Диабетическая нейроостеоартропатия Шарко: обзор патологии и опыт амбулаторного лечения

Демина А.Г., Бреговский В.Б., Карпова И.А. Диабетическая нейроостеоартропатия Шарко: обзор патологии и опыт амбулаторного лечения. Consilium Medicum. 2020; 22 (4): 55–60. DOI: 10.26442/20751753.2020.4.200130

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Demina A.G., Bregovskii V.B., Karpova I.A. Charcot diabetic neuroosteoartropathy: review of pathology and outpatient care experience. Consilium Medicum. 2020; 22 (4): 55–60. DOI: 10.26442/20751753.2020.4.200130

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Аннотация

Среди проявлений синдрома диабетической стопы диабетическая нейроостеоартропатия – ДНОАП (артропатия Шарко) занимает особое место. Частота выявления новых случаев ДНОАП в кабинетах «Диабетическая стопа» в Санкт-Петербурге в 2019 г. колебалась от 0,19 до 1,68% от принятых за год пациентов. Данная патология в большинстве случаев поздно диагностируется, что приводит к развитию тяжелых деформаций стопы вплоть до потери опороспособности конечности. Выраженные деформации и отек конечности в активную стадию процесса сопровождаются высоким риском повреждения, его инфицирования и риском ампутации. В статье представлены основные сведения об эпидемиологии, патогенезе, клинической картине и лечении ДНОАП, необходимые практикующему врачу вне зависимости от его специализации. Представлены результаты лечения активной стадии артропатии Шарко в условиях амбулаторного кабинета «Диабетическая стопа» с 2010 по 2020 г. (n=136). Выявлено преимущество индивидуальной разгрузочной повязки над туторами: медиана длительности лечения составила 9 (4–28) мес и 13 (6–20) мес соответственно; р<0,05. Охарактеризованы препятствия для широкого применения индивидуальных разгрузочных повязок у этой категории больных. Проведено сравнение результатов лечения в 2010–2014 гг. и в 2015–2020 гг.: частота отказа от иммобилизации снизилась с 49,6 до 30,9% (р<0,05), а медиана длительности иммобилизации – с 9 до 7 мес (р<0,05). На основании изучения опыта лечения пациентов со стопой Шарко авторами предложены организационные меры, которые позволили увеличить приверженность пациентов лечению и улучшить его результаты.

Ключевые слова: диабетическая стопа, диабетическая нейроостеоартропатия, стопа Шарко, сахарный диабет.

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Among symptoms of diabetic foot syndrome diabetic neuroosteoartropathy (Charcot foot) has a special place. Charcot foot occurrence in “diabetic foot” offices in Saint Petersburg in 2019 ranged from 0.19 to 1.68% patients. This pathology is diagnosed late in most cases that results in development of severe foot deformity until support ability of the limb is lost. Severe limb deformity and swelling in active disease stage are associated with high risk of injures, infection development and risk of amputation. The article presents essentials of epidemiology, pathogenesis, clinical presentation, and treatment of Charcot foot that are important for all medical practitioners regardless of postgraduate medical training. Results of active stage Charcot foot treatment in outpatient “diabetic foot” offices from 2018 to 2020 years are presented (n=136). Advantages of total contact cast use over removable cast walkers were found: median if treatment duration was 9 (4–28) months and 13 (6–20) months, respectively; р<0.05. Obstacles of wide use of total contact cast in these patients are characterized. Comparison of treatment results in 2010–2014 years and 2015–2020 years was performed, it was shown that frequency of immobilization refusal decreased from 49.6 to 30.9% (р<0.05), and median of immobilization duration time decreased from 9 to 7 months (р<0.05). Based on the research of experience of Charcot foot patients treatment the authors suggested organizational measures that allowed increasing patients’ compliance and improve treatment results.

Key words: diabetic foot, diabetic neuroosteoartropathy, Charcot foot, diabetes mellitus.

