Charcot Vs Osteomyelitis: Stop, Think & Treat Editorial Summary The cost of health care for ulceration and amputation in diabetes is estimated at between £962 million and £1 billion: which is approximately 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients it is suggested that ulceration was associated with a length of stay 8.04 days longer than that for diabetes admissions without ulceration. For clinicians it is vital to be able to distinguish between a diabetic foot ulcer and Charcot Neuroarthropathy.1
Introduction
W Dr Ahmad Bilal Senior Fellow in Foot and Ankle Surgery, Manchester University Hospitals Manchester, United Kingdom
Prof Anand Pillai Consultant Orthopaedic Foot & Ankle and Adult Reconstruction Surgeon Manchester, United Kingdom
132
ith escalating NHS spend on diabetic foot care, it is a clinical condition that needs more focused attention. Ulceration patients are at risk to develop deformity and ulceration due to neuropathy and loss of protective mechanism. Almost 50% of patients with a new diabetic foot ulcer had at least one admission within 6 months of their assessment, and those with severe ulcers are likely to have procedures involving foot care, revascularisation and amputation.2
Diabetic foot osteomyelitis (DFO) and Charcot neuroarthropathy (CN) are two common presenting conditions. It is important to bear in mind that presentation of both can be very similar and have some overlapping features, however it is very important to differentiate between the two because of the entirely different pathology and treatment. DFO often has as its inital presenting sign as soft tissue infection, spreading to the underlying osseus structures. CN on the other hand is a non-infectious destructive process affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase, and if it remains untreated, leading to deformity and ulceration.
two are: Diagnostic Tools: •
Clinical
•
Imaging
•
Biochemistry
•
Biopsy
Clinical Assessment History and clinical examination both are equally important to make the diagnosis. If the presentation is with an ‘angry’ looking foot with a background of recent infection, fever, systemica illness rather than a localised hot, red, swollen foot then the likelihood of infection is higher. Sometimes in a Charcot Neuroarthropathy there is history of minor trauma which triggers the condition. On clinical examination of a Charcot neuropathy, the foot will be warmer than the contralateral side at by least >2 degrees, however the swelling and oedema in Charcot will subside after 5 - 10 mins of foot elevation which is less likely with infection. Charcot is most commonly seen in the midfoot and is associated with neuropathy and loss in sensation. Circulation is also generally maintained. Infection is commonly associated with ulceration.
Biochemical Markers The diagnosis is even more challenging in the early red, hot swollen foot (stage 0 Eichenholtz3) in which no radiographic changes or when there is late presentation with osseous changes. In its early stage it can easily be confused with cellulitis and later with osteomyelitis. The diagnostic tools required to differentiate the
Wound Masterclass - Vol 1 - September 2022
Biochemical markers are a key investigative tool in the clinicians ‘toolbox’ to assist in elucidating the difference between these two conditions. In Charcot neuroarthropathy there will be mild increase in inflammatory markers (WBC, CRP)