Exp Clin Endocrinol Diabetes 2007; 115(6): 360-364
DOI: 10.1055/s-2007-970578
Article

© J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York

Weight-Bearing Intensity Produces Charcot Deformity in Injured Neuropathic Feet in Diabetes

R. Kimmerle 1 , E. Chantelau 2
  • 1Practice of Endocrinology and Diabetes, Düsseldorf
  • 2Department of Endocrinology, Diabetes and Rheumatology, Heinrich-Heine-University of Düsseldorf
Further Information

Publication History

received 31. 8. 2006 first decision 14. 11. 2006

accepted 14. 11. 2006

Publication Date:
08 June 2007 (online)

Abstract

The purpose of the study was to investigate the relationship between the intensity of unrestrained weight bearing after a non-fracture injury (e.g. sprain), and the development of osteoarthropathic deformities of the foot (Charcot foot) in patients with diabetic neuropathy.

Methods: 34 diabetic patients (14 Type 1, 20 Type 2) with foot bone injuries were studied in retrospect. At onset of injury symptoms (e.g. foot swelling), 32 of 34 feet displayed unremarkable X-ray, but pathologic MR imaging (e.g. bone marrow edema along the Lisfranc and/or the Chopart joint). Cumulative load forces after the onset of symptoms until treatment by total contact cast (TCC) were estimated using the product of body weight and number of weeks of ambulation (kg×week) as a surrogate. Feet were classified in 3 groups according to the degree of foot deformities found at the start of treatment with TCC: Feet without deformities (group A, n=16), feet with minor deformities (partially reduced plantar arch (group B, n=6) and feet with major deformities (collapsed plantar arch, group C, n=12)

Results: Feet in group A had been exposed to 262 (95% CI 135-390) kg×week, compared to 974 (95% CI 342-1606) in group B, and to 2348 (95% CI 1265-3430) kg×week in group C (p<0.05 between groups), indicative of a dose-response relationship between weight-bearing and progressive foot deformities. Destruction along the Lisfranc joint was observed in 2/16 feet in group A, versus 18/18 feet in group B and C combined (p<0.001). In group A, the undeformed feet were healed without major deformities (except for 2 non-compliant patients), whereas in group B and C feet remained as deformed as they were at TCC application.

Conclusion: Unrestrained weight-bearing of injured foot bones and joints of more than 400 kg×week (equivalent to 8 weeks of normal walking by a person of 50 kg body weight) prompts Charcot deformities, with disintegration of the Lisfranc joint. Early off-loading by TCC treatment allows healing without deformities.

