Medicina, Vol. 58, Pages 1763: Delayed Diagnosis of Bilateral Neuroarthropathy: Serious Impact on the Development of Charcot’s Foot, a Case Report

CN is characterised by painful or painless bone and joint destruction in limbs that have lost sensory innervation with the clinical presentation occurring in two phases, namely, acute and chronic [1]. The incidence and prevalence of CN varies between 0.1% and 0.4% in people with diabetes [5,6]. The unilateral presentation of CN is much more common than bilateral involvement [7]. However, there is a relative risk of developing multifocal CN in 9% of people with CN [8].The cause of this complication has not been completely elucidated. Several theories have been published, although the neuro-bone-inflammatory theory seems to be the most complete to explain CN. People with CN tend to have lower bone density in the lower limbs compared with neuropathic participants [9]. Studies using markers for bone formation and resorption highlighted increased osteoclastic activity compared with osteoblastic activity in the acute and chronic forms of CN [10,11]. In 2007, Jeffcoate [12] described CN as an increased inflammatory response to trauma, inducing increased bone lysis with the involvement of bone moulding factors, such as the receptor activator of the nuclear factor-B ligand, and its natural antagonist, osteoprotegerin.Due to the potentially devastating consequences of CN, its rapid diagnosis and treatment are essential. Although surgical treatment is more likely to be used in the chronic phase of CN [13,14,15], the current treatment of CN in the acute phase consists of prolonged immobilisation with full offloading and a removable cast (e.g., Aircast®) [16,17]. The earlier offloading is started, the better the outcome [18]. Offloading gives the affected foot time to heal and thus prevent progressive damage and deformation of the bone structure. Offloading is maintained for as long as the foot shows signs of inflammation, with the average duration varying between 3 to 12 months in data sets [19] As treatment must be strictly adhered to over the long term to ensure success, patient compliance is an important and sensitive issue [20]. In addition to offloading, patients often require management for foot ulcers and possibly surgical reconstruction for disabling bone or joint deformity or instability. When the foot is in remission, extensive follow-up is required to provide the correct orthopaedic footwear and monitor for signs of reactivation, which would require further offloading. Risk factors for recurrence remain somewhat unexplored [21] and poorly identified. Non-detachment of CN in the active phase can lead to advanced bone necrosis and lead to the disappearance of the affected joint [22]. It is important to note that all clinical trials based on the use of drug therapies for the management of CN have shown promising results depending on the duration of the offloading, even if they sometimes revealed a reduction in its duration [23,24,25].Our young patient probably consulted her general practitioner when CN was at stage 0 (oedema without fracture). Not only was her management of CN delayed, but her doctor’s recommendation to intensify her physical activity was in complete contradiction to the disease and probably aggravated it. The appearance of the fracture and the major deformation of the bone structure observed on the MRI seem related to this intensification of physical activity. The non-implementation of offloading was also a missed opportunity to reduce the impact of CN on the bone structure and limit its progression. Indeed, as the only validated treatment against bone destruction, offloading should be implemented as first-line management [16,17,18].Our study not only sheds light on consequences of delays in the diagnosis of CN, known in the literature to be close to 86.9 days [26], but also provides a description of a chain of management errors with the implementation of care that probably induced the transition of CN from an insipid state to the level of deformity.

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