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Charcot neuroarthropathy (CN) is a highly destructive, pathologic process with devastating consequences to foot structure and viability. The use of intramedullary fixation "superconstructs" allows for "re-bar" support of compromised bone and allows for some dynamic fixation. This study examines radiodensity in Hounsfield units (HU) to compare bone quality of medial column fixation targets using computed tomography scans between patients with and without midfoot CN. A retrospective chart review identified control (nondiabetic, non-CN; n = 29) and midfoot CN (n = 21) groups. Patient demographics and medical history were collected. Two reviewers measured the mean HU of a circular region of interest centered on the first metatarsal head and the anterior, middle, and posterior thirds of the talar body. Radiodensity was compared between groups, and among talar locations, Eichenholtz stages and Brodsky types, with statistical significance set at p ≤ .05. Age and body mass index were not significantly different between groups. The CN group maintained greater mean HU than the control group at the metatarsal head (p.001), and talar body locations (p.019). The difference in mean HU of these bones was not statistically significant between Stages 0 to 1 and Stages 2 to 3 or Brodsky Types 1 and 2. Mean HU differences among talus positions were not statistically significant. Indirect bone density analysis using HU showed an increased density in CN patients with no significant difference among talar body locations or midfoot Charcot stages and types. These results may assist in optimizing fixation length. Future studies may examine these densities in ankle CN.

Background Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC. Methods PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies’ quality. Results 22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82. Conclusions There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.

The primary aim of this study is to compare the preoperative risk factors and postoperative outcomes between Charcot neuroarthropathy patients with dislocation versus purely fracture pattern breakdown. The secondary aim is to compare the same factors between Charcot neuroarthropathy patients with dislocation versus fracture-dislocation pattern breakdown. A total of 55 patients with forefoot, midfoot, or hindfoot Charcot Neuroarthopathy were assessed at a mean follow up of 2.99 years. Bivariate analysis compared preoperative risk factors and postoperative outcomes, and segmented multivariable regression analysis was performed. Dislocation pattern Charcot had statistically significant higher rates of broken hardware (p = .05), mean age (p = .01), and revisional exostectomy (p = .01) compared to pure fracture pattern Charcot. Dislocation pattern Charcot was 12 times more likely to have revisions exostectomy (odds ratio [OR] 12.0, 95% confidence interval [CI] 1.84-78.37), and was 8 times more likely to have osteomyelitis (OR 7.8, 95% CI 1.4-42.7, p = .02) compared to the fracture-dislocation pattern Charcot. The patients with pure fracture pattern Charcot were 58.8 times more likely to have Charcot breakdown involvement of the talonavicular joint compared to the dislocation pattern cohort (OR 58.83, 95% CI 1.1-3220.3). Involvement of the talonavicular joint, in the fracture pattern Charcot associate with medial column collapse occurring at the onset of Charcot breakdown. The dislocation pattern in Charcot Neuroarthropathy demonstrated a higher propensity for residual collapse as demonstrated by the higher rates of broken hardware, osteomyelitis, and need for revisional exostectomy.

Charcot Marie Tooth disease (CMT) is the most common inherited neuropathy and is also called Hereditary Motor Sensory Neuropathy (HMSN). Whilst both motor and sensory deficits are present, motor deficits tend to predominate over sensory deficits. Charcot neuroarthropathic joints occur in conditions, most commonly diabetes nowadays, where joints are destroyed in association with reduced protective sensation, pain in particular. Three cases of development of Charcot joint disorders in patients with CMT are discussed and the literature is reviewed. Orthopaedic surgeons should be aware that Charcot joints can occur in CMT and surgery can be complicated by Charcot joints.

Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient– a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities. How to cite this article: Lahoti O, Abhishetty N, Shetty S. Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7–14-year Follow-up. Strategies Trauma Limb Reconstr 2021;16(2):96–101.

The primary aim was to determine the rate of complications in patients with peripheral arterial disease and diabetic Charcot neuroarthropathy who underwent osseous reconstruction. Complications included delayed healing, dehiscence, and major lower extremity amputation. A review of patients with Charcot neuroarthropathy requiring reconstruction secondary to ulceration or acute infection was performed. Descriptive analysis compared outcomes between those with and without peripheral arterial disease. Bivariate analysis and multivariate logistic regression were analyzed for delayed healing, dehiscence, and major amputation. In a cohort of 284 patients with diabetic Charcot neuroarthropathy who underwent osseous reconstruction, the rate of peripheral arterial disease was 20.8% (59/284). Bivariate analysis for delayed healing found hypertension (p = .0352), peripheral arterial disease (p = .0051), and smoking history (p = .0276) to be statistically significant factors. Delayed healing was 2.012 times more likely in the presence of peripheral arterial disease [OR 2.012 (95% CI 1.088-3.720)]. Bivariate analysis for major lower extremity amputation found renal disease (0.0003) (renal disease: ESRD and CKD) and peripheral arterial disease (0.0001) to be statistically significant factors. Major amputation was 4.414 times more likely in the presence of peripheral arterial disease [OR 4.414 (95% CI 2.087-9.334)]. Peripheral arterial disease was identified in 20.8% (59/284) of diabetic patients who underwent Charcot osseous reconstruction. Peripheral arterial disease increased the risk of delayed healing by 2.012 fold, and increased the risk of major lower extremity amputation by 4.414 fold. The rates of complications in patients with peripheral arterial disease were significantly higher than those without peripheral arterial disease who underwent osseous reconstruction.

The purpose of this study was to assess the intra- and inter-reader reliability of the 2 Charcot neuroarthropathy classifications (Sanders-Frykberg and Brodsky-Trepman), as well as Eichenholtz staging. We hypothesized that the inter-reader reliability, with respect to these 3 classification systems, would be moderate at best. Digital radiographic images were organized in a digital slide presentation without clinical information. All 5 reviewers underwent a standard training session administered by the principal investigator, reviewing 5 cases of Charcot neuroarthropathy. Images of 55 cases of Charcot neuroarthropathy and 5 normal cases were distributed to each of the 5 physicians electronically, who independently rated all 60 cases according to the 3 classification systems. The 95% confidence interval of the intraclass correlation coefficient estimate for Sanders-Frykberg was 0.9601 to 0.9833 at week 0 and 0.9579 to 0.9814 at week 8, which can be regarded as "excellent" reliability. For Trepman-Brodsky, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.8463 to 0.9327 at week 0 and 0.8129 to 0.9226 at week 8, which can be regarded as "good" to "excellent" reliability. For Eichenholtz, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.6841 to 0.8640 and 0.6931 to 0.8730 at weeks 0 and 8, respectively, which can be regarded as "moderate" to "good" reliability. The classification systems of Charcot neuroarthropathy are an important tool for communication among physicians. Based on the results at our institution, the Sanders-Frykberg classification exhibited the best inter-reader performance. The Trepman-Brodsky classification exhibited good to excellent reliability as well. The intraclass correlation coefficient of the Eichenholtz classification was moderate to good.

