Michael edwin Edmonds

• Professor at King's College London

Background There is emerging interest in the application of foot temperature monitoring as means of diabetic foot ulcer (DFU) prevention. However, the variability in temperature readings of neuropathic feet remains unknown. The aim of this study was to analyze the long-term consistency of foot thermograms of diabetic feet at the risk of DFU. Metho...

Aim People with active diabetic foot disease should be rapidly referred by health professionals along a pathway of care to a multidisciplinary foot team. The aim was to investigate patients' self-reported understanding of their foot risk status and reasons for their referral to a multidisciplinary foot team. Method This seven-month service evaluat...

Objective: Fractures in Charcot neuro-osteoarthropathy (CN) often fail to heal despite prolonged immobilization with below-knee casting. The aim of the study was to assess the efficacy of recombinant human parathyroid hormone (PTH) in reducing time to resolution of CN and healing of fractures. Research design and methods: People with diabetes an...

In a world where popular culture and concepts can become the norm without all the rigors of normal scrutiny, our attention is focused on identifying Charcot neuroarthropathy (CN) at a stage before radiological bone destruction occurs. The rationale is that early recognition can prevent a destructive chain of events and thus potentially reduce the b...

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to con...

Objective The aim was to assess the prognostic impact of perfusion assessments including ankle–brachial Index (ABI) and toe–brachial Index (TBI) on survival of patients who present with diabetic foot ulceration and to analyse clinical outcomes when patients are categorised into three levels of limb ischaemia. Method This was a retrospective cohort...

We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who under...

Peripheral arterial disease (PAD) is common below the knee in diabetes but arteries in the foot are controversially said to be spared of occlusive disease. This is relevant to the convenient site of vascular assessment that is recommended in guidelines. Should assessment be distal at toe/forefoot to detect foot disease or only proximal to detect di...

Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharg...

This chapter focuses on the clinical aspects of diabetic foot care. When setting up a diabetic foot clinic, one should understand that the natural history of the diabetic foot is aggressive and complex, and a special form of care is needed. In response to this complex and aggressive natural history, certain principles of care should be followed to...

Diabetic foot ulceration (DFU) is common with an estimated lifetime incidence between 19 and 34 percent and often very challenging to treat. A clear assessment of the DFU should be made to include wound characteristics, presence of features of infection and importantly, the current vascular status. There is a distinct difference in the presentation...

The differential diagnosis of a hot swollen foot falls into two parts, the infected hot swollen foot and the non‐infected hot swollen foot. The infected foot can be divided into the cellulitic foot, with no obvious skin breakdown or tissue loss and the cellulitic foot with tissue loss. Furthermore, the cellulitic foot with no tissue loss can be div...

Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharg...

Charcot neuroarthropathy (CN) or Charcot foot is a devastating complication of diabetic neuropathy, associated with an extensive bone and joint destruction, severe foot deformity, increased risk of ulceration, infection, and sometimes amputation. This chapter describes the current progress which has been made to illustrate the interaction between n...

Aim: To assess the usefulness of monthly thermography and standard foot care to reduce diabetic foot ulcer recurrence. Methods: People with diabetes (n=110), neuropathy and history of ≥1 foot ulcer participated in a single-blind multicentre clinical trial. Feet were imaged with a novel thermal imaging device (Diabetic Foot Ulcer Prevention Syste...

Diabetic foot ulceration (DFU) is one of the most feared complications of diabetes; it leads to significant morbidity and confers an increased risk of lower extremity amputation. Neuropathic DFU, defined as ulceration occurring in neuropathic feet without co-existent peripheral vascular disease, is perhaps the most common type, occurring in 50–60%...

The development of infection in the diabetic foot constitutes a foot care emergency, which requires urgent referral to a specialized foot care team. Often, the signs of infection are minimal in the presence of neuropathy, leading to a late presentation. The underlying principles of treatment are to diagnose infection early, culture the bacteria res...

