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Poster session 19: Charcot
P19.01
Improving the diagnostics of Charcot foot
Jorma Lahtela, Tampere University Hospital, Tampere, Finland
Heidi Haapasalo, Tampere University Hospital, Tampere, Finland
Ilkka Kaartinen, Tampere University Hospital, Tampere, Finland
Heikki-Jussi Laine, Tampere University Hospital, Tampere, Finland
Diabetic Charcot foot is difficult to diagnose, hard to treat and may result in considerable
disability necessitating early recognition.
Aim: The purpose of the study was to evaluate diagnostic routines and accuracy among
primary health care providers in a university hospital district of 0.6 million inhabitants.
Methods: During the time period from 2008 to 2009 educational tour was arranged among
primary health centers to improve recognition of Charcot foot. For the next 5 years number
of patients with suspicion of Charcot foot referred to the specialist care was drawn from
electronic medical records using data mining procedures. Patients were compared to the
hospital discharge registries (ICD-10 M14.6). All the medical records were manually
evaluated and data collected including demographics, clinical findings, diagnostic
procedures, treatment and outcome.
Results: Total of 602 patients was found. Sixty-two percent were male and 58% had type 2
diabetes. The average age was 62.4 years (range 19 - 96 yrs). The diagnosis of Charcot foot
based on clinical picture, x-ray, magnetic resonance (MRI), laboratory findings and follow-up
was filled by 146 patients (24%), 98 were men (67%). Average diabetes duration was 28
years and 108 patients (74%) had insulin. The average age was 60.8 years in men and 60.9
years in women. The number of patients with defined Charcot foot declined during the
consecutive follow-up years from 2009 to 2013 (52, 35, 20, 18, and 21, respectively). The
diagnostic delay for suspicion of Charcot foot was on average 12 weeks. Alternative
diagnoses included bone fractures (112 pts), gout (21 pts), deep vein thrombosis (16 pts),
cellulitis (21 pts), tarsal tunnel syndrome (6 pts), complex regional pain syndrome (6 pts),
undefined trauma (138 pts) and other reasons (136 pts). Patients with defined Charcot foot
all had signs of neuropathy but none had critical limb ischemia.
Conclusions: The diagnosis of Charcot foot is challenging. Education and clinical
awareness improved the diagnostic delay considerably leading to high number of referrals
with only one fourth fulfilling Charcot criteria. While uncommon, continuous education is
necessary to both professionals and patients. Data mining of the medical records may help
define the level of awareness.
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P19.02
Low prevalence of previous lower limb revascularisation in patients with diabetes and
acute Charcot foot: results from a case-control study.
Kris Doggen, Scientific Institute of Public Health, Brussels, Belgium
Hilde Beele, University Hospital Ghent, Ghent, Belgium
Kevin Deschamps, University Hospitals Leuven, Leuven, Belgium
Isabelle Dumont, Diabetic foot centre Ransart, Ransart, Belgium
Astrid Lavens, Scientific Institute of Public Health, Brussels, Belgium
Viviane van Casteren, Scientific Institute of Public Health, Brussels, Belgium
Giovanni Matricali, University Hospitals Leuven, Leuven, Belgium
Aim: Charcot foot is a rare but devastating complication of diabetes, leading to uncontrolled
inflammation and high risk of osteolysis in its acute phase. Preserved local perfusion is a
hypothesized prerequisite for the detrimental inflammatory response. We sought support for
this hypothesis by studying the prevalence of previous lower limb revascularisation (LLR), as
a marker of peripheral macroangiopathy, in patients with diabetes and Charcot foot.
Methods: Patients with diabetes and incident acute Charcot foot, but without a history of
diabetic foot ulcers (DFU) (Charcot group, N=50) were retrospectively identified in a
database used for quality of care monitoring in 36 Belgian specialized diabetic foot clinics in
the period 2005-2011. [1] Patients without Charcot foot, but who had diabetic foot ulcers
(DFU), served as controls (DFU group, N=3 147). Prevalence of previous LLR was
compared between both groups using logistic regression.