References

  • 1 Bader DL. (Ed) .Pressure Sores- Clinical Practice and Scientific Approach. Macmillan Press, Houndmills and London 1990
  • 2 Boack DH. Fractures of the midfoot (In German).  Ther Umsch. 2004;  61 467-474
  • 3 Boddenberg U. Healing time of foot and ankle fractures in patients with diabetes mellitus: literature review and report on own cases. (in German).  Zentralbl Chir. 2004;  129 453-459
  • 4 Boulton AJM. The diabetic foot: from art to science. The 18th Camillo Golgi Lecture.  Diabetologia. 2004;  47 1343-1353
  • 5 Brand PW. The diabetic foot. In: Ellenberg M, Rifkin H (eds) Diabetes mellitus: theory and practice. 3rd edn. Med Exam Publishing, New York pp 829-849
  • 6 Brand PW. Insensitive feet. A practical handbook on foot problems in leprosy. The Leprosy Mission. London 1977
  • 7 Chan CW, Rudins A. Foot biomechanics during walking and running.  Mayo Clin Proc. 1994;  69 448-461
  • 8 Chantelau E. The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture.  Diabet Med. 2005;  22 1707-1712
  • 9 Chantelau E, Onvlee GJ. Charcot foot in diabetes: farewell to the neurotrophic theory.  Horm Metab Res. 2006;  38 361-367
  • 10 Chantelau E, Richter A, Schmidt-Grigoriadis P, Scherbaum WA. The diabetic Charcot foot: MRI discloses bone stress injury as trigger mechanism of neuroarthropathy.  Exp Clin Endocrinol Diabetes. 2006;  114 118-123
  • 11 Chantelau E, Poll L. Evaluation of the diabetic Charcot foot by MR imaging or plain radiography - an observational study.  Exp Clin Endocrinol Diabetes. 2006;  114 428-431
  • 12 Daniel RK, Priest DL, Wheatley DC. Etiologic factors in producing pressure sores: experimental model.  Arch Phys Med Rehabil. 1981;  62 492-498
  • 13 Debrunner HU, Jacob HAC. Biomechanik des Fußes. 2. völlig neu bearbeitete Auflage. Bücherei des Orthopäden (Hrsg. Joachim Grifka), Band 49 Ferdinand Enke, Stuttgart 1998
  • 14 Edmonds ME, Petrova NL, Edmonds A, Elias DA. Early identification of bone marrow oedema in the Charcot foot on MRI allows rapid intervention to prevent deformity.  Diabetic Medicine. 2006a;  23 ((Suppl. 2)) 70
  • 15 Edmonds ME, Petrova NL, Edmonds A, Elias DA. What happens to the initial bone marrow oedema in the natural history of Charcot osteoarthropathy?.  Diabetologia. 2006b;  49 ((Suppl. 1): 684)
  • 16 Greider TD. Orthopedic aspects of congenital insensitivity to pain.  Clin Orthop Rel Res. 1983;  172 177-185
  • 17 Hardin EC, Su A, van den Bogert AJ. Pre-impact lower extremity posture and brake pedal force predict foot and ankle forces during an automobile collision.  J Biomech Eng. 2004;  126 770-776
  • 18 Horwitz T. Bone and cartilage debris in the synovial membrane. Its significance in the early diagnosis of neuro-arthropathy.  J Bone Joint Surg. 1948;  30-A 579-588
  • 19 Kiuru MJ, Pihlajamäki HK, Ahovuo JA. Bone stress injuries.  Acta Radiol. 2004;  45 317-326
  • 20 Kristiansen B. Ankle and foot fractures in diabetics provoking neuropathic joint changes.  Acta Orthop Scand. 1980;  51 975-979
  • 21 Lassus J, Tulikoura I, Konttinen Y. et al . Bone stress injuries of the lower extremity.  Acta Orthop Scand. 2002;  73 359-368
  • 22 Liniger C, Albeanu A, Bloise D, Assal JP. The tuning fork revisited.  Diabet Med. 1990;  7 859-864
  • 23 Lister J, Maudsley RH. Charcot joints in diabetic neuropathy.  Lancet. 1951;  ii 1110-1113
  • 24 Maluf KS, Mueller MJ. Novel Award 2002. Comparison of physical activity and cumulative plantar tissue stress among subjects with and without diabetes mellitus and a history of recurrent plantar ulcers.  Clin Biomech. 2003;  18 567-575
  • 25 Minde JK. Norrbottnian congenital insensitivity to pain.  Acta Orthop Suppl 321. 2006;  77 2-32
  • 26 Minde JK, Svensson O, Holmberg M, Solders G, Toolanen G. Orthopedic aspects of familial insensitivity to pain due to a novel nerve growth factor beta mutation.  Acta Orthopaed. 2006;  77 198-202
  • 27 Mittlmeier T, Morlock MM. Statische und dynamische Belastungsmessungen am posttraumatischen Fuß.  Der Orthopäde. 1991;  20 22-32
  • 28 Mittlmeier T, Beck M. Tarsometatarsal injuries- an often neglected entity (In German).  Ther Umsch. 2004;  61 459-465
  • 29 Muthukumar T, Butt SH, Cassar-Pullicino VN. Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT and MR imaging.  Semin Musculoskelet Radiol. 2005;  9 210-226
  • 30 Nigg BM. Biomechanics, load analysis and sports injuries in the lower extremities.  Sports Med. 1985;  2 367-379
  • 31 Onvlee GJ. The Charcot Foot. A critical review and an observational study of a group of 60 patients. Thesis. Medical Faculty University of Leiden/The Netherlands 1998
  • 32 Pecoraro RE, Reiber GE, Burgess EM. Pathways to limb amputation. Basis for prevention.  Diabetes Care. 1990;  13 513-521
  • 33 Peicha G, Preidler KW, Lajtai G, Seibert FJ, Grechenig G. Diagnostische Wertigkeit von Nativröntgen, Computer- und Magnetresonanztomographie beim akuten Hyperflexionstrauma des Fußes (In German).  Unfallchirurg. 2001;  104 1134-1139
  • 34 Piaggesi A, Viacava P, Rizzo L, Naccarato G, Baccetti F, Romanelli M, Zampa V, Del Prato S. Semiquantitative analysis of the histopathological features of the neuropathic foot ulcer.  Diabetes Care. 2003;  26 3123-3128
  • 35 Ragnarsson KT, Sell H. Lower extremity fractures after spinal cord injury: a retrospective study.  Arch Phys Med Rehabil. 1981;  62 418-423
  • 36 Rammelt S, Grass R, Zwipp H. Nutcracker fractures of the navicular and cuboid (In German).  Ther Umsch. 2004;  61 451-457
  • 37 Ritchie DA. Imaging the adult ankle and foot.  Foot and Ankle Surgery. 1997;  3 105-120
  • 38 Schon LC, Weinfeld SB, Horton GA, Resch S. Radiographic and clinical classification of acquired midtarsus deformities.  Foot & Ankle Int. 1998;  19 394-404

Correspondence

R. Kimmerle

Practice of Endocrinology and Diabetes

Aachener Strasse 196

D-40223 Düsseldorf

Email: rkimmerle@onlinehome.de

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