO remission and subsequently every 8 weeks until 48 weeks following remission. Remission was defined as temperature difference <2 °C between 2 feet confirmed twice (4 weeks apart) with clinical resolution of signs of inflammation. The primary outcome studied was proportion of patients achieving remission within 48 weeks and the time to remission., Results: Median age was 56.5 (48.8-65) and 57 (48.5-61.2) years, P  = .57; duration of diabetes 16 (10-25.3) and 14.9 (10-19) years, P  = .151; and estimated glomerular filtration rate 44.8 (21.1-65.6) and 45.7 (32.9-55.7) mL/min/1.73 m 2 , P  = .771, in group A and B, respectively. Median temperature difference at presentation between the affected and opposite foot was 3.4 °C (2.7-6.9) and 3.2 °C (2.2-4.0), P  = .119, respectively. All patients achieved remission in group A (100%) compared with 42 (80.8%) in group B ( P  = .006) (hazard ratio 0.52, 95% CI: 0.32-0.87; P  = .012). The median time to remission was similar in the 2 groups (15 [11-25] and 17.5 [14-31.5] weeks, P  = .229, respectively). 25-Hydroxyvitamin D 3 >14 ng/mL was significantly associated (OR 9.5, 95% CI 1.04-87.5, P  = .045) with remission., Conclusion: Anti-RANKL antibody added to SoC (TCC) induces remission of active foot CNO in greater proportions of patients with diabetes and CKD., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

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 23.6 0 (range, 11.1 0 to 42.5 0 ) and for the varus knees was 19.3 0 (range, 4.9 0 to 39.6 0 ). 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., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

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 main treatment, but surgical intervention has gained interest to improve poor long-term outcomes. Few long-term outcome studies exist on operative management of CN. A retrospective chart review was performed to analyze demographics, comorbidities, complications, and outcomes of operative management of CN. Patients were divided into two cohorts for analysis: limited surgical intervention (LSI) and reconstructive surgery (RS). Fifty-eight patients with CN treated surgically over 11 years were identified. Average follow-up was 46 months (range, 1 to 173 months). The mean age was 60.2 (range, 29 to 81) years, and the average body mass index was 34.3. Diabetes caused CN in 72.4 % (42/58) of patients. The LSI cohort (n = 32) had significantly higher rates of presenting infection (59.4 %; 19/32) and ulceration (87.5 %; 28/32) compared with the RS cohort (n = 26; 23.1 % [6/26] and 50 % [13/26], respectively). Rates of postoperative infection and ulceration were lower in the LSI group (25 % [8/32] and 34.4 % [11/32], respectively) than the RS group (42.3 % [11/26] and 42.3 % [11/26], respectively). The amputation rate for the LSI cohort was 21.9 % (7/32) compared with 23.1 % (6/26) for RS. This large, single-center study of operatively treated CN patients showed no significant difference between LSI and RS. This study provides data to help surgeons counsel patients on expected outcomes., Competing Interests: Declaration of competing Interests The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Dr. Murphy reports the following outside of this work: book royalties from Elsevier; research support from Wright Medical, Smith & Nephew, Arthrex, Allostem, and Biomimetic; consulting fees from Wright Medical and Arthrex; and IP royalties from Wright Medical. Dr. Murphy also serves on the editorial board of FAI. Dr. Bettin reports book royalties from Elsevier outside of this work. Dr. Richardson reports book royalties from Elsevier and IP royalties from Extremity Med outside of this work. Dr. Grear reports book royalties from Elsevier outside of this work. None of the other authors have any disclosures., (Copyright © 2024. Published by Elsevier Inc.)

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., (Published by Elsevier Inc.)