Results: The Charcot group was significantly younger than the DFU group (59.1 vs. 69.1
years, P<0.001). Age-adjusted prevalence of previous LLR was significantly lower in the
Charcot group than in the DFU group (3.5 vs. 29.8%, P<0.05), while the age-adjusted
prevalence of coronary artery disease and stroke did not significantly differ (41.7 vs. 38.3%,
P>0.05).
Conclusions: Charcot foot in diabetes only seems to occur in patients without a history of
LLR. Despite the limitation of the cross-sectional nature of this study, our findings support
the hypothesis that among patients with diabetes, Charcot foot occurs preferentially when
lower limb perfusion is preserved.
[1] Doggen K, Diabetes Metab Res Rev. 2014;30(5):435-43.
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P19.03
5-year incidence of active Charcot foot in relation to predictive risk factors in patients
after pancreas transplantation
Robert Bem, IKEM, Prague, Czech Republic
Alexandra Jirkovska, IKEM, Prague, Czech Republic
Michal Dubsky, IKEM, Prague, Czech Republic
Andrea Nemcova, IKEM, Prague, Czech Republic
Vladimira Fejfarova, IKEM, Prague, Czech Republic
Veronika Woskova, IKEM, Prague, Czech Republic
Radomira Koznarova, IKEM, Prague, Czech Republic
Frantisek Saudek, IKEM, Prague, Czech Republic
Aim: to evaluate incidence of Charcot foot (CF) during a 5-year follow-up period after
pancreas transplantation (PTX) and gain insight into possible risk factors for active CF after
transplantation.
Methods: From 1993 to 2009, 351 PTX (304 simultaneous pancreas-kidney transplantation
and 47 pancreas transplant alone) were performed at our hospital. During 5-year follow-up
period, the diagnosis of active CF was based on clinical and radiological findings and
confirmed by bone scan. Possible risk factors for active CF were evaluated according to
diabetes, its complications and transplantation (gender, age at the time of transplantation,
duration of diabetes, necessity and duration of dialysis before transplantation, type of
transplantation, the presence and grade of diabetic retinopathy, peripheral and autonomic
neuropathy, ischemic heart disease, history of amputations, functioning of graft(s), type of
immunosuppressive treatment, rejections, glycaemic control etc.). Univariate analysis and
stepwise logistic regression was used to determine which of the factor(s) are associated with
active CF occurrence after PTX.
Results: 5-year patient survival rate after PTX was 90%. The cumulative 5-year incidence of
active CF after PTX was 9.4% (27/351 – 7.7% of patients with new occurrence of CF, 6/351
– 1.7% patients with recurrence of CF)., One-year incidence of CF during 5 years follow-up
was: 1st 0.6%, 2nd 2.1%, 3rd 3.6%, 4th 1.9% and 5th year 1.9%; with significant increase in
the 3rd year in comparison with the 1st year after PTX (p<0.01). Univariate analysis and
stepwise logistic regression has shown that severe diabetic retinopathy, severe autonomic
neuropathy and previous CF (all p<0.05) are associated risk factors for activation of CF after
PTX. Other assessed factors were not significant.
Conclusions: Our study suggests high rate of active CF during 5-year follow-up period after
PTX; one-year incidence culminated in the 3rd year after PTX. The risk factors for activation
of CF were the presence of severe retinopathy, severe autonomic neuropathy and previous
CF.
Supported by the MZO 00023001 and GACR 14-03540S.