The care of the individual with diabetic foot disease (DFD) represents a significant challenge. In addition to the primary foot pathology, individuals with DFD are frequently compromised by multiple co-existent medical complications. Successful management of DFD, therefore requires simultaneous addressal of these issues alongside high-quality foot care. We explore the pharmacological treatments in DFD with an emphasis on the emerging putative technologies centred on addressing the pathobiology of wound healing but also discuss developments in infection control, Charcot neuroarthropathy, cardiovascular and diabetes care. Many of these will have a significant impact on future treatment paradigms and how we amalgamate these novel technologies may help shape the standard of care in DFD hereafter. However, there is a need for better quality of evidence and cost-effectiveness data prior to widespread adoption into routine care is considered.

Introduction: Insoles are recommended for the treatment of patients with neuropathic foot to distribute the foot plantar pressure while preventing recurrent ulceration. Different types of insole are available but the cost is the major limiting factor. Thus, it is justifiable to conduct this study to evaluate the efficacy of cost effective locally-designed bilayer Lunairmed insoles as an adjunctive treatment for patients with Eichenholtz Stage III Charcot neuroarthropathy in our centre. Methods: This was a prospective observational study conducted in tertiary centre, Malaysia from September 2016 to September 2017. A total of ten patients with Stage III Charcot neuroarthropathic foot without ankle instability were included. All patients were evaluated for foot plantar pressure by using Tekscan, short form (SF-36) and American Orthopaedic Foot and Ankle Society(AOFAS) score before and after using insoles. Results: Fifteen out of twenty feet showed reduction in peak plantar pressure (PP) and force-time-integral (FTI) at forefoot and heel after using bilayer Lunairmed insoles. There was a mean reduction of 24.8% of total foot PP. Conclusion: Locally designed bilayer Lunairmed insoles could be used to reduce PP in Eichenholtz Stage III Charcot neuroarthropathic foot without ankle instability. Bangladesh Journal of Medical Science Vol.20(3) 2021 p.646-650

Background Acute Charcot Neuroarthropathy (CN) is a destructive condition that is characterised by acute fractures, dislocations and joint destruction in the weight-bearing foot. The acute phase is often misdiagnosed and can rapidly lead to devastating health outcomes. Early diagnosis and management of CN is imperative to attenuate progression of this condition. Consequently, timely evidence-based assessment, diagnosis and management of acute CN is imperative. Objective To identify the factors that impact the delivery of evidence-based care in assessment, diagnosis and management of people with acute CN. Method Systematic searches were conducted in four databases to identify studies in English that included factors that impact the delivery of evidence-based care in the assessment, diagnosis and management of people with acute CN. Articles and consensus/guideline documents were assessed for inclusion by the researchers and disagreements were resolved through consensus. Additionally backward citation searching was used to source other potentially relevant documents. Information relevant to the research question was extracted and thematic analyses were performed using qualitative synthesis. Results Thirty-two articles and four additional consensus/guideline documents were included for data extraction and analyses. Information related to the research question was of expert opinion using the National Health and Medical Research Council (NHMRC) Levels of Evidence guidelines. Themes explaining practices that deviated from evidence-based care in assessment, diagnosis and management of acute CN centred around patient, health professional and health organisation/environmental. Delay to diagnosis is particularly influenced by the patient’s knowledge of when to seek help, practitioner knowledge in knowing how to recognise and refer for appropriate immediate care, confusion in imaging and offloading and geographical and local health service resources to appropriately manage the condition. Conclusion Individual and health professional awareness and geographical barriers are key challenges to the effective delivery of evidence-based assessment, diagnosis and management of people with acute CN. Acute CN represents a medical emergency warranting the need for expedited assessment, diagnosis and management by appropriately trained health professionals in the appropriate.

Charcot neuroarthropathy secondary to diabetes mellitus is a serious complication, requiring specialist management. As a relatively rare pathology bearing similarity to other, more common diseases, it may be misdiagnosed at initial presentation, potentially leading to delays in appropriate management. We conducted a 2-part online survey of primary care physicians within an academic medical institution to assess knowledge of presentation, complications, diagnosis, and treatment of Charcot neuropathy. The first section was designed to assess physician knowledge of Charcot foot, while the second section was completed only by physicians who were familiar with the condition and was designed to gauge their level of knowledge. Most clinicians were familiar with Charcot, encountering it at least annually. They identified common signs of Charcot (eg, swelling, pain) and complications due to its mismanagement (eg, ulcer, amputation). However, there was some disagreement on how to diagnose the pathology, with some relying on film, others referring to specialists, and some saying they were unsure. There was uncertainty on when to choose surgical options; fewer than half referred to specialists for help with this decision, and a quarter were unsure how to make the decision. While, in general, clinicians were aware of Charcot and its characteristics, there was confusion regarding how to diagnose or appropriate nonsurgical treatment.

Background Charcot neuroarthropathy of the ankle is an extremely challenging clinical dilemma, and its surgical management can be highly complicated. The goal of Charcot ankle treatment is to to restore a plantigrade and stable foot, and thus to avoid ulceration with subsequent infection. This report aims to introduce a method of correcting ankle deformity using a novel 3D printing technique. Patient and methods One patient with Charcot ankle deformity was operated in this study. The ankle deformity of this patient was quantified in three dimensions through computed tomography. On the basis of the computed tomography scans, a new titanium implant was designed and manufactured using 3D printing. The implant was applied in the surgery of tibio-talo-calcaneal arthrodesis to restore local anatomy of the affected ankle of the patient with Charcot neuroarthropathy. Results Evaluation of the post-operative radiography indicated union in the affected ankle. After surgery, the planar foot in this patient was restored. The patient was satisfied with the post-operative course, and joint fusion was successful as indicated by 2-year post-operative evaluation. The results of post-operative follow-up showed that the lower limb length of the patient with Charcot neuroarthropathy was salvaged, and the patient retained the plantigrade foot. Conclusion Three-dimensional printing technique combined with tibio-talo-calcaneal arthrodesis may help to correct ankle deformity in patients with Charcot neuroarthropathy.