Background: Although the awareness, diagnosis, management of the complications associated with diabetes have improved in African countries over the past decade, surveillance activities in Tanzania and anecdotal reports from other African countries have suggested an increased prevalence of Charcot Neuroarthropathy (CN) over the past few years. Aim: To characterize the epidemiology and the clinical burden of CN in a large diabetes population in Tanzania, and to evaluate outcomes of persons with the condition. Methods: This was a prospective analytic cohort study conducted between January 2013 through December 2015. Following informed consent, patients were followed at the outpatient clinic. Detailed clinical assessments and documented presence of diabetic peripheral neuropathy (DPN), macrovascular disease and microvascular disease were recorded. Education and counseling were part of the follow-up program. Results: 3271 ulcerations were presented at the clinic during the 3-year study period. 571 (18%) met the case definition for CN; all patients had Type 2 diabetes. The prevalence for each of the years 2013, 2014, and 2015 was 19/1192 (1.6%), 209/1044 (20%), and 343/1035 (34%), respectively; the increases in the slope of the trendline was statistically significant ( P  < .001). Conclusion: The prevalence of CN is increasing in the Tanzanian diabetes patient population, and is strongly associated with neuropathy. CN can lead to severe deformity, disability, and amputation. Due to the risk of limb amputation, patients with diabetes must seek immediate care if signs or symptoms appear and avoid delay in seeking medical attention. Early diagnosis of CN by caregivers is extremely important for successful outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Distinguishing between Charcot Neuroarthropathy (CN), osteomyelitis (OM), and CN complicated with superimposed OM in diabetic patients is crucial for the treatment choice. Given that current diagnostic methods lack specificity, advanced techniques, e.g., magnetic resonance imaging (MRI) and 99mTc-HMPAO-WBC Single Photon Emission Computed Tomography (SPECT/CT), are needed. This study addresses the challenges in distinguishing OM and CN., Methods: We included diabetic patients with CN and soft tissue ulceration. MRI and 99mTc-HMPAO-WBC SPECT/CT were used for the diagnosis. The patients were classified into three probability levels for OM (i.e., Definite, Probable, and Unlikely) according to the Consensus Criteria for Diabetic Foot Osteomyelitis (CC-DFO)., Results: Eight patients met the eligibility criteria. MRI, supported by SPECT-CT and CC-DFO, showed consistency with the OM diagnosis in three cases. The key diagnostic features included the location of signal abnormalities and secondary features such as skin ulcers, sinus tracts, and abscesses. Notably, cases with inconclusive MRI were clarified by SPECT/CT, emphasizing its efficacy in challenging scenarios., Conclusions: The primary objective of this study was to compare the results of MRI and 99mTc-HMPAO-WBC SPECT/CT with the CC-DFO score in the diabetic foot with CN and suspected OM. Advanced imaging offers a complementary approach to distinguish between CN and OM. This can help delineate the limits of the disease for presurgical planning. While MRI is valuable, 99mTc-HMPAO-WBC SPECT/CT provides additional clarity, especially in challenging cases or when metallic implants affect MRI accuracy.