The usual presentation of Charcot neuropathic osteoarthropathy (CN) is of a hot red swollen foot but later presentations are characterised by deformity and ulceration, which may be complicated by infection. Having reached the stage of significant foot deformity and sometimes ulceration, patients with CN may also have peripheral arterial disease. It...

In the modern management of the acute or active Charcot foot early diagnosis is crucial, preferably when the X-ray is still normal, although diagnostic abnormalities may be seen on the magnetic resonance imaging (MRI) scan or the single photon emission computed tomography/computed tomography (SPECT/CT) bone scan. The foot must then be immobilised a...

Charcot neuropathic osteoarthropathy (CN) or Charcot foot poses a significant challenge in clinical practice. A high clinical suspicion is needed to recognise the early presentation. The active CN presents with inflammation (redness, swelling, heat, dull ache/discomfort and loss of function). Bedside tests include assessment of neuropathy, blood su...

The approach to the diabetic foot consists of four simple steps: assessment, classification, staging and intervention. A simple assessment of the diabetic foot is described so that it is possible to classify and stage the foot, looking for eight clinical features, namely skin breakdown, infection, necrosis, ischaemia, neuropathy, deformity, callus...

The ischaemic foot may be divided into three clinical entities: the neuroischaemic foot, the critically ischaemic foot and the acutely ischaemic foot. The neuroischaemic foot is characterised by both ischaemia and neuropathy and complicated by ulcer. The perfusion is adequate to preserve the tissues intact in the absence of minor trauma and ulcerat...

Clinically, three distinct stages of diabetic foot infection may be recognised: localised infection, spreading infection and severe infection. Each of these presentations may be complicated by osteomyelitis. Localised infection refers to infection in the ulcer bed and the immediate surrounding skin. This may present with purulent discharge and limi...

The importance of the impact of neuropathy in the pathogenesis and management of the neuropathic foot is described. A pathway of limb salvage of the neuropathic foot is presented, summarising four important steps. Step 1 is debridement which removes the cellular burden of dead and senescent cells and also eliminates biofilm. Step 2 encompasses offl...

The underlying principles of medical management are to assess the severity of infection, ascertain the bacteria responsible for the infection and to treat aggressively with antibiotic therapy. Infection is usually graded, mild, moderate or severe. In some circumstances, typical signs of inflammation may be subtle or absent. It is important to have...

Infection is the greatest cause of tissue necrosis in the diabetic foot and is responsible for the majority of lower extremity amputations in diabetes. Infection plays a crucial role in the natural history of the diabetic foot, complicating ulceration in the neuropathic foot, the Charcot foot and the neuroischaemic foot. Signs and symptoms of infec...

Diabetic patients in renal failure present a major problem in terms of foot care. Neuropathy and arterial disease are present with extensive vascular calcification and this is associated with substantial risks for both morbidity and death. The classical lesion is dry digital necrosis. It may be precipitated by trauma and can spread to involve the m...

Recent management of the diabetic ischaemic foot has included consideration of the neuroischaemic foot as well as the critically ischaemic foot, both of which would be incorporated within the clinical entity of Chronic Limb Threatening Ischaemia as put forward by the Global Vascular Guidelines. This is further exemplified by the recent WIfI classif...

The total contact cast (TCC) is a useful treatment to offload neuropathic foot ulcers. The classical TCC is applied with the patient lying in a supine position, using minimal undercast padding with added protection at the bony prominences followed by a top layer of Plaster of Paris. The TCC has been modified such that it is a semi-rigid boot made o...

Objective People with diabetic neuropathy who have previously ulcerated are at high risk of re-ulceration. They should regularly attend podiatry clinics for surveillance and routine protective podiatric treatment. It has been suggested that inflammation prior to skin breakdown shows up as a hotspot on a thermal image even in the absence of clinical...

Comprehensive management of a severe diabetic foot infection focus on clear treatment pathways. Including rapid, radical debridement of all infection in addition to intravenous antibiotics and supportive measures. However, inexperienced surgeons can often underestimate the extent of infection, risking inadequate debridement, repeated theatre episod...

