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A New Natural History of Charcot Foot: Clinical Evolution and Final Outcome of Stage 0 Charcot Neuroarthropathy in a Tertiary Referral Diabetic Foot Clinic

Ruotolo, Valeria MD*; Di Pietro, Barbara MD; Giurato, Laura MD*; Masala, Salvatore MD; Meloni, Marco MD*; Schillaci, Orazio MD†‡; Bergamini, Alberto MD§; Uccioli, Luigi MD*

doi: 10.1097/RLU.0b013e318292eecb
Original Articles

Purpose The purpose of this study is to describe the usefulness of 18F-FDG PET/CT scanning in the diagnosis and follow-up of stage 0 Charcot foot (CNO) and CNO outcomes when therapeutic options are driven by this image modality.

Patients and Methods We selected 25 out of 40 diabetic patients with an acute CNO, without any bone involvement at x-ray (stage 0 CNO). Diagnostic criteria were inflammatory clinical signs of the affected foot and skin temperature difference greater than 2°C compared with the contralateral foot (ΔT). All patients underwent x-ray, MRI, and 18F-FDG PET/CT scanning (expressed as standardized uptake value, SUVmax) at baseline (T0). All patients underwent another 18F-FDG PET/CT within 1 month after ΔT was less than 2°C [clinical recovery (T1)] and again every 3 months until SUVmax was less than 2 [final recovery (T2)]; at this time, MRI confirmed the end of the inflammatory condition.

Results T0 ΔT was 3.04 ± 1.65°C. All patients showed T0 SUVmax of the affected foot higher than the contralateral one (3.83 ± 1.087 vs. 1.24 ± 0.3; P < 0.001). At clinical recovery (T1), defined by ΔT below 2°C, the inflammatory signs were no longer present (T0 vs. T1 ΔT = 3.04 ± 1.65 vs. 0.9 ± 0.55°C; P < 0.0001). At T1, SUVmax was unchanged from T0 (3.80 ± 1.69 vs. 3.83 ± 1.09; P = ns).

At final recovery (T2), ΔT was 0.74 ± 0.29°C (similar to T1 ΔT), while the SUVmax dropped from T1 to T2 (3.8 ± 1.69 vs. 1.72 ± 0.52; P < 0.0001). Standard therapy was total contact cast and removable cast walker until T2 (15.12 ± 5.45 mo). No patient developed foot bone fractures nor had relapses during follow-up (21.75 ± 16.7 mo).

Discussion PET/CT scan allows the quantification of the inflammatory process; therefore, it may drive clinical decisions in the management of acute CNO better than clinical criteria. None of our patients developed foot bone fractures or had relapses during follow-up driven by PET/CT scan.

From the Departments of *Internal Medicine, †Diagnostic Imaging and Interventional Radiology, Rome; ‡Neuromed IRCCS Pozzilli, Province of Isernia; and §Department of Public Health, University of Tor Vergata, Rome, Italy.

Received for publication October 26, 2012; revision accepted March 9, 2013.

Conflicts of interest and sources of funding: none declared.

The work has been entirely done at the Policlinico Tor Vergata, Rome, Italy.

Reprints: Luigi Uccioli, MD, Policlinico Tor Vergata, viale Oxford 81, 00133 Rome, Italy. E-mail:

© 2013 by Lippincott Williams & Wilkins