Objective To describe the case of a woman with long-standing poorly controlled type 1 diabetes mellitus who developed bilateral Charcot foot while pregnant. To the best of our knowledge, this is the first reported case of this condition in pregnancy. Methods We performed a retrospective review of physical paper medical records; electronically held laboratory results, including glycated hemoglobin; and imaging reports, including plain radiographs and magnetic resonance imaging. Results The Charcot feet were treated by standard offloading in total-contact casts or below-knee removable walking boots. As 1 side resolved, the patient was stepped down into normal footwear on one side and a below-knee walking boot on the other. A review of the literature suggests that the increase in ligamentous laxity associated with a rise in circulating hormones, such as relaxin, increases the risk of developing Charcot neuroarthropathy. Conclusion Bilateral concurrent Charcot neuroarthropathic foot is uncommon, and to our knowledge, this is the first reported case in pregnancy. We present a possible explanation for why there is an increased risk for the development of Charcot neuroarthropathy in pregnancy.

Surgical complications are more common in patients with complicated diabetes (presence of inner organ failure, neuropathy). Of all patients undergoing ankle fracture fixation, approximately 13% are diabetic and 2% have complicated diabetes mellitus. Non-operative management of ankle fractures in patients with complicated diabetes results in an even higher rate of complications. Insufficient stability of ankle fractures (treated operatively, or non-operatively) can trigger Charcot neuroarthropathy, and result in bone loss, deformity, ulceration, and the need for amputation. Rigid fixation is recommended. Hindfoot arthrodesis (as primary procedure or after failed ankle fracture management) can salvage the limb in approximately 80% of patients. Early protected weight bearing can be allowed, provided rigid fixation without deformity has been achieved. Cite this article: EFORT Open Rev 2020;5:457-463. DOI: 10.1302/2058-5241.5.200025

The local intrinsic abductor digiti minimi muscle flap is ideal for lateral, plantar lateral traumatic or diabetic foot wounds following adequate surgical debridement to eradicate any soft tissue and/or osseous infection. Although the indications and surgical technique have been well-described in the literature, the authors present a unique modification of tunnelling the harvested muscle flap directly from the donor site to the plantar recipient foot wound by maintaining the intact overlying skin island at the surface of the fifth metatarsal base. This modification allows preservation of the patient's skin integrity in this area, thereby minimising potential morbidity at the major pedicle site. After the harvested muscle is tunnelled through the intact skin island, an adjacent local random flap mobilisation, autogenous or allogeneic skin graft can then be used for coverage over the muscle inset if primary wound closure is not feasible. Simultaneous soft tissue or osseous surgical procedures and/or surgical offloading with external fixation at the time of index surgery may be necessary to achieve optimal outcomes. The authors present a modified surgical technique for the abductor digiti minimi muscle flap that can be performed in the surgical reconstruction of a soft tissue wound in patients with diabetic Charcot neuroarthropathy.

Highlights • Forefoot arthrodesis by using screws and Kirschner wire fixation could achieve a satisfactory bony union. • AOFAS score of the right foot gradually improved from 45 to 86 in six months period after arthrodesis. • There was an improvement of right foot’s Meary’s angle from 22° to 8° six months after surgery. • The proper diagnosis and treatment of CN could prevent ulceration and lower extremity amputation. • Continuous follow-up and patient compliance are essential to minimize the complications of arthrodesis., Introduction One of the surgical intervention options for Charcot neuroarthropathy (CN) is arthrodesis. The arthrodesis procedure for the foot and ankle joint have been widely used in previous studies. This study aimed to evaluate the functional and radiological outcomes after arthrodesis procedure for the CN patient with Brodsky type 1/Eichenholtz stage III. Presentation of case A 49-years-old diabetic woman presented with alteration of her right foot’s shape and a cracking sensation while walking in the last six months. Rocker-bottom deformity and a decreased sensation on the right foot were found, and the initial American Orthopaedic Foot & Ankle Society (AOFAS) score was 45. Subsequently, forefoot arthrodesis of the right foot was performed. Discussion Several studies state that arthrodesis procedure is often used for CN management in order to achieve a plantigrade and stable foot. This study presents an improvement of the foot arch, AOFAS score, and union of the talus six months after surgery. Conclusion The arthrodesis procedure by using screws and Kirschner wire (K-wire) fixation is an effective method in CN management if the patient is compliant. This study showed a good result, anatomically restored the foot arch, and excellent radiological union, but different tools to analyze foot functional status and longer follow up period are needed for a better analysis.

With worsening diet and increasing prevalence of diabetes, patient encounters with Charcot neuropathic arthropathy (CNA) are expected to increase. Without intervention, the pathology progresses with further subluxation/dislocation and fracture, placing soft tissues at risk of preulceration or formal ulceration, infection, and potentially major amputation. The need to avoid amputation is of paramount importance. Although a formal single eradicating tool for CNA is lacking, there is capacity to intervene in ways that may curtail the pace of destruction. This article reviews understanding of the disease process and provides guidance to surgical reconstruction of the deformity.

This case study describes a middle-aged man presenting to the emergency department with unilateral distal extremity swelling. This is a frequently observed symptom associated with many common conditions, which makes identifying the rare and destructive disease of neuropathic osteoarthropathy extremely challenging for the nurse practitioner.

The author presents the case of a 63-year-old man who was diagnosed with type 2 diabetes 15years ago (2004) and with ulcers in both feet with 12years of clinical course (which have required hospital admissions). The patient was diagnosed with moderate Charcot neuroarthropathy in 2009 using foot X-rays, receiving no specific treatment for this condition. The ulcers had been treated with multiple healing products, with poor results, for ten years.

