Bilateral Charcot neuroarthropathy following successive surgical arterial revascularisation to both legs in a patient with diabetes — an interesting case history

Neil Baker and Isam Osman

An unusually good blood supply and peripheral neuropathy are reportedly accepted prerequisites for the pathogenesis of Charcot neuroarthropathy (CN) in people with diabetes. There is anecdotal evidence that CN does not occur in the presence of peripheral vascular disease. We report the first case of a person with diabetes who had revascularisation surgery performed to both legs independently, which was subsequently followed by CN in the corresponding feet. This case illustrates the importance of a good blood supply in the development of CN. Furthermore, it supports the concept that reduced arterial supply is protective against the development of CN. This case also highlights the need for regular follow-up reviews where postoperative hyperaemia is evident.

Citation: Baker N, Osman I (2023) Bilateral Charcot neuroarthropathy following successive surgical arterial revascularisation to both legs in a patient with diabetes — an interesting case history. The Diabetic Foot Journal 26(1): 36–9

Article points

1. A very good blood flow is a prerequisite for active Charcot development

2. Although this is a rare case, it is advised to be vigilant in monitoring a hot, swollen, inflamed foot and leg after vascular intervention in a patient with existing neuropathy

3. Early detection and immobilisation (cast) of active Charcot with regular follow up is imperative to facilitate optimal resolution and reduction in deformity

4. Differential diagnosis is essential in the presentation of a neuropathic red/ discoloured (dark), hot, swollen foot and leg, particularly if ulceration is present.

Authors

Neil Baker is Consultant Diabetes /Vascular Podiatrist, Sana Clinic Al Shaab Kuwait; formerly Ipswich Hospital NHS Trust; Isam Osman is Consultant Vascular Surgeon, King Saud Medical City, Riyadh, Saudi Arabia; formerly Ipswich Hospital NHS Trust;

Key words

- Charcot

- Neuropathy

- Peripheral arterial disease

- Vascular intervention

Diabetes and menopause

Metabolic changes that occur during menopause are associated with increased incidence of type 2 diabetes and its risk factors, while menopausal symptoms have a negative effect on a person’s day-to-day life, and consequently their diabetes self-management. In women who are going through menopause, effective hormone replacement therapy (HRT) can improve a wide array of cardiometabolic risk factors as well as the risk of new-onset type 2 diabetes. This factsheet covers the relationship between menopause and type 2 diabetes and provides recommendations on optimising HRT in women with diabetes.

Author: Claire Partridge, RGN, MSc Health Sciences (Diabetes)

Citation: Partridge C (2023) At a glance factsheet: Diabetes and menopause. Diabetes & Primary Care 25: [Early view publication]

The impact of venous leg ulcers on a patient’s quality of life: considerations for dressing selection

Patients with venous leg ulcers (VLUs) experience a wide range of physical and psychosocial issues. This paper focuses on the impact of the sequelae of VLUs and the interventions that can be used to minimise that impact on patient wellbeing. VLU-related issues are described, such as high exudation with risk of leakage, soiling of clothing and bed linens, and the embarrassment this can cause. This also leads to the need for more frequent dressing changes, and potential dressing-related trauma associated with pain, stress and anxiety. Finally, dressing characteristics that should be considered in order to address these issues and improve the quality of life of patients with VLUs are discussed.

Authors:

Dot Weir and Phil Davies

Dot Weir is Wound Clinician, Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, New York, US;

Phil Davies is Senior Global Medical Affairs Manager, Medical and Economic Affairs, Mölnlycke Health Care, Gothenburg, Sweden

Ten top tips: realistic expectations about amputation

Authors:

Margaret Doucette and Stephanie Seabolt

Margaret Doucette is Associate Chief of Staff for Research at Boise VA Medical Center and Medical Director for the Wound/High Risk Foot/ Amputee Program. Clinical Associate Professor Univ of Washington, US;

Stephanie Seabright is Registered Nurse Clinical Research Coordinator at the Boise VA Medical Center working in wound/high risk foot clinic and Masters of Science in Nursing graduate student at Western Governor’s University, US Am putation of a lower extremity can be devastating, debilitating and demoralising, or it can be a successful, beneficial, definitive end point to a nonhealing diabetic foot ulcer (DFU). The decisionmaking process of if, and when, to amputate begins at the first patient visit and should be incorporated into the patient discussion early on for all high-risk patients. While prevention of amputation is most commonly the goal, early identification of risk factors and risk stratification can help design a realistic care plan, compassionately inform patient expectations and steward resource allocation. These 10 top tips will help guide you with the plan of care.

Physiotherapists’ knowledge and use of electrotherapy in the management of chronic wounds

Chronic wounds are becoming of public health concern, and despite extensive literature supporting the use of electrotherapy in the management of chronic wounds, Nigerian physiotherapists are rarely involved in wound care. This study sought to determine physiotherapists’ knowledge and use of electrotherapy in wound management. It used a self-administered questionnaire to collect information from physiotherapists in various practice settings. It was found that the majority of respondents (98.7%) had a good understanding of the role of electrotherapy in wound care, but had a poor understanding of both precaution (10.2%) and wound assessment (7.9%). Only 11.8% of physiotherapists were found to be involved in wound care and there was no association between knowledge and job rank (P =0.27).

Author:

Chioma Lynn Onuchukwu

Chioma Lynn Onuchukwu is Chief Physiotherapist, Enugu State University Teaching Hospital, Enugu, Nigeria

Phage therapy for diabetic foot infection

      The treatment of diabetic foot infections (DFIs) represents a costly and growing challenge to the NHS. DFIs can be difficult to treat for a variety of reasons, including late presentation of advanced infection, and antibiotic tolerance or resistance. Bacteriophage (phage) are ubiquitous viruses that infect and kill bacteria in a species-, sometimes even strain-, specific manner. Phages have been used to treat bacterial infection since 1919, but their use in the geopolitical West ceased in the 1930s due to a variety of factors, including the mass production of antibiotics. The modern antibiotic resistance crisis has driven renewed interest in phage therapy and 2,241 patients with mostly with antibiotic refractory infections have been treated since 2000, 79% of whom improved. This includes at least 310 patients with chronic wound infections, among whom 86.1% achieved clinical resolution or improvement of infection. Reassuringly, the available evidence suggests that phage therapy is safe and without notable side effects. Some phages also possess enzymes capable of degrading the biofilms that afford antibiotic tolerance to bacteria and underpin many chronic infections. Phages also act independent of antibiotic resistance, allowing the treatment of even pan-resistant bacteria, and topical or local application to DFIs means antimicrobial activity is independent of a patient’s peripheral perfusion. Presently only an option when antibiotics are not meeting a patient’s clinical needs, future integration of phage therapy at all levels of DFI care will radically transform the outlook for DFIs in the UK. Reducing the number of serious infections and amputations will not only benefit patients but will deliver vast savings to the NHS and reduce the amount of antibiotics used, making phage therapy a tangible response to the antibiotic resistance crisis.

Authors:

Matthew J Young, Lesley ML Hall and Joshua D Jones

This article first appeared in our sister publication, The Diabetic Foot Journal, in the November 2022 issue. Citation: Young MJ, Hall LML, Jones JD (2022) Phage therapy for diabetic foot infection 25(4): 30–7

Matthew J. Young is Consultant Physician, Royal Infirmary of Edinburgh, Edinburgh, UK;

Lesley ML Hall is Consultant Physician, Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK;

Joshua D Jones is Consultant Physician, Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, UK; Clinical Microbiology, Ninewells Hospital, NHS Tayside, Dundee, UK