BACKGROUND: Foot complications in diabetes are common and destructive, resulting in substantial healthcare costs and high rates of morbidity. Coastal areas have a significantly higher burden of disease. People with diabetes experience disproportionately high rates of psychological health issues, including anxiety, depression and diabetes distress. These can affect self-management and concordance with preventive measures and treatments of foot complications, negatively impacting on outcomes. Access to psychological health services is variable across the United Kingdom and there is a paucity of high-quality evidence for the effectiveness of treatments for diabetes distress. This study aimed to explore experiences of psychosocial burden and perceptions and experiences of psychosocial support, among patients with diabetes and foot complications living in a coastal area.
METHODS: Patients were eligible to participate if they had experienced diabetes-related foot complications (amputation, ulceration and/or Charcot neuroarthropathy) within the last 5 years and scored positive for diabetes distress on a validated screening tool (DDS2). Eligible patients completed cross-sectional questionnaires describing symptoms of diabetes distress (DDS17), anxiety (GAD-7) and depression (PHQ-9) and to take part in a face-to-face, semi-structured interview. Questionnaires were analysed using frequencies and interviews were analysed using reflexive thematic analysis.
RESULTS: A total of 183 patients completed the DDS2 screening questionnaire. Of these, 56 (30.6%) screened positive for diabetes distress. Twenty-seven patients completed DDS17, GAD-7 and PHQ-9 questionnaires. Eleven (40.7%) participants indicated high levels of diabetes distress and four (14.8%) indicated moderate distress. Seventeen participants (age range 52-81 years; 12 men) took part in an interview. Four key themes were identified: impact of living with foot problems; emotional consequences of foot problems; experiences and perceptions of psychological support; and strategies to cope with the emotional impact of foot problems.
CONCLUSIONS: Diabetes distress was prevalent among patients with diabetes-related foot complications. Foot problems impacted on participants\' daily activities, social lives and ability to work. Despite expressing feelings of ongoing fear, worry and depression relating to their foot problems, only one participant had accessed formal psychological support. Many participants relied on talking to podiatrists at routine appointments and described developing various strategies to cope. The psychosocial burden of living with foot complications in diabetes must not be overlooked by health professionals. Findings from this study can inform the design of future services and interventions.

OBJECTIVE: Our aim was to characterize the ultrasonographic features of patients with acute Charcot neuroarthropathy (CN) of the foot.
METHODS: In this prospective study, 26 patients with CN of the foot proved by MRI were enrolled. All patients were in early stage of CN with normal radiography (grade 0 modified Eichenholtz classification system). Ultrasonographic examination of mid-tarsal and ankle joints was performed with a 7-15 MHz linear probe.
RESULTS: Ages of our patients ranged from 38 to 67 years (57.3 ± 6.4). About 96.2% of our patients (25 patients) had diabetes mellitus. Ultrasonographic findings were as follows: effusion/synovitis (100%) with high Doppler activity (92.3%) in the mid-tarsal joints, and effusion/synovitis (92.3%) and high Doppler activity (84.6%) in the ankle joints. Bone erosions were present in the distal fibula in 23 patients (79.3%), while in distal tibia in 9 patients (34.6%). Tendonitis was found in tibialis posterior tendons in 23 patients (88.4%), and in peroneal tendons in 22 patients (84.6%). A combination of active synovitis (in mid-tarsal joints and ankle joints), active tendonitis (of tibialis posterior and peroneal tendons), and erosions in the distal end of fibula was present in 21 patients (80.8%).
CONCLUSIONS: Ultrasonography is able to detect soft tissue inflammation and pre-radiographic bony changes in early stages of CN. Key Points •Ultrasound is a useful diagnostic tool for pre-radiographic stages of Charcot joint. •High-grade synovitis, high-grade tenosynovitis, and bony erosions are highly suggestive of Charcot arthropathy.