Lateral dislocation of the subtalar joint is a relatively uncommon pathology. It has previously been described in the literature secondary to acute trauma. This form of dislocation can also be acquired and seen in severe long-standing cases of flatfoot and Charcot neuroarthropathy. This study aims to describe this "sidecar" deformity, etiologies of the deformity, and the surgical options for correction. This study was performed by reviewing medical records of a single foot and ankle surgeon for patients who met inclusion criteria and underwent surgical correction. The study period was from October 2010 to July 2017. Statistical analysis was performed using chart-review information to examine variables affecting selected outcome measures. The outcome measures evaluated were minor and major complications, as well as functional limb status. A total of 16 patients were included in the study. Etiology included 10 severe flatfoot deformities and 6 Charcot deformities. Seven patients underwent staged reconstruction, and 9 underwent a single-stage reconstruction. Seven patients (44%) had complications; all were major and required unplanned reoperation. In all 16 patients (100%), limb salvage and a functional limb resulted. We conclude that patients with a limb-threatening sidecar deformity can be successfully treated with reconstruction. This is challenging and associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring a staged reconstruction with multiple surgeries as well as the possibility of amputation.

In a world where popular culture and concepts can become the norm without all the rigors of normal scrutiny, our attention is focused on identifying Charcot neuroarthropathy (CN) at a stage before radiological bone destruction occurs. The rationale is that early recognition can prevent a destructive chain of events and thus potentially reduce the burden to patients and health care providers. In this article, we describe the evolution of stage 0 CN, and the use of modern imaging in characterizing the abnormalities recognized by these modalities and how they aid our understanding and supplement our knowledge. We review the potential of these imaging modalities, assessing how far we have come in characterizing stage 0 and if we have robust criteria for the identification of stage 0 in the natural history of CN.

La Neuroartropatia de Charcot (NA), a pesar de ser documentada desde hace cerca 120 anos, es apenas en las dos ultimas decadas que su comprension viene en incremento, dado el entendimiento en la causalidad y la relacion proporcional con el incremento de la prevalencia de diabetes mellitus Ello genera retos importantes en su tratamiento enfocado actualmente en la preservacion a priori de la extremidad dada la relacion de la amputacion con incremento del gasto cardiaco, la perdida de calidad de vida, depresion, infeccion a niveles mas elevados de la extremidad, incremento de costos a largo plazo para el sistema sanitario, perdida de calidad de vida y la asociacion elevada con mortalidad a 5 anos incluso mayores a neoplasias tan prevalentes como de mama y colon Aunque el diagnostico es predominantemente clinico, el apoyo en quimica sanguinea, en imagenes convencionales y/o de resonancia magnetica, PET/TC ayudan a diferenciar el proceso per se y la posible relacion con infeccion subyacente El advenimiento de cirugias reconstructivas y la compresion tecnica de ellas vienen dando pistas para conseguir el objetivo de preservar la extremidad y rehabilitar a los pacientes diabetico Se hace una revision de la literatura mas reciente Nivel de evidencia: IV Charcot Neuroarthropathy (NA), despite being documented for close to 120 years, it is only in the last two decades that its comprehension has increased, given the understanding of causality and the proportional relationship with the increase in the prevalence of diabetes mellitus This generates important challenges in its treatment, currently focused on the a priori preservation of the limb, given the relationship of amputation with increased cardiac output, loss of quality of life, depression, infection at higher levels of the limb, increased long-term costs to the health system, loss of quality of life, and high association with 5-year mortality, which is even higher than the prevalence of cancers, such as breast and colon Although the diagnosis is predominantly clinical, the support in blood chemistry, in conventional imaging and / or magnetic resonance imaging, PET / CT, help to differentiate the process per se, as well as the possible relationship with underlying infection The advent of reconstructive surgeries and their technical compression are providing clues to achieve the aim of preserving the limb, and rehabilitate diabetic patients A review of the topic is presented herein Evidence Level: IV

Background: The diabetic Charcot foot syndrome is a serious and potentially limbthreatening lower-extremity complication of diabetes. Introduction: The present review provides a concise account of the advances made over the last twentyfive years in understanding the pathogenesis and management of Charcot neuroarthropathy (CN). Methods: In this study, the widely known pathogenetic mechanisms underpinning CN are brought into focus, particularly the role of RANKL/RANK/OPG system and advanced glycation end production in the pathogenesis of CN. Furthermore, other potential triggering factors, namely nitric oxide, endothelial dysfunction, macro calcifications and body weight that influence CN have also been discussed. Results: The wide range of diagnostic tools available to clinicians for accurate staging of this pathology has been examined, particularly radiological and nuclear medicine imaging. Additionally, the difficult differential diagnosis between osteomyelitis and CN is also elucidated. Conclusions: The review concludes with the comprehensive summary of the major promising therapeutic strategies, including conservative treatment involving orthopedic devices, pharmacological approach, and the most common surgical techniques currently employed in the diagnosis and treatment of this acute disease.

Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.

Background: Prior research shows increased foot temperatures are predictive of diabetes-related foot complications. Our aim was to describe normative skin foot temperatures for individuals with diabetic peripheral neuropathy to better inform new technologies. We also explored for potential risk factors which correlate with changes in foot temperatures. Methods: We conducted a retrospective chart review of adult patients >18 years of age with diabetes mellitus and clinically diagnosed diabetic peripheral neuropathy with pedal digital thermometry performed between 2009 and 2018. A total of 58 patients met these criteria. Univariate modeling was based on covariates that may affect foot temperature including age, peripheral arterial disease, toe pressure, seasonality of measurement, smoking pack-years, caffeine use, insulin use, and calcium channel blocker use. Results: In patients with diabetic peripheral neuropathy, mean toe temperatures of 27.67°C (6.300°C), forefoot of 28.58°C (5.36°C), midfoot of 29.21°C (3.81°C), and rearfoot of 29.88°C(3.83°C) were demonstrated. A modest negative correlation between seasonality and toe and metatarsal temperatures ( r = −0.38, P < .05; r = −0.43 P < .01, respectively) was demonstrated. Midfoot temperatures were modestly and positively correlated to the presence of small fiber symptoms ( r = 0.33, P = .03). Positive modest correlation with rearfoot temperatures and amount of pack-year history ( r = 0.30, P = .03) was seen. Conclusion: Normative foot temperatures in neuropathic patients were found to be inversely associated with seasonality at the toe and metatarsal level. Smoking and pack-year history demonstrate modest correlation previously unseen in temperature analyses and warrant further exploration. Normative temperatures in neuropathic patients can better inform new technologies for the prevention of diabetic foot ulcer and Charcot neuroarthropathy.