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Список литературы

1. Rogers L, Frykberg R, Armstrong D et al. The Charcot Foot in Diabetes. Diabetes Care 2011; 34: 2123–9.
2. Sohn M, Lee L, Stuck R et al. Mortality risk of charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone. Diabetes Care 2009; 32: 816–21.
3. Sohn M, Stuck R, Pinzur M et al. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care 2010; 33: 98–100.
4. McEwen L, Ylitalo K, Herman W. Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD). J Diabetes Complications 2013; 27: 588–92.
5. Younis B, Shahid A, Arshad R et al. Charcot osteoarthropathy in type 2 diabetes persons presenting to specialist diabetes clinic at a tertiary care hospital. BMC Endocrine Disorders 2015; 15 (28). http://doi.org/10.1186/s12902-015-0023-4
6. Watkins P, Edmonds M. Sympathetic nerve failure in diabetes. Diabetologia 1982; 25: 73–7.
7. Stevens M, Edmonds M, Foster A. Selective neuropathy and preserved vascular responses in the diabetic Charcot foot. Diabetologia 1992; 35: 148–54.
8. Baker N, Green A, Krishnan S et al. Microvascular and C-fiber function in diabetic charcot neuroarthropathy and diabetic peripheral neuropathy. Diabetes Care 2007; 30: 3077–9.
9. Yasuda H, Shima N, Nakagawa N et al. Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclasto-genesis-inhibitory factor and is identical to TRANCE/RANKL. Proc Natl Acad Sci USA 1998; 95: 3597–602.
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[Iaroslavtseva M.V., Ul'ianova I.N., Galstian G.R. Sistema osteoprotegerin (OPG) – ligand retseptora-aktivatora iadernogo faktora kappa-V (RANKL) pri diabeticheskoi neiroosteoartropatii i obliteriruiushchem ateroskleroze arterii nizhnikh konechnostei. Sakharnyi diabet. 2007; 10: 24–7 (in Russian).]
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[Pavliuchenko C.V., Zhdanov A.I., Orlova I.V. Sovremennye podkhody k khirurgicheskomu lecheniiu neĭroosteoartropatii Sharko (obzor literatury). Travmatologiia i ortopediia Rossii. 2016; 22: 114–23 (in Russian).]
27. Демина А.Г., Бреговский В.Б., Карпова И.А., Цветкова Т.Л. Изменения распределения нагрузки под стопой Шарко в отдаленные сроки неактивной стадии. Сахарный диабет. 2018; 21: 99–104.
[Demina A.G., Bregovskii V.B., Karpova I.A., Tsvetkova T.L. Izmeneniia raspredeleniia nagruzki pod stopoi Sharko v otdalennye sroki neaktivnoi stadii. Sakharnyi diabet. 2018; 21: 99–104 (in Russian).]
28. https://iwgdfguidelines.org/wp-content/uploads/2019/05/IWGDF-Guidelines-2019.pdf