The objective of this study was to identify bone fractures and joint dislocations that have greater association with the severity of arch collapse in patients with Charcot foot involving the midfoot.A retrospective study in 28 (N = 29 feet) patients who had Charcot foot deformity of the midfoot. The study included stage III of Eichenholtz classification, and Schon classification types I to III. Talar-first metatarsal and calcaneal pitch angles and cuboid height were used to evaluate the severity of the midfoot deformity in a weightbearing lateral radiograph. Two investigators evaluated the bone fracture and joint dislocation involved in weightbearing antero-posterior and lateral radiographs.There were 13 (46%) feet that showed pattern 1, 9 (31%) feet with pattern 2, and 7 (25%) feet with pattern 3 according to the Schon classification. One foot had a combination of patterns 1 and 2. Midfoot ulceration occurred in 64% (n = 19) of feet. In the multivariate analysis, plantarflexion of talar-first metatarsal angle was predicted by navicular-medial cuneiform dislocation (p = .007 [-20.620-3.683]), an increase of the negative calcaneal pitch angle by fragmentation of the cuboid (p = .003 [-15.568-3.626]), and increment of the negative cuboid height by navicular-medial cuneiform and medial cuneiform-first metatarsal dislocations (p = .040 [-12.779-0.317], p = .002 [-13.437-3.267], respectively).Bone fractures and dislocations in the sagittal plane seem to contribute to midfoot collapse, but navicular-medial cuneiform dislocation/non-union and cuboid fragmentation predict severe rocker-bottom deformity in cases of Charcot foot., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., Competing Interests: Disclosure The authors have no relevant disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Charcot Neuroarthropaty (CN) is a complication of diabetes with devastating consequences as it produces severe deformities in the foot developing in recurrent ulcers that rise the probability of amputation. There are several diseases mentioned in the literature that have to be considered for the differential diagnosis of CN, often related to the acute phase (gout, ankle sprain, inflammatory arthritis, cellulitis, venous thrombosis) but there is paucity of information related to the differential diagnosis in later stages (coalescence, remodeling) when there is deformity of the foot. Clinicians and diabetologists are not familiarized with orthopedic pathology and do not have in mind certain diseases that could mimic CN in the subacute or chronic phases and this can develop in a wrong diagnosis. It is important to make a correct diagnosis in patients with suspected CN not only in the acute phase but also in the chronic phase to establish an accurate treatment. This article is a review of the differential diagnosis of CN in subacute and chronic phases showing similarities and differences that can help clinicians and diabetologists to make an accurate diagnosis and treatment. We describe unusual diseases like tendon and muscles disorders, Frieberg's disease, complex pain regional syndrome, transient regional osteoporosis and osteomyelitis superimposed to CN and the main features of each one that could help in making a differential diagnosis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kress et al.)

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., (Copyright © 2024 the American College of Foot and Ankle Surgeons. All rights reserved.)

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., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

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., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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%)., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Charcot Neuroarthropathy (CN) is a complex and incapacitating disorder characterized by neuropathy, progressive deformity, and joint destruction. It is of substantial interest within the diabetic population as this ailment chiefly affects individuals with diabetes. The pathophysiology of CN is multidimensional, connecting peripheral neuropathy, repetitive trauma, and autonomic dysfunction. The review analyses the mechanisms directing the development of CN, emphasizing the influence of diabetes in individuals who lean toward this condition. Clinical presentation and diagnosis of CN in diabetic patients present unique challenges. Complex clinical features have also been discussed, including joint deformities, insidious onset, and painless swelling, which mimic other musculoskeletal conditions. The diagnostic approaches, involving clinical examination and radiological imaging, are analyzed for early and accurate diagnosis. Risk factors and epidemiology emphasize the prevalence of CN within the diabetic population and draw attention to common risk factors contributing to its development. Significant factors such as glycemic control, duration of the disease, and type of diabetes are important in estimating an individual's risk for CN. Complications, such as foot ulcers and amputations, provide an understanding of the severe outcome of this condition on patients' quality of life. Management approaches and treatment involving conservative and surgical approaches are reviewed in depth. A multidisciplinary approach to patient care is emphasized, given the complex nature of CN and the comorbidities existing in diabetic individuals. Prognosis and prevention comprise approaches for mitigating the risk of CN in diabetic patients, such as glycemic control, regular foot examinations, and patient education. This thorough review aims to outline the intricate relationship between CN and diabetes, offering an understanding of pathophysiology, clinical complexities, diagnostic nuances, treatment modalities, and prevention strategies., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Bansod et al.)

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., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Zhang, Li, Li, Du and Wu.)

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.

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., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Chitlange et al.)

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., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Liu, Wang, Zhang, Liang, Liu and Zhao.)

