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The Diabetic
Foot Journal

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If every Charcot looked the same

Matthew Young

Groove Armada’s celebration of individuality highlights the very opposite of what we are asked to achieve in the modern NHS, with protocols and guidelines threatening to do away with clinical freedom. Whilst maverick and non-evidenced practice has to be prevented, there are some situations in which there is such a lack of evidence that care has to adapt to a rapidly changing situation based on first principles. Charcot foot is one of them.

The foot has 33 joints and any of these can develop Charcot change, so the patterns of disease are widely variable and the deformities that result create an almost infinite set of challenges. The Holy Grail for foot clinics is to diagnose Charcot feet early, immobilise them and minimise these deformities.

Chantelau and Richter in Germany (summarised alongside) and Ruotolo et al in Italy (summarised below) attempted to minimise the deformity by diagnosing Charcot change at the “very early stage 0” point where visible X-ray changes have not occurred. Ruotolo et al used a novel PET/CT imaging approach and Chantelau and Richter used a more conventional magnetic resonance imaging (MRI) approach in hot swollen neuropathic feet. Both had a dramatic effect on preventing deformity, leaving the midfoot looking the same as it was before the process began in all of the Italian cases and 70% of the German ones. I would need to see the results of the Ruotolo et al study replicated before I could be certain that they had the same population as the other studies.  No fractures at all would be different from the Charcot patients I see, but then maybe I get them too late!

Aragón-Sánchez et al (summarised on the next page) describe two cases of an increasingly recognised situation, in which osteomyelitis triggers the Charcot process. The complex needs of ulcer care, infection control and stabilisation of the Charcot joint are often conflicting and outcomes are, in many clinics’ experiences, generally poor. The pre-referral care of the patients looks to have been sub-optimal and the management approach was certainly radical, but the outcomes were good, which provides some hope for these difficult feet.

To read the article summaries, please download the PDF from the article options link at right.

Groove Armada’s celebration of individuality highlights the very opposite of what we are asked to achieve in the modern NHS, with protocols and guidelines threatening to do away with clinical freedom. Whilst maverick and non-evidenced practice has to be prevented, there are some situations in which there is such a lack of evidence that care has to adapt to a rapidly changing situation based on first principles. Charcot foot is one of them.

The foot has 33 joints and any of these can develop Charcot change, so the patterns of disease are widely variable and the deformities that result create an almost infinite set of challenges. The Holy Grail for foot clinics is to diagnose Charcot feet early, immobilise them and minimise these deformities.

Chantelau and Richter in Germany (summarised alongside) and Ruotolo et al in Italy (summarised below) attempted to minimise the deformity by diagnosing Charcot change at the “very early stage 0” point where visible X-ray changes have not occurred. Ruotolo et al used a novel PET/CT imaging approach and Chantelau and Richter used a more conventional magnetic resonance imaging (MRI) approach in hot swollen neuropathic feet. Both had a dramatic effect on preventing deformity, leaving the midfoot looking the same as it was before the process began in all of the Italian cases and 70% of the German ones. I would need to see the results of the Ruotolo et al study replicated before I could be certain that they had the same population as the other studies.  No fractures at all would be different from the Charcot patients I see, but then maybe I get them too late!

Aragón-Sánchez et al (summarised on the next page) describe two cases of an increasingly recognised situation, in which osteomyelitis triggers the Charcot process. The complex needs of ulcer care, infection control and stabilisation of the Charcot joint are often conflicting and outcomes are, in many clinics’ experiences, generally poor. The pre-referral care of the patients looks to have been sub-optimal and the management approach was certainly radical, but the outcomes were good, which provides some hope for these difficult feet.

To read the article summaries, please download the PDF from the article options link at right.

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