Severe foot and ankle deformities can be associated with high complication rates and impaired quality of life in patients. Surgical correction using a talectomy procedure has previously been described in many lower extremity pathologies and is a powerful tool for the correction of severe foot and ankle deformity. This study aimed to describe the role of talectomy and the outcomes of this procedure in patients presenting with severe foot and ankle deformity. A review of 45 patients undergoing talectomy by a single surgeon was completed. Data extracted included the cause of deformity, history of infection, body mass index, and relevant comorbidities. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Statistical analysis was performed by using a Wilcoxon rank sum test and a Fisher exact test looking at variables affecting selected outcome measures. Limb salvage occurred in 38 of 45 patients (84.4%). Patients with an infection history had 89% lower odds of a functional limb at final follow-up (p = .0389). Six of 7 patients (85.7%) who ultimately underwent amputation had a history of prior infection. Women had 8.25 times higher odds of having a functional limb compared with men (p = .047). All 13 patients with major complications had neuropathy (p = .024). Patients with chronic lower extremity deformities can successfully be treated with a talectomy as a part of the reconstructive procedure. This is a challenging patient population that is associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring major amputation.

OBJECTIVE: To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population.
METHODS: Patients treated with a lower limb cast between 2006 and 2018 were identified using plaster room records. Their electronic records and radiological reports were reviewed for details about their cast, past medical history, and any VTE recorded in our hospital within a year of casting.
RESULTS: There were 136 episodes of casting in 100 patients. The mean age was 55 years (22 to 91). The mean time in a cast was 45 days (five days to eight months). A total of 76 patients had neuropathy secondary to diabetes. No patient received chemical thromboprophylaxis while in a cast. One VTE (0.7% of casting episodes) was documented. This was confirmed by Doppler scan nine days after removing the cast.
CONCLUSIONS: The frequency of VTE was higher than that of the general population (0.05%); this is most likely attributable to our patients\' apparent increase in VTE risk as suggested by The National Institute for Health and Care Excellence (NICE). These findings suggest that thromboprophylaxis is not routinely indicated in patients who undergo immobilization of the lower limb in a cast, although the risks of VTE should be assessed. While the cast itself does not pose an increased risk, other pathologies, such as active cancer, mean that each individual case needs to be considered on their merit. Cite this article: Bone Joint J 2019;101-B:691-694.

BACKGROUND: We evaluated treatment of osteomyelitis in the foot in the presence of Charcot neuroarthropathy, a devastating condition with progressive degeneration and joint destruction. We hypothesized that there was a difference in (1) amputation rate, (2) amputation level, (3) duration of antibiotic therapy, and (4) duration of immobilization for treatment of osteomyelitis within versus outside the Charcot zone.
METHODS: Forty patients (43 ft) diagnosed with Charcot neuroarthropathy and osteomyelitis of the same foot were retrospectively analyzed. Some patients were successfully treated for osteomyelitis at different sites on the same foot at different times, thus 60 cases of osteomyelitis were identified in 40 treated patients. Cases were divided according to osteomyelitis localization: Group 1 had osteomyelitis outside the active Charcot region; Group 2 had osteomyelitis within the active Charcot region.
RESULTS: Male patients (n = 29; mean age 58.2, range 40.1 to 77.5 years) were younger than female patients (n = 11; mean age 70.4, range 51.4 to 87.5, p = 0.02 years). Amputation rate was 52% overall (26/40 patients; 26/43 ft): 63% of 30 Group 1 cases and 40% of 30 Group 2 cases (p = 0.09). Amputation level (p = 0.009), duration of antibiotic treatment (p = 0.045) and duration of immobilization (p = 0.01) differed significantly between the groups.
CONCLUSIONS: Osteomyelitis within the Charcot region is associated with a higher level of amputation and longer durations of antibiotic therapy and immobilization. Osteomyelitis outside and within the Charcot affected region should be considered separately. If osteomyelitis occurs outside the active Charcot region, primary amputation may be preferred to internal resection.
METHODS: Retrospective cohort chart review study.

