https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/198 Thu, 20 Apr 2017 11:16:23 +0000 Permanent deformity and disability can occur in diabetic Charcot arthropathy (neuropathic arthropathy) if not diagnosed and treated promptly. We report two patients with uncontrolled diabetes mellitus in whom the diagnosis of ankle neuro-arthropathy was delayed by up to six months, with misdiagnoses including ankle arthritis, osteomyelitis and cellulitis. The clinical scenario and appearances of the ankle and foot were typical of Charcot arthropathy. Unfortunately, both of them sustained ankle fracture-dislocation without a history of significant trauma. Both the patients were treated by ankle arthrodesis (fusion of joint). Prevention and early diagnosis of diabetic foot is the key to avoid the development of complications. In diabetic patients, a higher index of suspicion for the possibility of Charcot’s disease is needed. Address for Correspondence: Dr. Chowdhury Iqbal Mahmud, Registrar (Orthopaedics), Room No.1110, BIRDEM Hospital, Ibrahim Memorial Diabetic Centre, 122, Kazi Nazrul Islam Avenue, Dhaka-1000, E-mail: cimahmud@yahoo.co.uk   Diabetic Charcot arthropathy, also known as neuropathic arthropathy, is a part of diabetic foot disease. Diabetic foot is usually associated with neuropathy which may lead to ulceration and neuroarthropathy. Diabetic neuropathic arthropathy is a destructive process of the bony components of a denervated joint. Diabetes mellitus is now the most common cause of neuro-arthropathy, which often manifests itself as a ‘Charcot foot’. Patients usually have established diabetes with a sensory neuropathy, and present with painless or painful swelling and warmth in the region of the ankle and/or mid foot.1,2   A 80-year-old man with type 2 diabetes of 15 years duration was reffered to BIRDEM hospital OPD with a 7 days history of dull pain and swelling in his right ankle and foot following a minor trauma. He was unable to walk and his ankle was grossly deformed and unstable. There were no signs of inflammation, and sensation in the foot including pain and touch was reduced. He was known to have neuropathy and peripheral vascular disease with poor control of blood sugar. Intermittent pain and swelling in the foot had started six months previously. He was treated by doctors with diagnosis of ankle arthritis and osteomyelitis on different ocassions. Several courses of antibiotics and analgesics were prescribed. Two separate ankle and foot X-rays were done in BIRDEM, which revealed gross osteopenia, soft tissue swelling and fracture-dislocation of the right ankle with bony fragmentation of the mid foot (Fig.1). His inflammatory markers of the blood were unremarkable. Fig. 1. Pre-operative X-ray:Fracture and dislocation in a right ankle Charcot joint     A 65-year-old man with type 2 diabetes of eight years duration was referred to BIRDEM hospital OPD with unexplained pain and swelling in his left foot and ankle. He was known to have retinopathy, neuropathy and peripheral vascular disease. His glycaemic control was poor. Pain and swelling in the ankle and foot had started six months previously. He could walk with the help of a crutch. His ankle was deformed and unstable, and sensation in the foot including pain and touch was reduced. He had been investigated by his general practitioner. As there was no history of trauma, his physician did not get a x-rays done. Alkaline phosphatase, C-reactive protein, urate level were slightly elevated and rheumatoid factor was normal. Possible diagnosis was considered as gout and cellulitis and several courses of antibiotics were prescribed.       