Diabetic foot ulcers are a complex, multifaceted, and widespread complication of diabetes mellitus. Although there are a multitude of risk factors contributing to diabetic foot ulcer development, pressure and (more recently) shear stresses are two biomechanical metrics that are gaining popularity for monitoring risk factors predisposing skin breakdown. Other areas of diabetic foot ulcers under research include plantar temperature measuring, as well as monitoring wear-time compliance and machine learning/AI algorithms. Charcot arthropathy is another diabetes complication that has a relationship with diabetic foot ulcer development, which should be monitored for development alongside ulcer development. The ability to monitor and prevent diabetic foot ulcer development and Charcot neuroarthropathy will lead to increased patient outcomes and patient quality of life., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Charcot neuroarthropathy (CN) is a serious diabetic complication with a poor prognosis and a high rate of misdiagnosis. Furthermore, beta(2)-microglobulin amyloidosis (Abeta2M) makes the diagnosis and therapy more difficult and complex. This case report highlights the pathophysiology, clinical evaluation, treatment, and prevention of the major diabetic complications associated with CN and Abeta2M that cause poor quality of life, limit the patient's ability to walk independently, and are directly or indirectly linked with a high risk for lower limb amputation. Ankle CN was discovered in a 36-year-old single female with a history of type 1 diabetes mellitus and diabetic nephropathy. We performed early internal fixation. However, because she lived alone and needed hemodialysis three times a week, wearing a brace and non-weight-bearing were extremely inconvenient. Furthermore, she did not experience any pain and only some edema; thus, she proceeded to bear weight ahead of schedule without authorization. Due to the premature weight-bearing and poor compliance, the patient suffered severe bone resorption and infection and eventually had to undergo amputation. Abeta2M was suggested by bone pathological sections. We present a case of failed internal fixation of ankle CN with Abeta2M, emphasizing the importance of social factors and postoperative management., Competing Interests: The authors declare that they have no conflict of interest.

The pathophysiology of Charcot neuroarthropathy (CN) includes a number of gray areas, particularly regarding the onset of inflammation which induces the disruption of the bone remodeling factor responsible for the onset of bone lysis. This clinical insight highlights a potential link between this inflammation and the rapid correction of chronic hyperglycemia (Dardari et al., 2022), which is known to be responsible for a particular type of neuropathy known as treatment-induced neuropathy of diabetes (TIND). Our description makes an additional contribution to shed light on the mysterious physiopathology of CN., Competing Interests: Declaration of interests The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Aim: This study aims to explore the feasibility of using serial MRI without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot, in order to decide whether a large-scale trial is warranted., Methods: A multicentre, randomised, prospective, two arm, open, feasibility study (CADOM) of people with diabetes with a suspected or confirmed diagnosis of Charcot neuroarthropathy. Participants were randomised (1:1) to 'standard care plus', including repeated foot temperature measurements and X-rays, or the intervention arm, with additional three-monthly MRI, until remission of Charcot neuroarthropathy or a maximum 12 months (active phase). Participants were then followed-up for a further 6 months, post remission to monitor for relapse of the Charcot neuroarthropathy (follow-up phase). Feasibility outcomes were recruitment, retention, data completeness, adherence to study procedures and safety of the intervention MRI. We also collected clinical efficacy outcomes, this included time in cast/off-loading device which will be the primary outcome of a future definitive trial. Finally, we collected patient reported outcomes, and data on health and social care usage., Results: One-hundred and five people were assessed for eligibility at five sites. 64/105 potential participants meet the eligibility criteria to participate in the study. Forty-three participants were randomised: 20 to standard care plus and 23 to MRI intervention. The main reason for ineligibility was a previous episode of Charcot neuroarthropathy. Thirteen participants were withdrawn post-randomisation due to an alternative diagnosis being made. Of the remaining 30 participants, 19 achieved remission, 6 had not gone into remission at the end of the 12 month active phase so exited the study. Five participants were lost to follow-up. Of the MRIs that were not disrupted by COVID-19 pandemic 26/31 (84%) were completed. For the visits that were conducted face-to-face, completion rates of patient-reported outcome measures were between 71 and 100%. There were no safety incidents associated with the intervention MRI. As this was a feasibility study it was not designed to test the effectiveness of serial MRI in diagnosing remission. The time in cast/off-loading device was 235 (±108.3) days for the standard care plus arm compared to 292 (±177.4) days for the intervention arm. There was no statistical difference in the time in cast/off-loading device between the two arms of the study: Hazard Ratio (HR) 0.405 (95% CI 0.140-1.172), p = 0.096., Discussion: The findings support a definitive randomised controlled trial to evaluate the effectiveness of MRI in diagnosing remission in Charcot neuroarthropathy. The rates of recruitment, retention, data, and MRI completeness show that a definitive study is feasible., Study Registration: ISRCTN, 74101606 . Registered on 6 November 2017., (© 2023. The Author(s).)