Recommendation: Differentiation between acute Charcot neuroarthropathy (CN) and acute infection/osteomyelitis is complex and requires multiple (>1) diagnostic criteria. These criteria include an emphasis on the presence of neuropathy, history, and physical examination. The absence of skin wounds and resolution of swelling/erythema with elevation makes the likelihood of infection very low. In unclear cases, laboratory testing, histologic examination and culturing of bone specimens, scintigraphy, and imaging, especially magnetic resonance imaging (MRI), may be of benefit. Level of Evidence: Moderate. Delegate Vote: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus)

Charcot neuroarthropathy is a systemic disease with pathological changes in the musculoskeletal system, which leads to fractures, dislocations, and deformities involving multiple bones and joints, particularly those of the feet. While the common underlying cause of Charcot neuroarthropathy is diabetes mellitus, it is also associated with congenital insensitivity to pain (CIP). CIP is a rare disorder caused by loss-of-function mutations in SCN9A encoding Nav1.7. In this study, we report a patient with CIP from a consanguineous family susceptible to Charcot neuroarthropathy with a novel SCN9A mutation. This report involves the case of a middle-aged man who suffered from CIP, had repeated painless fractures, and developed bone and joint destruction. The physical and radiological examinations revealed that multiple joints were swollen and deformed, and soft-tissue trauma was evident. We identified a novel homozygous SCN9A mutation (p.Cys1339Arg) by whole-exome sequencing (WES), which was verified using Sanger sequencing. In addition, the wild-type (WT) and mutated p. Cys1339Arg were assessed in HEK293 cells expressing Nav1.7, and the results showed that p. Cys1339Arg almost abolished the Nav1.7 sodium current. In conclusion, Charcot neuroarthropathy associated with CIP demonstrated a wider spectrum of Charcot neuroarthropathy than was previously recognized or documented. In addition, this finding is conducive to understanding the critical amino acids for maintaining the function of Nav1.7, thus contributing to the development of Nav1.7-targeted analgesics.

Introduction Ankle arthrodesis is one of the managements for a significantly unstable Charcot ankle. Some of the methods of internal fixation for ankle arthrodesis include the use of intramedullary nails, screws, and plates. Ankle arthrodesis using intramedullary nails has become more popular. However, studies evaluating the use of plate fixation, particularly double posterior lateral plating, are limited. We report the clinical and radiological outcomes of double posterior lateral plating ankle arthrodesis in three diabetic Charcot ankle patients. Presentation of case Three patients, aged 73, 67, and 65 years old, complained of ankle pain and with a history of type 2 diabetes mellitus. The physical examination revealed swelling and erythema without a sign of active infection. The radiological examination showed ankle deformity, and the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scores were 5, 10, and 0, respectively. All patients were diagnosed with a diabetic Charcot ankle and underwent ankle arthrodesis using double posterior lateral plating. Four months and six months follow up revealed talus union, improved ankle deformity, and improved AOFAS Ankle-Hindfoot scores to 70, 76, and 73, respectively. Discussion Various methods of ankle arthrodesis are retrograde intramedullary nails, screws, and plates. In this report, we opt for plate fixation because it allows for stable internal fixation, adequate compression, high angular stability, and a lower irreversible deformation in osteoporotic bone. Conclusion Double posterior lateral plating ankle arthrodesis provided satisfactory clinical and radiological outcomes. This method can be an alternative for patients with Charcot ankle requiring ankle arthrodesis., Highlights • Double posterior lateral plating ankle arthrodesis is satisfactory. • This method can be an alternative for patients with Charcot ankle. • Plate fixation allows stable internal fixation and adequate compression.

AimsInflammatory osteolysis is the sine-qua-non of active Charcot neuroarthropathy (CN). This study is aimed to provide mechanistic insights into pathogenesis of CN by exploring the role of methylprednisolone or zoledronate for remission of active CN. MethodsThirty-six patients with active CN (temperature difference >2°C from normal foot) were evaluated for time to remission. Patients were off-loaded with total contact cast and randomised to receive either methylprednisolone (1gm), zoledronate (5mg) or placebo (100ml normal saline) once monthly infusion for three consecutive months. Change in inflammatory cytokines (TNF-α, IL-1β), bone turnover markers (P1NPand CTX) and bone mineral content (BMC) was assessed. ResultsTime to remission of active CN was 19.4 ± 2.8 weeks with methylprednisolone compared to14.6 ± 4.4 and 13.5 ± 2.9 weeks (p0.05), while IL-1β reduced by 30% (p=0.02) with methylprednisolone, 21% with zoledronate and 16% with placebo (p>0.05). P1NP decreased by 5%, 24% and 19% with methylprednisolone, zoledronate and placebo, respectively. CTX decreased by 35% and 11% with zoledronate and placebo respectively but increased with methylprednisolone (18%) (p>0.05). Conclusion Effective suppression of either inflammation with methylprednisolone or osteoclastogenesis with zoledronate do not translate into earlier remission of active CN. The role of non-cytokine and non-inflammatory pathways for the activation of osteoclastogenesis in CN is purported.

BACKGROUND: Charcot neuroarthropathy (CN) of the foot and ankle, which is complicated with infection, is debilitating disease and presents challenges until now. External fixation with half-pins is useful as provisional treatment. AIM: The purpose of this retrospective case series is to summarize the patient characteristic, type of surgical intervention, outcome, and complication of infected CN treated in our hospital. MATERIALS AND METHODS: This case series studied retrospectively patients with CN of the foot and ankle due to diabetes mellitus type II, complicated by infection, who required surgical treatment in a single institution, from 2018 to 2019. Diagnosis was based on chronic deformity (fracture or dislocation) as proven on X-ray and recently developed infection as shown through clinical, laboratory, and radiological evaluation. RESULTS: We studied seven patients with CN classified as Eichenholtz Stage 3 (100%) and Brodsky type 3A alone (n = 3) (Figure 1), and type 3A with other types (n = 4). The mean age is 44.6 years old (range, 35–60) and mean body mass index was 24.08 kg/m2 (range, 21.45–25.39). Signs of infection include leukocytosis (n = 6), soft-tissue swelling (n = 4), ulcer (n = 4), and osteomyelitis (n = 1) at presentation. Operative treatment consisted of debridement, followed by external fixation only (n = 4), combined external fixation and pinning (n = 2), and intramedullary pinning only (n = 1). The mean hospital length of stay was 4.5 days (range, 3–7). We performed short-term follow-up after a mean of 4.12 months (range, 1.3–5.3) and long-term after a mean of 15.02 months (range, 11.27–16.8), the limb salvage rate was 100% in both. One patient had revision of external fixation. As for functional outcome, at the time of long-term follow-up mean visual analogue scale was 0.75 (range, 0–2) and American Orthopaedic Foot and Ankle Score was 66.25 (range, 57–77). CONCLUSION: In this study, mostly external fixation with half-pins and methyl metacrylate was used based on the bone condition and patient’s compliance. Despite of its limitation, this method is effective when it is combined with strict blood glucose level and infection control.