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P19.04
Charcot foot disease: a retrospective multicenter study in Spain
Jordi Viadé, University Hospital Germans Trias i Pujol, Badalona, Spain
Ricard Pérez, University Hospital Trias I Pujol, Badalona, Spain
Montserrat Doria, University Hospital Arnau de Vilanova, Lleida, Spain
Melsió Lladó, University Hospital Son Espases, Balearic Islands, Spain
Teresa Huguet, University Hospital Mutua de Terrassa, Terrassa, Spain
Elisabet Costa, University Hospital Trueta, Girona, Spain
Jorge Luis Reverter, :, University Hospital Trias I Pujol, Badalona, Spain
Elisabeth Palomera, Consorci Sanitari del Maresme, Mataró, Spain
Mateu Serra-Prat, Consorci Sanitari del Maresme, Mataro, Spain
Didac Mauricio, University Hospital Trias I Pujol, Badalona, Spain
Objective: To assess the characteristics, management and relevant outcomes of Charcot
foot disease
Methods: In a descriptive, retrospective, multicenter study (5 centers), we included all
registered initial episodes of patients with acute Charcot foot, or those attending the diabetic
foot clinic with any problem and with the presence of chronic Charcot foot disease. Diabetesrelated and foot-related data were collected. We predefined the following patient-oriented
outcomes at follow-up: new ulcer, amputation, hospitalization and death. Association of
variables was done by Pearson Chi-Square or Fisher’s exact test, and Mann-Whitney U test.
Results: A total of 83 patients (54 men; 77 with type 2 diabetes) were included, 33 with
acute Charcot foot (17 right foot). Mean age and diabetes duration were 61.4±12.5 y and
5.3±3.7 y, respectively. Mean HbA1c was 8.6±4.9%. Retinopathy, nephropathy and
nephropathy were present in 50, 42 and 82 patients, respectively. Only 7 patients had no
palpable distal pulses. Fifty-four patients had a history of previous ulcer and 32 of previous
amputation. Also, 28 patients had active foot ulcers at initial visit (plantar: 18; digits: 7; other:
2). Disease patterns in 70 affected feet (Sanders-Frykberg) were: I:3; II:41; III:25; IV:1; V:0.
Radiological classification, (Eichenholtz stage): 0-I:24; II:30; III:16. Initial treatments
prescribed were off-loading in 47 and biphosphonates in 14 patients.
Follow-up data was available in 80 patients after 1.8±1.6 yr from initial assessment. Followup events occurred in 38 patients (47.5%): 22 with new ulcers; 7 major amputation; 20
hospitalization; 4 deaths. The study of variables associated with these outcomes revealed
that development of new ulcers was associated with bilateral Charcot foot (p=0.003).
Hospitalization was associated with history of previous foot ulcers at initial assessment
(p=0.038). None of the study variables was associated with amputation or death. The
composite outcome (patients with any outcome) was associated with bilateral Charcot foot
(p=0.040), nephropathy (p=0.009), and history of previous ulcers (p=0.035).
Conclusions: Patients with acute and chronic Charcot foot show a high frequency of
relevant co-morbidity, and also development of new adverse outcomes at follow-up.
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P19.05
Diabetic Charcot Neuroarthropathy: prevalence, demographics and outcome in an
Irish tertiary referral centre
Aonghus O'Loughlin, Health Service Executive, Galway, Ireland
Edel Kellegher, Health Service Executive, Dublin, Ireland
Caroline McCusker, Health Service Executive, Dublin, Ireland
Ronan Canavan, Health Service Executive, Dublin, Ireland
Aim: The aims of this research is to determine the prevalence, clinical characteristics and
outcomes of patients with Diabetic Charcot Neuroarthropathy (DCN) referred to a tertiary
referral centre in Ireland from 2006 – 2012. This will inform the development of a national,
Register., DCN is a devastating complication for people with diabetes mellitus. The failure to
diagnose DCN and institute treatment in the acute phase leads to permanent deformity and
significant morbidity.1 The development of a register with structured diabetic podiatric care
for DCN should provide information on the prevalence and demographic of DCN with
improved outcomes.
Methods: Case finding was performed by searching three independent lists for the period
2006-2012 including: SYNGO radiology database; HIPE database of hospital inpatient
discharges; and, combined list from podiatry, endocrinology, vascular surgery and
orthopaedic clinics. A consensus meeting with chart review was undertaken to confirm
diagnosis of DCN. A proforma was completed from chart review in order to determine clinical
characteristics, initial treatment and outcomes for patients with DCN.