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1. Rogers L, Frykberg R, Armstrong D et al. The Charcot Foot in Diabetes. Diabetes Care 2011; 34: 2123–9.
2. Sohn M, Lee L, Stuck R et al. Mortality risk of charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone. Diabetes Care 2009; 32: 816–21.
3. Sohn M, Stuck R, Pinzur M et al. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care 2010; 33: 98–100.
4. McEwen L, Ylitalo K, Herman W. Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD). J Diabetes Complications 2013; 27: 588–92.
5. Younis B, Shahid A, Arshad R et al. Charcot osteoarthropathy in type 2 diabetes persons presenting to specialist diabetes clinic at a tertiary care hospital. BMC Endocrine Disorders 2015; 15 (28). http://doi.org/10.1186/s12902-015-0023-4
6. Watkins P, Edmonds M. Sympathetic nerve failure in diabetes. Diabetologia 1982; 25: 73–7.
7. Stevens M, Edmonds M, Foster A. Selective neuropathy and preserved vascular responses in the diabetic Charcot foot. Diabetologia 1992; 35: 148–54.
8. Baker N, Green A, Krishnan S et al. Microvascular and C-fiber function in diabetic charcot neuroarthropathy and diabetic peripheral neuropathy. Diabetes Care 2007; 30: 3077–9.
9. Yasuda H, Shima N, Nakagawa N et al. Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclasto-genesis-inhibitory factor and is identical to TRANCE/RANKL. Proc Natl Acad Sci USA 1998; 95: 3597–602.
10. Jeffcoate W. Vascular calcification and osteolysis in diabetic neuropathy – is RANK-L the missing link? Diabetologia 2004; 47: 1488–92.
11. Iaroslavtseva M.V., Ul'ianova I.N., Galstian G.R. Sistema osteoprotegerin (OPG) – ligand retseptora-aktivatora iadernogo faktora kappa-V (RANKL) pri diabeticheskoi neiroosteoartropatii i obliteriruiushchem ateroskleroze arterii nizhnikh konechnostei. Sakharnyi diabet. 2007; 10: 24–7 (in Russian).
12. Mabilleau G, Edmonds M. Role of neuropathy on fracture healing in Charcot neuro-osteoarthropathy. J Musculoskelet Neuronal Interact 2010; 10: 84–91.
13. Petrova NL, Petrov PK, Edmonds ME, Shanahan CM. Inhibition of TNF-a Reverses the Pathological Resorption Pit Profile of Osteoclasts from Patients with Acute Charcot Osteoarthropathy. J Diabetes Res 2015; 2015: 917945.
14. Korzon-Burakowska A, Jakóbkiewicz-Banecka J, Fiedosiuk A et al. Osteoprotegerin gene polymorphism in diabetic Charcot neuroarthropathy. Diabet Med 2012; 29: 771–5.
15. Bruhn-Olszewska B, Korzon-Burakowska A, Węgrzyn G et al. Prevalence of polymorphisms in OPG, RANKL and RANK as potential markers for Charcot arthropathy development. Sci Rep 2017; 7: 501.
16. Milne T, Rogers J, Kinnear E et al. Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-arthropathy: a systematic review. J Foot Ankle Res 2013; 30.
17. Chantelau E, Grützner G. Is the Eichenholtz classification still valid for the diabetic Charcot foot? Swiss Med Wkly 2014. https://smw.ch/article/doi/smw.2014.13948
18. http://cr.rosminzdrav.ru/#!/schema/963
19. http://cr.rosminzdrav.ru/#!/schema/970#doc_a3
20. Chantelau E, Richter A. The acute diabetic Charcot foot managed on the basis of magnetic resonance imaging – a review of 71 cases. Swiss Med Wkly 2013; 143: w13831
21. Game F, Catlow R, Jones G et al. Audit of acute Charcot's disease in the UK: the CDUK study. Diabetologia 2012; 55: 32–5.
22. Armstrong D, Lavery L. Acute Charcot's Arthropathy of the Foot and Ankle. Phys Ther 1998; 78: 74–80.
23. Jude E, Selby P, Burgess J et al. Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetologia 2001; 44: 2032–7.
24. Pitocco D, Ruotolo V, Caputo S et al. Six-month treatment with alendronate in acute Charcot neuroarthropathy. A randomized controlled trial. Diabetes Care 2005; 28: 1214–5.
25. Busch-Westbroek T, Delpeut K, Balm R et al. Effect of Single Dose of RANKL Antibody Treatment on Acute Charcot Neuro-osteoarthropathy of the Foot. Diabetes Care 2018; 41: e21–e22.
26. Pavliuchenko C.V., Zhdanov A.I., Orlova I.V. Sovremennye podkhody k khirurgicheskomu lecheniiu neĭroosteoartropatii Sharko (obzor literatury). Travmatologiia i ortopediia Rossii. 2016; 22: 114–23 (in Russian).
27. Demina A.G., Bregovskii V.B., Karpova I.A., Tsvetkova T.L. Izmeneniia raspredeleniia nagruzki pod stopoi Sharko v otdalennye sroki neaktivnoi stadii. Sakharnyi diabet. 2018; 21: 99–104 (in Russian).
28. https://iwgdfguidelines.org/wp-content/uploads/2019/05/IWGDF-Guidelines-2019.pdf

Авторы

А.Г. Демина*, В.Б. Бреговский, И.А. Карпова

СПб ГБУЗ «Городской консультативно-диагностический центр №1», Санкт-Петербург, Россия
*ans.dem@bk.ru

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Anastasiia G. Demina*, Vadim B. Bregovskii, Irina A. Karpova

City Consultative and Diagnostic Centre №1, Saint Petersburg, Russia
*ans.dem@bk.ru

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