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., Competing Interests: Conflict of Interest None declared., (Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Bone in diabetes mellitus is characterized by an altered microarchitecture caused by abnormal metabolism of bone cells. Together with diabetic neuropathy, this is associated with serious complications including impaired bone healing culminating in complicated fractures and dislocations, especially in the lower extremities, so-called Charcot neuroarthropathy (CN). The underlying mechanisms are not yet fully understood, and treatment of CN is challenging. Several in vitro and in vivo investigations have suggested positive effects on bone regeneration by modifying biomaterials with sulfated glycosaminoglycans (sGAG). Recent findings described a beneficial effect of sGAG for bone healing in diabetic animal models compared to healthy animals. We therefore aimed at studying the effects of low- and high-sulfated hyaluronan derivatives on osteoclast markers as well as gene expression patterns of osteoclasts and osteoblasts from patients with diabetic CN compared to non-diabetic patients with arthritis at the foot and ankle. Exposure to sulfated hyaluronan (sHA) derivatives reduced the exaggerated calcium phosphate resorption as well as the expression of genes associated with bone resorption in both groups, but more pronounced in patients with CN. Moreover, sHA derivatives reduced the release of pro-inflammatory cytokines in osteoclasts of patients with CN. The effects of sHA on osteoblasts differed only marginally between patients with CN and non-diabetic patients with arthritis. These results suggest balancing effects of sHA on osteoclastic bone resorption parameters in diabetes.

Charcot neuroarthropathy (CN) is a destructive complication of the joints in patients with diabetes and should be managed from the onset of the first symptoms to avoid joint deformity and the risk of amputating the affected joint. Here, we describe the case of a young 24-year-old patient living with type I diabetes who developed active bilateral CN in both tarsal joints. This case of neuroarthropathy was uncommon due to the bilateral presentation at the same level of the joint. Despite the patient consulting from the beginning of the symptoms, none of the physicians suspected or diagnosed CN, leading to a delay in management and the aggravation of bone destruction by CN. This highlights the importance of early management of CN with the need to refer people with suspected CN to specialised diabetic foot care centres.