Charcot's neuroarthropathy is a destructive complication of the joints, which is often found in people with diabetes with peripheral neuropathy. Despite the fact that its description was published almost 130 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be described. Thanks to the use of bone remodelling, new therapeutic classes have emerged, we hope that this review will shed light on the pathology from its discovery through to the current state of knowledge on its classification, diagnosis and treatment methods.

Background Charcot neuroarthropathy (CN) of the midfoot was traditionally treated non-operatively with off-loading in a total contact cast (TCC). After introduction of the super construct concept, promising results were reported, however there is a need for further studies on this concept. Analysis of non-operative versus operative treatment is presented as well as our results from a consecutive series of 20 patients operated with the superconstruct concept. Methods Twenty patients were operated from July 2017 until June 2020. Mean age was 58 years (50–80), mean weight was 116 kg (68–156), giving a BMI of 31 (26–45). Preoperative patients off-loaded in a TCC until decreased swelling and skin temperature measurement or ulcer had healed, mean 16 weeks immobilization. Surgery was without tourniquet, using a standard medial and lateral incision. Mean follow up is 24 (5–40) months. Results Mean operation time was 227 (150–315) minutes. Medial column fusion was mandatory, in five cases as an isolated procedure, in 12 cases in combination with lateral column fusion and in three cases with a talocalcaneal fusion. Preoperative lateral Meary angle decreased from 23.5 to 9.6°, antero-posterior Meary angle decreased from 16.0 to 4.7°. Eight patients had postoperative incisional wound problems. Four patients had partial implant removal. All healed with a good clinical result. Two patients had an acute Charcot attack in the ankle joint during postoperative mobilization. One had a severe collapse of the talus resulting in a below knee amputation, giving an amputation rate of 5%. Radiographic examination at follow up, showed bone union of all patients. Nineteen patients are ambulated in orthopedic shoes at latest follow up, giving a 95% satisfactory result. Conclusion Superconstruct reconstruction of CN midfoot collapse is a safe procedure. There are incisional wound problems, recognition and fast treatment of these complications is important to achieve good results. There is a risk for overloading the ankle, initiating a new acute Charcot attack. Attention must be on this problem. The surgical technique is demanding and should be performed by experienced foot and ankle surgeons in a multidisciplinary team set up.

We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who underwent 3 phase bone scintigraphy with &ldquo, High Resolution&rdquo, SPECT/CT. The imaging demonstrated that Stage 0 Charcot foot has a distinct bone pathology, which can be classified into three groups: (1) fractures on Computed Tomography (CT) with accompanying focal uptake of tracer on SPECT, (2) bony abnormalities apart from fracture on CT with focal uptake of tracer on SPECT, and (3) normal CT but focal bony uptake of tracer on SPECT. The CT component of SPECT/CT detected bony fractures in 59% of patients. Early treatment with below knee cast and follow-up for 24 months showed only 4 patients who developed Stage 1 Eichenholtz Charcot foot. Our findings support the use of 3 phase bone scintigraphy with SPECT/CT in the characterization and early diagnosis of CN. Stage 0 Charcot foot has a distinct bone pathology which requires urgent treatment to prevent progression to Stage 1 Eichenholtz Charcot foot. If SPECT/CT is unavailable, CT alone will detect bone fracture in 59% patients.

Charcot Neuroarthropathy (CN) of the ankle/hindfoot is a devastating condition that results in a loss of alignment, bony malleolar protrusions and frequently leads to ulceration, infection, and amputation. Major limb amputations in this patient population has a 5-year mortality rate approximating 39%-68%. The treatment goal for CN of the ankle/hindfoot is to provide stability with a plantigrade foot that is infection free, shoeable and allows independent weight bearing. The use of a circular frame external fixator is often required when treating patients with CN of the ankle/hindfoot because they often present late with deformity, soft tissue compromise and infection which are contraindications to primary internal fixation. These patients require urgent surgical attention to salvage the limb or risk amputation. In this narrative review article we will discuss the indications, management options, surgical technique, evidence and describe our experience in the use of circular frame external fixation in patients with ankle/hindfoot Charcot Neuroarthropathy.

Category: Diabetes; Trauma Introduction/Purpose: Management of complex foot and ankle deformities secondary to charcot neuroathropathy represents a significant challenge. This is a consequence of medical co-morbidities, vascular disease, peripheral neuropathy, and immune compromise with the surgical challenges of progressive bony defomity and bone resorption. To combat these challenges ‘superconstructs’ have been developed to improve fixation. These aim for fusion beyond the zone of injury with adequate deformity correction all whilst maintaining viability of the soft tissue envelope and mechanical function. This can be achieved with internal fixation using indication specific plates and beaming techniques, external fixation with a circular frame or a combination of the two. The aim of this study was to evaluate of a tertiary referral hospital in the operative management of charcot neuroarthopathy. Methods: This is a retrospective two surgeon case series with all cases jointly operated upon. Cases were identified from a locally held diabetic patient registry as those undergoing charcot foot and ankle reconstruction from 2017 to 2019. No exclusion criteria were outlined. Patient demographics and co-morbidities were collected, pre-op radiological markers (meary’s angle) measured and repeated at 6 weeks and one year. Pre-op radiographs were classifed accroding to brodsky classification. Patient outcomes were recorded of amputation, mortality, ulcer recurrence, reported pain, stable heel, ability to ambulate, need for revision surgery, need for prolonged antibiotics, fusion and surgical complications. PROMS were requested and still awaited at time of submission. Results: Eleven Cases were identified from ten patients, all were included for analysis. Three patients had internal fixation, two had external fixation and six had combined internal with external fixation. Eight patients were Brodsky 1, two patients were Brodsky 3 and one patient was Brodsky 2. Limb salvage was 100% with nil amputations, mortality 0%, ulcer recurrence 0%, 100% improved pain score, and 100% with a stable heel. Meary’s angle improved by a mean of 14o from -16o to -2o at 1 year. Fusion rate determined clinically and radiologically with X-ray was 100% with mean of 129 days and range of (360 - 52). Mean follow-up 454 days and range (547-417). Complications of 2 tibial fractures and 1 deep infection with delayed wound healing. Conclusion: The outcomes of using all three methods is positive with 100% limb salvage, 100% fusion rate, 100% ulcer free and maintenace of Meary’s angle at 1 year post op. We believe that combined internal and external fixation, not widely reported in the literature, is a good option in these cases. The complications reported here were in the first three patients undergoing said technique and represent a learning curve.