Neuroarthropathy, or “Charcot arthropathy”, is a diagnosis that predates the modern era of long-term survival with diabetes, having been first described in patients with tertiary syphilis.5 Charcot arthropathy is a severe destructive arthropathy which can occur in any patient with a sensory deficit. It was originally described in tertiary syphilis. Nowadays most cases occur in diabetics, but about 10% of Charcot patients have other causes, such as spina bifida, hereditary motor/sensory neuroapthy, post-traumatic sensory deficits, alcoholic peripheral neuropathy and sensory neuropathy of unknown origin.6,7 The progression of Charcot neuroarthropathy most often follows a predictable clinical and radiographic pattern, and is classified by the widely recognized Eichenholtz classification, which consist of 3 stages of fragmentation, coalescence and reconstruction.11 Charcot arthropathy can be sudden and dramatic. It is one of the most difficult and intractable sources of excess mechanical pressure in the diabetic foot and can create large osseous prominences in various locations. Ulceration and rapid progression to osteomyelitis can follow. A large prospective study of risk factors for ulcerations in a population of male diabetic patients showed that the presence of Charcot arthropathy carried the highest relative risk of all of the factors examined, eclipsing even the absence of protective sensation.12 Management is based on a variety of factors, including location, phase of the disease process, presence of infection, deformity, and comorbidities. Treatment should be guided by specific and realistic goals, depending on the severity of the disease and the patient’s functional capacity. This can vary from basic shoe modifications to major limb amputations. It is important to prevent the development of Charcot arthropathy by controlling blood sugar and early diagnosis of diabetic foot. Marked osteopenia has been noted in patients with Charcot neuroarthropathy and Bisphosphonates have shown promising short-term results in preventing bone resorption.14 Arthrodesis (fusion of joint) may be the only option in severly unstable and deformed joint. Effective internal fixation techniques in arthrodesis include screws, pin, and plate fixation. Simon et al. showed promising results with fusion during the fragmentation stage, with no major complications, and a return to regular shoe wear in a mean of 27 weeks.17 Correction of deformity may be a good option by midfoot osteotomy-fusion, triple fusion or tibio-talo-calcaneal fusion, depending on the level of deformity.6,18   There is clearly a worrying lack of awareness of the possibility of Charcot arthropathy in diabetic patients presenting with acute foot and ankle swelling. A high index of diagnostic suspicion is required. Diabetic Charcot feet are often thought to be relatively rare, but this is not the impression received by our department. Indeed, more patients with the condition appear to be presenting. Strict metabolic control, prevention or minimisation of deformity by total contact casting or use of a diabetic walker boot and avoidance of weight bearing may prevent or delay the development of complication of diabetic arthropathy. A safe clinical policy would be to assume that diabetic patients with recent onset of foot or ankle swelling have neuroarthropathy until proved otherwise. References 2.   Jeffcoate W, Lima J, and Nobrega L. The Charcot foot. Diabetic Med 2000; 17: 253–258. 4.   Jude EB, Selby POL, Burgess J et al. Biphosphonates in the treatment of Charcot neuro arthropathy: a double blind randomised controlled trial. Diabetologia 2001; 44: 2032–2037. 6.   Schon LC, Easley ME and Weinfeld SB. Charcot neuroarthropathy of the foot and ankle.Clin Orthop Relat Res 1998; 349: 116-131. 8.   Gough A, Abraha H, Li F et al. Measurement markers of osteoclast and osteoblast activity in patients with acute and chronic diabetic Charcot neuroarthropathy. Diabet Med 1997; 14: 527-531. 10.Brodsky JW. The diabetic foot, in Coughlin MJ, Mann RA, Saltzman CL, eds: Surgery of the foot and ankle, ed 8. St. Louis, MO, Mosby, 2006; 1281-1368. 12.Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The seattle diabetic foot study. Diabetes Care 1999; 22: 1036-42. 14.Rogers MJ. New insights into the molecular mechanisms of action of bisphosphonates. Curr Pharm Des 2003; 9: 2643-2658. 16.Shaw JE, Hsi WL, Ulbrecht JS, Norkitis A, Becker MB, Cavanagh PR. The mechanism of plantar unloading in total contact casts: Implications for design and clinical use. Foot Ankle Int 1997; 18: 809-817. 18.GJ Sammarco and SF Conti. Surgical treatment of neuroparthropathic foot deformity. Foot and Ankle Int 1998; 19: 102–109. 2026 Ibrahim Medical College. All rights reserved.