There are multiple factors that lead to the development of the diabetic foot ulceration (DFU). The ultimate goal when treating DFU is to prevent amputation. Initial therapy should include debridement, maintaining a healthy wound environment, and offloading. In the setting of infection or a nonhealing DFU, surgical intervention may be necessary. The goals of this article are to discuss the key aspects of the initial examination, standard nonoperative treatment, and the operative treatment options for patients with DFU., Competing Interests: Disclosure D.K. Wukich is a consultant for Orthofix, Stryker Wright and receives royalties from Arthrex. He is also on the executive board of the International Association of Diabetic Foot Surgeons. K.M. Raspovic is a consultant for Orthofix. M.J. Johnson has no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Surgical reconstruction of Charcot arthropathy in the foot and ankle is extremely difficult. The fundamentals of reconstruction are necessary to provide adequate outcome. Removing and resecting the diseased bone is needed along with good anatomic alignment and rigid fixation. This reconstructive surgery is not only difficult from medical management point of view but also involves patient compliance and good technical components of the surgery from the surgeon. The surgeon must have skills with internal and external fixation, a good understanding of lower extremity vascular disease, and a good understanding of infectious disease and plastic surgical techniques of the lower extremity., Competing Interests: Discloser Relative to this article, there are no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The Charcot diabetic foot presents unique challenges to the podiatric surgeon in the quest to salvage the limb. This disorder is an intersection of prototypical metabolic diseases and neurodegenerative disorder. Furthermore, it can be considered a disease of bone and ligaments that is often complicated by peripheral vascular disease and serious deep infection. Presently, simplistic ablative surgical procedures and the brace-makers art, still have a valid place in treating this disorder. Newer methods of surgical reconstruction are rapidly evolving to address distorted and nonfunctional limb. This article seeks to evidence the principles and practice of beaming the Charcot midfoot. As will be presented, the beam is a load-sharing device, which can be surgically introduced in an intramedullary method to restore architecture and strength to the Charcot foot. Problems with beam failure and migration have resulted in unsatisfactory outcomes as will be discussed. New Charcot-specific beams are currently reaching the podiatric surgeon with hopes of improving durability. In this article, we aim to address the surgical art of the beam, the engineering principles of beaming, and the novel introduction of a truss/tie rod configuration of beaming., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Diabetes mellitus with the lack of glycemic control increases risks for developing comorbidities affecting organ systems responsible for critical function. The development of diabetic neuropathy predisposes patients to the onset of Charcot neuroarthropathy (CN). There is significant complexity with treatment of diabetic-induced CN, which can have an often delayed or missed diagnosis. Supervision and treatment from trained specialists are required to provide care for this multifaceted disease process. It is essential for patients to partner with glucose control, comorbidity prevention and care, as well as lower extremity management. Ultimately, CN can result in significant lower extremity deformity placing patients at risk of limb and life., Competing Interests: Disclosures The author has nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Charcot can be a difficult clinical entity to diagnose in the acute phase, and clinicians should have a high clinical suspicion in neuropathic patients who present with erythema, edema, and warmth of the foot or ankle. Immobilization and nonweight-bearing should be immediately initiated when the diagnosis of Charcot has been made and patients should remain nonweight-bearing until the affected bones/joints have coalesced. Educating patients and managing expectations is crucial to improve compliance with the conservative treatment of Charcot and avoid the long-term sequelae including severe deformity, ulceration and infection, and amputation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough review of clinical history and detailed assessment provide the treating surgeons with key information to guide treatment pathway. Vigilance is required when opting for nonoperative treatment in undisplaced stable ankle fractures in patients with peripheral neuropathy. The presence of critical ischemia in injured limb demands vascular consultation and ultimately, an intervention before surgical fixation of ankle fracture. An extended period of immobilization is one of the key principles in the management of ankle fracture patients with diabetes., Competing Interests: Disclosure The authors have nothing to disclose., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background and Aims: An article's scientific impact has often been measured by the number of citations it receives, and a citation analysis can help determine impactful works in medical specialties. The objective of this study is to describe the metrics and levels of evidence of articles in Charcot neuroarthropathy., Methods: This study reviewed the top 100 most cited articles available when searching for articles in electronic database using the keywords "Charcot neuroarthropathy." Each article was examined for the number of citations, publication type, journal specialty, authorship, country of origin, year of publication, level of evidence, and total sample size., Results: The number of citations ranged from 20 to 490. The 100 most cited articles were published in 48 journals, spanning from general to more specific subspecialty journals. 19% of articles were published by the Journal of Foot and Ankle Surgery. The most common level of evidence was V (42 out of 100 articles), and most articles were literature reviews (n = 42) and case series (n = 27). The median sample size in experimental studies was 29. Out of 100 articles, only 5 were randomized controlled trials., Conclusions: The median year of most cited publications, 2008, suggests a need for newer studies reviewing Charcot neuroarthropathy. The paucity of articles with an evidence level of 1 or 2 along with small median sample size suggests a lack of scientifically rigorous studies reviewing Charcot neuropathy. Identification of most cited papers about Charcot neuroarthropathy gives clinicians insight into the general scientific review of the disorder., Level of Clinical Evidence: N/A., (Copyright © 2022 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Infection imaging has been an important part of nuclear medicine practice. Infections in prosthetic joints and diabetic foot are associated with devastating complications, posing substantial challenge for both diagnosis and overall management. For many years, conventional nuclear medicine techniques have been used to frame a painful joint arthroplasty or diabetic foot infection. The various functional nuclear imaging modalities used include labeled leukocyte imaging, combined leukocyte-marrow scintigraphy, antigranulocyte antibody scintigraphy, 3-phase bone scintigraphy, and fluorodeoxyglucose PET/computed tomography, yet no single method has proved to be highly sensitive and specific and at the same time safe, simple, and time-effective., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Cardiac autonomic neuropathy (CAN) in people with diabetes is associated with high mortality. We aimed to study age and disease duration, independent prevalence of CAN in people with diabetic foot complications., Methods: 530 patients with diabetes were screened to undergo CAN assessment (automated CANS-analyser). CAN was defined as "early", "definite," or "severe" according to the Toronto consensus. History pertaining to autonomic symptoms, prior cardiovascular events (CVE), and assessment for peripheral neuropathy was done. Participants were grouped into those with diabetic foot complication (group A, n = 82) [Charcot foot (n = 42), diabetic foot ulcer (n = 40)]; with DPN without foot complications (group B, n = 82); and without DPN or foot complications (group C, n = 82)., Results: Symptoms of autonomic dysfunction were prominent in people with foot complications than the other groups. Resting heart rate was significantly greater in those with foot complications [99.89 ± 26.71 (group A) vs. 86.99 ± 22.24 (group B) vs. 88.32 ± 17.08 (group C); P = 0.001]. The prevalence of CAN was 75.6% in group A (51.2% early, 12.2% definite, 12.2% severe), 57.2% in group B (45.1% early, 12.2% severe) and 58.5% in group C (43.9% early, 1.2% definite, 13.4% severe) (P = 0.002). Patients with foot complications were more likely to have CAN (75.6% vs. 57.9%, P < 0.001). Charcot foot had higher prevalence of CAN (78.6%) as compared with those with DFU (72.5%) or without DFU or DPN (57.9%), P < 0.001., Conclusion: CAN is present in more than two-third of patients with diabetes and foot complications with highest prevalence in Charcot neuroarthropathy., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Journal of Endocrinology and Metabolism.)