Category: Diabetes; Ankle; Diabetes; Hindfoot Introduction/Purpose: Charcot neuroarthropathy of the hindfoot (Brodsky type 2 and 3) can involve significant talar collapse / bone loss leading to hindfoot instability, the goal of treatment to create a stable plantigrade shoeable ulcer and infection free foot. This can often be achieved with tibiotalocalcaneal (TTC) arthrodesis but a plantigrade foot can be challenging in setting of significant talar bone loss. Structural allograft has been used in association with TTC fusions in a number of settings but not explored in the treatment of charcot hindfoot. The goal of this study was to examine the outcomes of structural allografting combined with TTC arthrodesis for the treatment of charcot hindfoot. Methods: Retrospective review of all patients treated at our institution with a Brodsky type 2 or 3 was performed over a five year period from 2014 - 2019. We identified twenty-two patients, 12 males and 10 females with a mean age of 57 years. All underwent surgery by the senior author, a fellowship trained foot and ankle orthopedic surgeon. Patients with infection were treated with antibiotics and a Taylor spatial frame prior to definitive stabilization. Non-infected patients were either placed in a total contact cast (TCC) if they were in active charcot or underwent primary charcot reconstruction. If after initial treatment patients had a plantigrade foot, they were placed in stiff soled rocker bottom shoe with custom accommodative insoles. Patients who did not have a plantigrade foot underwent TTC arthrodesis to achieve this. Femoral head allograft was used if excessive talar bone loss or collapse of the hindfoot was noted. Results: At final follow up 13 patients (59%) of the cohort achieved grade 1, an infection and ulcer free plantigrade foot that was able to fit in a shoe. 7 (32%) of patients achieved grade 2, a plantigrade foot in brace, and 2 (9%) achieved level 3 a plantigrade foot. No patients in this cohort underwent amputation. Average duration of treatment until final status was 18 months (minimum 2, maximum 37), number of interventions 3.9 (minimum 1, maximum 10). Of the twelve patients who required allograft, they averaged 4.25 interventions and average time of 17.6 months until final status. Of those who did not require allograft, they averaged 3.4 interventions with follow up of 11.9 months. Conclusion: Our data suggests that patients with Brodsky type 2 and 3 charcot arthropathy of the ankle and hindfoot even with infection can be successfully treated with staged treatment. This includes external fixation and infection management, followed by tibiotalocalcaneal intramedullary nail fixation with or without femoral head allograft to allow for a plantigrade foot and weight bearing in a stiff soled rocker bottom shoe. Further study is needed to determine long term outcomes and relapse rates.

Charcot neuroarthropathy of the foot and ankle is associated with periarticular deformities and progressive radiographic changes. There have been studies analyzing the radiographic angulations and deformity progression in Charcot neuroarthropathy deformity. The aim of this paper is to provide systematic review of studies that evaluate foot and ankle radiographic parameters in patients with Charcot neuroarthropathy. A multidatabase search including, medline, EMBASE, Google Scholar, Cochrane Library, Clinicaltrials.gov and reference lists of included studies, was performed from 1980 to 2020. A total of 7 articles were included that analyzed radiographic angulations in Charcot neuroarthropathy deformity. The articles could be categorized into nonoperative angulation measurements, and pre- versus postoperative angulation measurements. The presence of ulcerations and the severity of the Charcot neuroarthropathy deformity were found to result from predominantly sagittal plane deformity. The deformity initiates with medial column collapse and progresses to continual lateral column collapse. Surgical intervention resulting in immediate postoperative improvement in angular measurements, however, without beaming of both the medial and lateral column, there was recurrence of the lateral column deformity. This systematic review of articles analyzing angular deformities in Charcot neuroarthropathy patients, demonstrates the progressive sagittal plane breakdown patterns of Charcot as well as the benefits of surgical intervention.

With a complex and often misunderstood etiology, acute Charcot neuroarthropathy (ACN) is a devastating complication of peripheral neuropathy. In patients with diabetes, timely diagnosis of ACN in the foot and ankle is essential to prevent loss of both limb and life.Herein, the authors evaluate the growing body of evidence in identifying targeted pathways for future therapeutic interventions. A literature search was conducted through the PubMed research database. Searched terms included 'Charcot,' 'foot and ankle,' 'neuroarthropathy,' 'pathophysiology,' 'arthropathy,' 'diabetic foot,' and 'Charcot foot.'The interplay between the acute inflammatory response, cytokine signaling, and bone metabolism equilibrium can now be better understood with the aid of several novel immunobiologic mechanisms. The more recently elucidated roles of advanced glycation end-products, neuropeptides, monocyte differentiation, and genomics combine with classical Charcot pathophysiology to aid researchers and clinicians alike in combatting this often puzzling consequence of peripheral neuropathy.

Summary We report the onset of acute Charcot neuroarthropathy during pregnancy in two patients with type 1 diabetes using retrospective review of case notes. We describe for the first time the onset of acute Charcot neuroarthropathy during pregnancy in two patients with type 1 diabetes. Pregnancy may promote the onset and worsening of a number of diabetic complications. A link between pregnancy and the onset of acute Charcot neuroarthropathy is demonstrated for the first time in this report. Learning points: Patients with already diagnosed sensitive neuropathy can develop an active phase of Charcot neuroarthropathy during pregnancy. The rapid correction of hyperglycaemia may induce an active phase of Charcot neuroarthropathy during pregnancy.