Results: 40 cases of DCN were identified, resulting in an estimated period prevalence of
0.3%. The majority of patients were male (68%); most patients had T2DM (73%). Mean ±SD
for age was 58±10 years, for duration of diabetes was 15±9 years, and for HbA1c at
diagnosis of DCN was 65±16 mmol/mol. Treatment in the acute phase included no treatment
(53%), offloading (50%), bisphosphonates (5%) and surgery (5%). 38% of patients
developed subsequent foot ulceration and 20% required amputation.
Conclusions: This is the first prevalence estimate of DCN in Ireland., These data suggest
diagnosis of DCN is missed in the acute phase that results in a significant risk of diabetic
foot ulceration and amputation. The strategy used to identify and follow patients will inform
the development of a national register to improve outcomes for these patients.
References:
1.Rogers LC et al. Diabetes Care. 2011 Sep;34(9):2123-9.
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P19.06
Diabetic osteoarthropathy care in Sweden – a national inventory.
Linda Wennberg, Karolinska Institutet/CLINTEC, Stockholm, Sweden
Paul Lundgren, Dep of Orthopedics, Södertälje Hospital, Södertälje, Sweden
Introduction: Osteoarthropathy, is a rare foot complication in patients with diabetes mellitus.
The acute clinical manifestations calls for an immediate management in order to prevent
irreversible bone/joint destruction and an increased risk of amputation. Unfortunately,
osteoartopathy is an often overlooked and misdiagnosed complication. The condition has a
major negative effect on the patients quality of life as well as substantial health economical
costs. Enhanced early diagnosis would improve the possibilities for an optimal management
of patients with osteoarthropathy. In Sweden we currently lack knowledge of how the
management of patients with this condition is organized at a national level. Aim: The
purpose of the study was to make a national inventory on caregivers organisation for
diagnosis and treatment of diabetes-osteoarthropathy.
Methods: A questionnaire was distributed to Swedish hospitals with emergency department
for orthopedic patients, totally 63. The questionnaire comprised number of patients per year,
current guidelines, diagnostic methods as well as treatment and access to reconstructive
foot surgery. The data obtained was analyzed and computed in terms of frequencies and
percentages using SPSS 22.
Result: There was a 95% response rate., Three respondents stated that they never had any
contact with patients with diabetic osteoarthropathy, resulting in an analysis of 57
questionnaires. Most of the respondents (79%) specified the absence of established
procedures for managing patients with osteoarthropathy. The most common diagnostic
method was clinical diagnosis and conventional plain radiography (95%). MRI or
scintigraphy was used by 19% and 10.5% respectively. As a treatment method, 84% used a
total contact cast, and 38% orthoses. Two clinics indicated a treatment duration of less than
3 months, thirty clinics (53%) a treatment duration of 3-6 months and sixteen clinics (28%) a
duration of 6-12 months. Only four clinics indicated duration longer than 12 months, while 2
clinics did not provide any treatment at all. Conclusion: This inventory indicates a national
need for an improvement in knowledge as well as guidance regarding the care of patients
with diabetes -osteoarthropathy.
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P19.07
Service review of integrated care of Charcot foot arthropathy in Chinese diabetic
patients - 19 years experience in Kwong Wah Hospital
Chi Pan Yuen, Kwong Wah Hospital, Hong Kong, Hong Kong
Wai Lam Chan, Kwong Wah Hospital, Hong Kong, Hong Kong
Wing Cheung Wong, Kwong Wah Hospital, Hong Kong, Hong Kong
Aim: Diabetes is the most common cause of charcot foot arthropathy in Hong Kong. Our
retrospective review aims at:
(1) To share the experience on service delivery to patients with charcot foot arthropathy
(2) To delineate the epidemiology, characteristic and clinical outcomes of charcot foot
arthropathy in Chinese diabetic patients
(3) To maintain and improve the quality of care for charcot foot arthropathy patients
Methods: Patient records since 1995, with the establishment of multidisciplinary Diabetic
Foot Clinic in Kwong Wah Hospital, were retrieved. The epidemiology, clinical presentations
and management outcomes of diabetic charcot foot arthropathy patients were retrospectively
reviewed and analysed.