Background: Charcot neuroarthropathy (CNA) of the upper extremity occurs most frequently in shoulders. However, CNA in the hands is uncommon and seldom be reported. The onset of CNA is usually insidious. If this process continues undetected, it can result in joint deformity, ulceration and/or superinfection, loss of function, and amputation or even death. In this article, we are going to present three cases of CNA in the hands of individuals with cervical spinal cord injury (SCI) with central cord syndrome., Case Presentation: Three male individuals with cervical spinal stenosis contracted tetraplegia (American Spinal Injury Association Impairment Scale Grade D, D, and B) due to spinal cord contusion after a trauma and developed hand swelling without pain 2 to 3 months after their SCI. X-ray showed degenerative joint changes in the hands. CNA was considered due to the patient's history of cervical SCI, loss of motor function and sensation, symptoms of painless swelling, physical examination, and X-ray findings. The self-care sub scores of Spinal Cord Independence Measure III improved slightly only during rehabilitation and follow-up due to poor hand function., Conclusions: CNA may develop after a central or peripheral neurological disorder. Nearly every joint of the body can be affected and the lower limbs are the most frequently involved. However, CNA of the hand is rare. We present three patients with CNA in the hands after cervical SCI and review the features and early differential diagnosis of CNA. Currently there is no specific treatment available. Therefore, early identification of CNA and adequate protection to the affected joints seem important., (© 2022. The Author(s).)

Aims: Charcot neuroarthropathy (CN) is a complication of neuropathy, in people with diabetes. Treatment requires the prolonged wearing of an offloading device, which can be challenging. The importance of understanding people's perspectives for promoting their engagement in self management is well known. However, no such studies have been done in CN. This qualitative study aimed to understand people's experiences of CN., Methods: Semi-structured interviews with a purposive sample of 14 participants with CN, recruited from a randomised controlled trial. We gathered opinions, thoughts and the meanings participants attributed to their experiences of CN and its physical, socio-economic and physiological effects and how this affected their families and relationships. We analysed the interviews using Inductive Thematic Analysis., Results: Four analytic themes were identified: (1) 'Trapped at home isolated and missing social life and daily life routines'; (2) 'Disruption to people's roles, responsibilities, relationships and mobility, which people adapted to try and address and manage'; (3) 'Pain which participants related to the direct or indirect consequences of wearing the cast or boot'; and (4) 'Blame for developing CN, attributed to themselves and healthcare professionals'. Participants described guilt about needing more support, expressing frustration, low mood and low self-esteem., Conclusion: This study highlights experiential aspects of the previously unrecognised burden of CN. Its physical, social and emotional impacts on participants and their families are substantial and sustained. There is a need to raise clinical awareness of CN and its wider effects., Trial Registration: ISRCTN74101606. Registered on 6 November 2017, http://www.isrctn.com/ISRCTN74101606?q=CADom&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search., (© 2022 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

