Charcot Neuroarthropathy in a Diabetic Patient. The Need for a Multidisciplinary Interventions

A 63-year-old male patient was diagnosed with type 2 diabetes 15 years ago (2004). An estimated 13.8% of the Spanish population has diabetes [1] and it is expected that the number of individuals with diabetes will reach 4.4% of the world population by 2030. The patient presented with dyslipidemia, polyneuropathy and ulcers in both feet with 12 years of clinical course, which have required at least fi ve hospital admissions to treat infections since the disease was diagnosed.

hallux metatarsophalangeal joint. The patient also presented with ulcers on the left foot, on the fi rst and second toes, in the plantar metatarsophalangeal region. The ulcers had been treated with multiple healing products, with poor results, for ten years. The patient had been seen by the vascular surgeon to check for a moderate ischemia. The patient had not had an Ankle-Brachial Pressure Index (ABPI) test, but he had had a Doppler ultrasonography. The patient reported that, on several occasions, a supracondylar amputation had been suggested to him, but the patient rejected this on many other occasions [3].
Lower-extremity amputations are preceded by diabetic foot ulcers in up to 85% of cases. All of these data give us a notion of the loss in the quality of life of these patients and the economic impact that this condition has on the health system.

Ongoing medical treatment on admission:
• Glargine insulin: 28units at breakfast.

Infection (I):
Wound culture was performed on two occasions due to increased exudate and lack of healing, revealing colonization by Staphylococcus aureus, which was treated with oral antibiotics given the lack of progress in healing. A probe-to-bone test was performed: the result was negative. Foot X-rays were also performed to check for possible osteomyelitis, which was discarded in principle ( Figure 3).

Infl ammation (I):
Once we verifi ed that the arterial compromise was moderate, in accordance with the vascular surgery report, we applied, with the due precautions, low-

Outcome
After two months, the ulcer on the right foot was completely closed, but the ulcer on the left foot was not. The previously established plan was followed and a foot X-ray was requested.
Subsequently, the patient visited the trauma specialist, who assessed the treatment of the Charcot neuroarthropathy and established a differential diagnosis with chronic osteomyelitis [4].
At the time of this evaluation, the patient had a 1×1cm plantar wound on the left foot, with abundant periwound hyperkeratosis, red wound bed with granulation tissue, thickened edges, occasionally macerated due to moderate to high levels of exudate. Despite wound care and the improvement in the underlying condition, complete closure of the ulcer was not achieved. The patient presented with a deformity of the sole of the foot, in the tarsometatarsal joint of the hallux [5], which was sometimes painful despite his sensory neuropathy.
The patient was informed about the X-ray results and was advised to rest as much as possible and to refrain from leaning on the left foot due to the possibility of bone fractures and complications greater than those already observed in the   X-ray. The offl oading of the foot was maximized by applying a 1.5cm felt pad and by replacing the orthopedic shoe with another orthopedic shoe with more anterior offl oading.

Research is needed
The patient has a diabetic neuropathy which had progressed poorly and resulted in severe Charcot neuroarthropathy.
Bone deformities had led the patient to rest on the sole of the foot inadequately, which, in turn, caused non-healing diabetic foot ulcers, since the fundamental cause had not been resolved. Charcot neuroarthropathy may be scientifi cally explained by neurovascular causes, by which the increase of peripheral blood in the bones of the feet produces bone resorption, demineralization and osteopenia. Due to autonomic neuropathy, sympathetic vascular tone is lost, resulting in increased perfusion. The destruction of the autonomic fi bers results in increased blood fl ow and bone hyperemia [6].
Diabetic foot patients should be treated simultaneously by professionals from multiple disciplines: endocrinologists, vascular surgeons, podiatrists, trauma specialists, and nurses, mainly. Different specialists treating the patient individually (i.e. without coordination) can prevent the correct resolution of the problems that a patient of this type may present with.
This, in turn, implies much higher costs for the health system due to the prolonged duration of the care delivered and the corresponding costs in human and material resources.
Having diabetic foot units and referral non-healing wounds units is an essential need of any health system. These units would provide benefi ts in economic terms and in terms of patients' quality of life. The X-rays included are representative of the course of Charcot neuroarthropathy in a diabetic foot that has not been treated adequately due to the lack of a coordinated multidisciplinary team, thus causing harm to both the patient and the health system.