Background: The pathogenesis of CN is still unknown. An increase of the bone blood supply seems to be one of the mechanisms involved. A feature of CN is a bone reabsorption. IGF-1 can influence the bone tissue by various mechanisms but its vasodilatory effects in others tissues are well-known. Alendronate have an inhibitory effect on bone reabsorption. Aim of this study is to evaluate the effect of alendronate on foot bone density in CN and above all if this effect can be mediated by a modification in IGF-1 levels.

Methods: Twenty patients with a diagnosis of acute CN of the foot were enrolled. According to the randomization, 11 patients were treated with 70 mg of alendronate per os once a week (TG) and 9 patients were followed as control group (CG). Markers of bone turnover [urinary hydroxyprolin, serum collagen carboxyl-terminal telopeptide of type 1 collagen (ICTP), serum bone alkaline phosphatase (B-ALP)], IGF-1 and BMD by dual energy X-ray absorptiometry (DEXA).

Results: ICTP didn’t show significant difference between the two groups (0,54±0,05 ng/ml vs 0,56±0,06 ng/ml p< 0,6) at the outset, after six months the treated group had a significant decrease of this parameter (0,54±0,05 ng/ml vs 0,30±0,03 ng/ml p< 0,05).

In TG hydroxyprolin followed the same trend showing a significant decrease after the six month treatment (18±3,2 mg/l vs 13±3,6 mg/l p< 0,05).

At the same time B-ALP reduction was almost significant (36±4,8% vs 23±3,9% p=0,06)

DEXA demonstrated an improvement in total foot mineralization in the TG(0,18±0,06 g/cm2 vs 0,24±0,08 g/cm2 p< 0,05) and in the distal phalanxes (0,194 g/cm2 vs 0,242 g/cm2 p< 0,01) (fig. 3). Only the TG showed a significant decrease of IGF-1 throughout the trial (142,8±24 vs 123,5±41 ng/ml p< 0,05).

Conclusions: The increase in bone blood flow could be linked to the vascular effects of IGF-1. Alendronate in acute phase helps to stop bone reabsorption and this effect could be mediated by the decrease of IGF-1 levels.

Aim: Evaluation of multifactorial treatment of Charcot foot disease in diabetic patients

Materials and Method: We followed 25 diabetic patients with Charcot foot in acute phase (Eichenholtz Stage I) from 2001 to 2003 (mean follow-up 22 months) admitted to the Day Hospital of Diabetology of the Catholic University of Rome. All patients presented a good vascularization (ABI > 0.9) and osteomielytis was excluded by means of 111Indium labelled leukocyte scintigraphy.

Six patients presented a structural derangement localized to the forefoot (Pattern I according to Sanders and Frykberg Classification), one to the ankle (Pattern IV) and 18 to the mid-foot region (Pattern II and III). At first clinical evaluation, 13 patients presented a plantar monolateral ulcer. Their treatment was multifactorial. An offloading regimen was adopted, with the use of a total contact cast and crutches, in order to avoid weight-bearing on the affected foot for the first two months. Patients responsive to the treatment were successively treated with a pneumatic cast (Air cast) and partial weight-bearing for another four months. Four unresponsive patients underwent surgical treatment. 10 patients were also treated with alendronate (70 mg per os once a week). Three patients died during treatment and one during the follow-up, three of them for cardiovascular disease, one for bronchopneumopathy.

Results: All patients reached the quiescent or chronic phase (Eichenholtz Stage III) at an average of six months from the onset of the treatment (range 3 to 9 months). No major or minor amputation was performed. Multifactorial treatment prevented the development ulcers in all patients that started the treatment without this complication (12 patients). 7 out of 13 ulcerated patients developed a recalcitrant ulcer (unresponsive to medical and orthotic treatment). 4 patients underwent surgical treatment: midfoot arthrodesis with Ilizarov external fixation (2 patients), rockerbottom deformity resection (one patient), Lelievre realignment (one patient). 3 patients healed after surgical treatment. Thus an overall amount of 9 out of 13 ulcerated patients healed after multifactorial treatment.

Conclusions: Multifactorial treatment demonstrated effective in the management of Charcot foot in diabetic patients. Medical and orthotic treatment alone is effective in preventing complication throughout the natural history of the disease. Medical and orthotic treatment alone is frequently unsuccessful in treating plantar ulcers when major deformities has already developed. Medical and orthotic treatment combined with surgical treatment demonstrated an increased percentage of success.

We performed 55 operations in 40 patients affected by diabetic foot and referred to the Diabetic Day Hospital from 1998 to 2003. Surgical procedures can be grouped as: (a) emergency operations: mostly for surgical debridment; (b) operations such as functional amputation of the limb at various levels; and (c) conservative operations such as preventive correction of deformities or restoration of morphology and function.

We performed 39 amputations; 15 conservative procedures (including ring external fixation in “Charcot foot”); and one emergency procedure (sepsis). We never used local ischaemia while operating diabetic patients. Patients follow-up ranges from 6 months to 6 years. One fourth of patients died for reasons not directly associated with diabetic foot but often related to the diabetes. The vast majority of patients mantained adequate control of the disease, wore special “diabetic shoes”, and judged the result of the operation very positively and consider their situation much improved after the operation. Surgical wound closure took from 2 to 20 weeks (mean 6 weeks). More than half of the patients can walk without support. It is relevant to note that about half of the patients had previous operations for the same problem but about 90% of the patients required no further operation after the one we performed.

Orthopaedic surgical treatment may effectively restore walking ability in those patients who lost it because of diabetic foot problems.