The RANKL-GLYC study aims to explore the impact of the rapid correction of chronic hyperglycemia on the receptor activator of nuclear factor-kappa B ligand (RANKL) and its antagonist osteoprotegerin (OPG). RANKL and OPG are considered the main factors in the pathophysiology of Charcot neuroarthropathy, a devastating complication of the joints that remains poorly understood. The study began recruiting patients in September 2021 and ends in June 2022; the final study results are scheduled for January 2023.

Background: Charcot neuroarthropathy (CN) is a systemic disease characterized by progressive bone loss and destruction, which is usually closely related to diabetes, HIV, etc. However, CN caused by syringomyelia accounts for only 5% of CN cases; the shoulder and elbow are most often involved, and the hip joint is rarely affected. As a rare factor, cervical spondylotic myelopathy (CSM) can be associated with syringomyelia, which is scarcely reported in the literature. Here, we present the first case report to date of CN of the hip caused by syringomyelia secondary to CSM., Case Summary: We describe a 76-year-old male patient who was diagnosed with CSM due to neck pain and weakness of limbs 16 years ago. Four years ago, he noticed recurrent swelling of the right hip with pain and was diagnosed with degenerative arthritis. Recently, however, his symptoms gradually worsened, and because of progressive pain, destabilization and weakness of the right hip, he was admitted to our hospital. Through systematic physical, radiographic and laboratory examinations, we finally reached a diagnosis: CN of the right hip associated with syringomyelia secondary to CSM. After comprehensive evaluation of the patient's condition, we performed right total hip arthroplasty. During the follow-up, the patient felt well clinically and could walk independently with a knee brace., Conclusion: We suggest a possible etiological association between CSM and syringomyelia, which may reflect a potential pathogenesis of CN. We encourage clinicians to actively carry out a detailed medical history and comprehensive physical and imaging examinations in patients with joint lesions, especially chronic shoulder neck pain, to rule out the possibility of this association, which plays a crucial role in the early diagnosis of CN. Arthroplasty may no longer be an absolute contraindication to surgical treatment of CN. Reasonable selection of the surgical strategy can markedly improve the clinical symptoms and quality of life of patients., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflict of interest., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: To identify differences in radiographic outcomes in weight-bearing lateral X-ray to predict the probability of ulceration in patients with midfoot Charcot neuroarthropathy (CN) differentiated by lateral and medial column deformities., Methods: Thirty-five patients who suffered from CN midfoot deformity participated in this 1 year prospective study in a specialized diabetic foot unit. Lateral talar-first metatarsal angle, calcaneal pitch, and cuboid height were performed by digital radiographs in the weight-bearing lateral view. Patients were followed up for 1 year or until an ulcer ulceration event occurred in the midfoot region., Results: ROC analyses showed that all patients with medial pattern deformity that developed a midfoot ulcer had a lateral talar-first metatarsal angle greater (negative) than -27.5 degrees (°). All patients with lateral pattern deformity that developed a midfoot ulcer had a calcaneal pitch greater (more negative) than -5° and a cuboid height greater (more negative) than -1.5°., Conclusions: Lateral talar-first metatarsal angle was the greatest predictor of midfoot ulceration, with greater than -27.5° measurement correlating with ulceration occurrence in patients with medial deformity. Calcaneal pitch and cuboid height were the greatest predictors of midfoot ulceration with greater than -5 and -1.5°, respectively in patients with CN lateral deformity.