In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an alternative to plate and screw fixation. Exposure is minimized for implantation, and this technique supports the longitudinal columns of the foot as a rigid load-sharing construct. A published data review identified a paucity of data regarding metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to describe metatarsal diaphyseal morphology qualitatively and quantitatively in an effort to provide data that can be used by surgeons when selecting axially based intramedullary fixation. Twenty fresh-frozen cadaveric below-the-knee specimens were obtained. The metatarsals were exposed, cleaned of soft tissue, and axially transected at the point of the narrowest external diameter. Next, a digital caliper was used to measure the size and shape of the diaphysis of the first through fourth metatarsals. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between the endosteal cortical surfaces was measured. Triangular endosteal canals were only found in the first metatarsal, and the remainder of the metatarsal canals were largely round or oval. These data help to approximate the size of fixation needed to achieve maximal screw-endosteal purchase.

In the nineteenth century, French scientific institutions became interested in young \"mental calculators,\" arithmetical prodigies able to quickly and accurately perform complex mental calculations. The first scientists to study mental calculators were phrenologists who sought to prove the existence of a calculating organ in the frontal lobe. Paul Broca introduced one such mental calculator, Jacques Inaudi, to the Anthropological Society of Paris in 1880. Broca attributed extraordinary faculty for mental calculation to memory functioning (the psychological hypothesis) rather than physiological difference (the phrenological hypothesis). In 1892, prominent French Academy of Sciences member Jean-Martin Charcot produced a noteworthy study of Inaudi on the organization\'s behalf. Charcot observed that Inaudi called upon auditory memory rather than visual memory in his mental calculations, unlike most mental calculators who preceded him. Like Broca, Charcot was skeptical of the phrenological hypothesis, though he noted that Inaudi\'s skull was markedly plagiocephalic. Interestingly, anthropological examination of Inaudi is consistent with the themes of modern cognitive neuroscience. Thus, Charcot seems to have anticipated present research on the localization of mental calculation and memory for numbers. 1. (1)The Academy of Sciences, founded in 1666 by Louis XIV (1638-1715) with the goal of contributing to the advancement and application of the sciences in France, was one of the earliest European scientific institutions. As a prestigious society, it played an active role in defining scientific and technological research policy as well as drafting and publishing official reports.

OBJECTIVE: The aim of this study was to assess and compare the response to two forms of treatment-immobilization with zoledronic acid injection and immobilization with oral weekly Alendronate, in patients with diabetes mellitus and acute Charcot arthropathy (CA) of foot in terms of clinical and radiological parameters.
METHODS: Patients attending the endocrinology and podiatry clinic with history of diabetes mellitus and Acute CA were taken for study. The patients were randomized into two treatment groups. Group Z-zoledronic acid injection along with total contact cast (TCC). Group A-Tab. Alendronate 70 mg. once a week till the complete clinical resolution of acute CA along with TCC. Forty-five patients were randomized and 40 of them completed the study. The primary end point was complete clinical resolution of acute CA-defined as temperature difference between normal and affected foot <1°F.
RESULTS: Among the 40 patients, 30 (75%) had complete clinical resolution. The mean number of days taken for complete clinical resolution since the initiation of treatment (either Zoledronic acid or Alendronate) was approximately 122 days. There was no significant difference in a number of days required for complete clinical resolution, between the two forms of therapy. There was more than 50% reduction in the visual score between the baseline and the final scan. The target to non-target ratio in the skeletal phase also showed an average of 40% reduction from the baseline to the final skeletal scintigraphy.
CONCLUSIONS: Both Intravenous Zoledronic acid and oral alendronate had comparable efficacy with respect to the time taken for attaining complete clinical resolution of acute CA of foot. However, Alendronate therapy was cost effective among the two. (99m)Tc MDP bone scan can be used as an adjuvant to the clinical parameters in assessing the response to therapy.