Results: There were 43 diabetic patients (47 feet) diagnosed with Charcot foot arthropathy
over 19 years. Male patient were more common (n=27, 64%). The mean age was 64 at the
time of diagnosis (range, 35-89). The mean interval from the first diagnosis of diabetes to
Charcot arthropathy is 9.4 years (range, 0-30). Most common presentation is swelling (n=29,
61.7%). Although Charcot arthropathy is classically painless, a minority of patient presented
with pain (n=5, 10.6%). More patients have history of preceding trauma (n=29, 61.7%), but
most are trivial injury. Although all patients had unilateral pathology at the time of
presentation, contralateral limb involvement was diagnosed in four patients, ranged 1 to 5
years since the initial presentation (n=4, 9.3%). Delay in diagnosis is common if the patients
were first managed by non-orthopaedic surgeon (110 days vs 10 days). Recurrent ulceration
is not uncommon (n=11, 23.4%). Two patients underwent major amputation, both were
related to deep infection.
Conclusions: Charcot foot arthropathy is uncommon in Chinese diabetic patients (6.3 in
1000), however the outcome can be disastrous if the diagnosis was delayed or missed.
Common presentation is unilateral painless foot swelling in long-standing diabetic patient.
With high index of suspicion and early referral to orthopaedic surgeon, we expect there will
be earlier diagnosis, proper management and less morbidity and mortality. As the
contralateral limb involvement can be delayed up to 5 years, long-term follow-up for this
group of patient is essential.
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P19.08
Cost effective and cosmetically appealing conservative management options for the
Charcot foot
Dennis Janisse, Medical College of Wisconsin, Milwaukee, United States
Aim: The purpose of this abstract is to shed light on and create a new way of thinking about
simple, conservative management of the Charcot foot in the patient with diabetes.
Methods: The content of this presentation is based on a review of current standards of
practice in the United States compared to care protocols elsewhere in the world., Review is
augmented by trends observed and techniques employed during the author’s forty years of
clinical experience caring for patients with Charcot foot.
Results: While the standard of conservative management of Charcot foot in many regions of
the world is the prescription of custom shoes, there are many alternatives which patients
may find easier to use and more cosmetically appealing. There are many ways to modify
and adapt commercially available, “normal-looking” shoes to fit a deformed Charcot foot.,
Some of these include rocker soles, stabilizers and removing the outsole and widening the
shoe for a custom fit. These shoes will also use a custom foot orthosis inside to provide an
enhanced custom fit.,
Conclusions: Custom shoes are labor intensive to fabricate and are often very costly., Their
looks can leave something to be desired when compared to “normal” shoes., Patients are
typically much more accepting of a shoe if it isn’t obviously medical in appearance., The
methods discussed in this presentation are useful in improving not only patient acceptance
but also patient compliance with the prescribed treatment plan., Improved compliance results
in better outcomes with less frequent and fewer recurrences or complications.
www.diabeticfoot.nl
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P19.09
Surgical treatment of diabetic Charcot foot with external fixation
Roberto De Giglio, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Alexander Kirienko, -Humanitas Clinic Institute, Rozzano, Italy
Teresa Mondello, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Giuliano Sacchi, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Gianmario Balduzzi, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Introduction: Charcot arthropathy is a disabling pathology of the foot and the ankle, which
requires an effective treatment to improve clinical and functional outcomes and prevent foot
amputation. Our aim is is to propose a treatment algorithm for correcting deformity and
restoring a plantigrade, shoeable foot in patients with diabetic Charcot foot.