Background Charcot neuroarthropathy is a complication of peripheral neuropathy associated with diabetes which most frequently affects the lower limb. It can cause fractures and dislocations within the foot, which may progress to deformity and ulceration. Recommended treatment is immobilisation and offloading, with a below knee non-removable cast or boot. Duration of treatment varies from six months to more than 1 year. Small observational studies suggest that repeated assessment with magnetic resonance imaging improves decision-making about when to stop treatment, but this has not been tested in clinical trials. This study aims to explore the feasibility of using serial magnetic resonance imaging without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot. A nested qualitative study aims to explore participants’ lived experience of Charcot neuroarthropathy and of taking part in the feasibility study. Methods We will undertake a two-arm, open study and randomise 60 people with a suspected or confirmed diagnosis of Charcot neuroarthropathy from five NHS, secondary care multidisciplinary Diabetic Foot Clinics across England. Participants will be randomised 1:1 to receive magnetic resonance imaging at baseline and remission up to 12 months, with repeated foot temperature measurements and X-rays (standard care plus), or standard care plus with additional three-monthly magnetic resonance imaging until remission up to 12 months (intervention). Time to confirmed remission of Charcot neuroarthropathy with off-loading treatment (days) and its variance will be used to inform sample size in a full-scale trial. We will look for opportunities to improve the protocols for monitoring techniques and the clinical, patient-centred and health economic measures used in a future study. For the nested qualitative study, we will invite a purposive sample of 10–14 people able to offer maximally varying experiences from the feasibility study to take part in semi-structured interviews to be analysed using thematic analysis. Discussion The study will inform the decision whether to proceed to a full-scale trial. It will also allow deeper understanding of the lived experience of Charcot neuroarthropathy, and factors that contribute to engagement in management and contribute to the development of more effective patient-centred strategies. Trial registration ISRCTN, ISRCTN74101606. Registered on 6 November 2017.

Objective: A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes. Method: A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997–2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded. Results: A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction. Conclusion: Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.

Vascularized osteocutaneous free flaps have seen increasing use in foot and ankle surgery for the repair of bony defects secondary to chronic nonunion, osteomyelitis, and fractures. One example is the Medial Femoral Condyle (MFC) Flap. The utility of the MFC flap for the repair of a bony defect in a diabetic patient, however, has yet to be explored. We report the long-term results of a case describing the use of an MFC flap to reconstruct an osseous defect resulting from first metatarsophalangeal joint resection in a diabetic patient.

We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.

Highlights • Retrograde IM Nailing is a promising therapy for Charcot osteoneuroarthopathy. • Assessment using VAS, AOFAS Scale, and SF-36 showed good result. • No complication were recorded with this procedure using Expert Tibia Nail. • Overall patients satisfaction for this procedure was 9/10., Introduction Charcot osteoneuroarthopathy (CN) is a progressive degenerative arthropathy determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines. The aim of treatment is to maintain the foot on plantigrade position, recover foot deformity, osseous stability, and prevent ulceration. Intramedullary fixation in calcaneotalotibial arthrodesis has been described in promotion of rigid internal fixation with minimal soft tissue violation producing deformity correction, minimal periosteal aggression, vascular damaged and good functional outcome, with less postoperative fusion time and able to achieve fusion of the ankle and the subtalar joint after failed fusion. Presentation of case Two patients with charcot foot underwent tibiocalcaneal arthrodesis with retrograde intramedullary technique by Expert Tibial Nail (ETN). The patients are both male 59 years with right ankle deformity 9 months prior to admission and history of trauma and 40 years old with history of Type 2 Diabetes Mellitus. Visual analog scale (VAS), AOFAS and SF score were assessed pre and post operative. Discussion A good stability, plantigrade ankle and painless foot on both patients were achieved with a mean score 9 for satisfaction. Pre and 3 months post operative VAS were 4 and 1, AOFAS Scale were 58 and 83, mean of SF-36 were 28.4 and 48.6 for physical condition, 37.3 and 67.2. for mental condition consecutively. No severe postoperative complication were recorded Conclusion Tibiotalocalcaneal arthrodesis with retrograde intramedullary technique using ETN system was proven to have a good option for ankle joint salvage with improvement of clinical and functional score. Hence, its application in the charcot joint is promising.

Diabetes mellitus is the most common cause of Charcot neuropathy affecting foot and ankle. Acute Charcot foot (CF) presents with a red and swollen foot in contrast to the painless deformed one of chronic CF. Enhanced osteoclastogenesis plays a central role in the pathogenesis of acute CF. Many studies have shown elevated levels of bone turnover markers in patients with acute CF confirming it. These findings have led clinicians to use anti-resorptive agents [bisphosphonates (BP), calcitonin, and denosumab] along with immobilization and offloading in acute CF patients. The maximum evidence among all anti-resorptive agents is available for BPs, although its quality is low. Pamidronate has been shown to reduce the markers of activity of CF like raised skin temperature, pain, edema, and bone turnover markers in the majority of studies. Intravenous BPs are known to cause acute phase reactions leading to flu-like illness following their first infusion, which can be ameliorated by oral acetaminophen. Alendronate is the only oral BP used in these patients. It needs to be taken on an empty stomach with a full glass of water to avoid esophagitis. The side-effects and contraindications to BPs should be kept in mind while treating acute CF patients with them.

Aims/Introduction The aim of the present study was to identify the extent of small fiber neuropathy in diabetic patients with Charcot neuroarthropathy (CN). Materials and Methods A total of 20 patients with CN were compared with 20 age‐ and diabetes duration‐matched patients with type 2 diabetes and 20 age‐matched control participants. All patients underwent corneal confocal microscopy with quantification of corneal nerve morphology and assessment for vibration perception threshold, and a subset of patients with CN underwent assessment of sudomotor function and neuropathic pain. Results In patients with CN compared with type 2 diabetes patients and control participants, there was a significant reduction in corneal nerve fiber density (14.94 ± 8.23 vs 23.86 ± 7.71, P = 0.004 vs 34.84 ± 9.13, P < 0.001), corneal nerve branch density (18.61 ± 16.7 vs 41.62 ± 22.67, P = 0.032 vs 76.47 ± 38.44, P < 0.001) and corneal nerve fiber length (8.40 ± 4.83 vs 14.87 ± 4.76, P = 0.001 vs 21.24 ± 6.48, P < 0.001), electrochemical skin conductance on the feet (20.57 ± 13.99 vs 61.50 ± 22.26, P < 0.001 vs 76.23 ± 12.01, P < 0.001) and hands (30.86 ± 18.10 vs 61.13 ± 19.14, P = 0.001 vs 68.31 ± 11.96, P < 0.001), and a significant increase in the vibration perception threshold in the feet (38.46 ± 15.10 vs 14.15 ± 10.25, P < 0.001 vs 7.75 ± 4.01, P < 0.001). Conclusions Patients with diabetes and CN have severe large and particularly small fiber neuropathy.