Method: Between 2010 and 2013 we treated 13 patients (7 males and 6 females, meanly
aged 48.27 years; 1 patient affected by type 1 diabetes and 12 patients by type 2 diabetes)
with different kind of deformities of the mid-and hindfoot (4 patients with arthropathy and
dislocation at the level of the Lisfranc joint, 5 patients with Chopart joint dislocation, 1 patient
with a combined pathology of the Lisfranc and the talo-navicular joints, 1 patient with
pathology of the Lisfranc and the subtalar joints, 1 patient with necrosis of the talar body, 1
patient with osteomyelitis and amputation of the 4th and the 5th rays with associated rigid
equino-varus deformity. 7 patients had plantar skin ulcerations, because of articular
instability and overload at the plantar arch.
Results: All the patients have been treated with open resection, partial intra-surgery
reduction, frame application and progressive correction of the residual deformities. In the
case with necrosis of the talus a tibio-talar arthrodesis was performed, in one case with
equino-varus deformity after the initial closed deformity correction a panarthrodesis was
performed using the same frame. Treatment time with the frame was at mean 3 4 month, we
achieved plantigrade foot in all cases. All the skin ulcerations healed during the treatment.
The mean follow-up time has been 34 months. No deep infection or recurrent skin
ulcerations; no amputations were required
Conclusions: External fixation technique permits avoid major amputation, restore the foot
morphology and may be considered like the best solution for patients who are the highest
risk for complications or have failed with standard orthopaedic methods of internal fixation.
We recommend one step surgical technique of dynamic external fixation for the treatment of
Charcot deformities in the diabetic foot, with progressive correction of associated residual
deformities.
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P19.10
Management of neuropathic (Charcot) ankle with tibiotalocalcaneal arthrodesis in
high-risk patients
Victor Dubois-Ferriere, Jewish General Hospital; McGill University, Montréal, Canada
Ruth Chaytor, Jewish General Hospital; McGill University, Montréal, Canada
Aim: Charcot neuroarthropathy of the ankle is a devastating complication of neuropathy. It is
characterized by severe deformity with high risk of ulcer and amputation. Salvage
arthrodesis of the ankle has been shown to be a reliable option in preventing those
complications. However, history or presence of ulcer has often been considered as a
contraindication. In this situation, amputation is frequently the unique option. We report the
clinical experience with tibiotalarcalcaneal (TTC) arthrodesis as an alternative of amputation
in patients with severe ankle Charcot deformities.
Methods: Retrospective review of 6 consecutive patients treated for an ankle Charcot with a
TTC arthrodesis using a retrograde intramedullary nail, between 2011 and 2014. All patients
had severe deformity that precludes successful treatment with bracing.
Data collection included demographic and radiographic data, complications, and clinical
outcomes.
Results: Age ranged from 42 to 69 years (mean of 54.6). There were 5 males and 1 female.
Four patients had a diabetic neuropathy and 2 a neuropathy of no determined etiology.
Three patients had a history of ulcer, and 2 had an ulcer at time of surgery. A plantigrade
foot could be obtained in all cases. At a mean follow-up of 10 months, 4 patients developed
a post-operative infection. Three were treated conservatively and 1 required surgery for
débridement. No amputation has been performed. Among patients presenting with an ulcer,
one has healed and the other is healing without complications. All patients could ambulate in
full weight bearing and have progressed to fusion. No recurrence of ulcer has been
observed.
Conclusions: Treatment of Charcot neuropathy of the ankle is challenging. In this study,
patients were relatively young with a devastating injury that otherwise results in a below
knee amputation frequently. As expected, salvage management resulted in a high
complication rate. However, a stable configuration and a plantigrade foot could be obtained
in every patient. Despite the short duration of follow-up, no recurrence of ulceration has been
observed. A TTC arthrodesis with a retrograde intramedullary nail sounds to be a feasible
alternative to amputation for the treatment of severe ankle Charcot in a high-risk population.
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