Objective In March 2018, the Explorer study, an international, double-blind, randomised controlled trial (RCT), established that adding a TLC-NOSF (UrgoStart Contact, Laboratoires Urgo, France) dressing to good local standard of care (SoC) significantly and substantially increases wound closure and reduces the healing time of neuroischaemic diabeti...

The conservative management of the charcot foot

This book provides a practical guide to the treatment of patients as risk from limb amputation. The most common presentations of the diabetic foot are presented in concise and evidence-based chapters covering the neuropathic foot, the Charcot foot, the ischemic foot, and the infected foot. Each section includes an introduction to the clinical appro...

Background Thermal imaging is a useful modality for identifying preulcerative lesions (“hot spots”) in diabetic foot patients. Despite its recognised potential, at present, there is no readily available instrument for routine podiatric assessment of patients at risk. To address this need, a novel thermal imaging system was recently developed. This...

Background: Various tests are used to detect diabetic peripheral neuropathy by assessing sense perception in the feet. Tests vary in terms of time and resources required. Simple tests are those that can be conducted quickly and easily in primary care without laboratory equipment. There are some limitations to these simple tests, an example being t...

The aim of this multi-center, prospective, observer-blinded, parallel group, randomized controlled trial was to assess the safety and efficacy of EDX110, a nitric oxide generating medical device, in the treatment of diabetic foot ulcers in a patient group reflecting "real world" clinical practice compared against optimal standard care. Participants...

The “diabetic foot attack” is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a hig...

Diabetic neuroarthropathy of the knee or Charcot knee (CK) is a lesser-known complication of diabetes mellitus, with a limited number of case reports and small case series published in the literature. The majority of these reports describe the complexities and challenges that arise in these patients undergoing knee arthroplasty procedures. We prese...

Peripheral arterial disease is a major risk factor for amputation in patients with diabetes. Its presentation is different from that of the occlusive arterial disease in patients without diabetes. In diabetes, peripheral arterial disease develops at a younger age and women and men are equally affected. The vascular changes have a predominantly dist...

Diabetic foot ulcers remain difficult to heal and nutritional supplementation may be an important complementary therapeutic measure. However, we need to clarify many issues before such supplementation is more widely used. Indeed, improvements are needed in the following areas: evaluation of nutritional inadequacy, completion of randomized controlle...

Background: Diabetic foot ulcers are serious and challenging wounds associated with high risk of infection and lower-limb amputation. Ulcers are deemed neuroischaemic if peripheral neuropathy and peripheral artery disease are both present. No satisfactory treatment for neuroischaemic ulcers currently exists, and no evidence supports one particular...

Recently, infrared thermography has emerged as a novel technique for early detection of inflammation and incipient tissue damage in high-risk diabetic foot patients. Several studies have demonstrated that regular temperature monitoring reduces the risk of diabetic foot ulceration (1), (2). In these studies, temperature assessment has been limited t...

There are no accepted methods to grade bone marrow oedema (BMO) and fracture on magnetic resonance imaging (MRI) scans in Charcot osteoarthropathy. The aim was to devise semiquantitative BMO and fracture scores on foot and ankle MRI scans in diabetic patients with active osteoarthropathy and to assess the agreement in using these scores. Three radi...

Aims: Diabetic complications, and in particular diabetic foot ulcers (DFUs), are associated with low health-related quality of life (HRQoL). We evaluated whether the presence of diabetic complications also influenced the improvement of HRQoL during DFU treatment. Methods: 1088 patients presenting for DFU treatment at the centers participating in...

Infrared thermal imaging has attracted attention as a possible useful modality for early detection of incipient tissue damage in high-risk diabetic foot patients. Previous studies using single spot hand-held thermometers have shown that areas with foot temperature 2.2°C or greater than the corresponding contralateral site are at risk of an ulcer. W...

In this paper a description is given of the development, characterisation and first results of a thermal imaging device aimed at significantly reducing the incidence of diabetic foot ulceration (DFU). These devices will be used in three clinical centres and in two preliminary clinical trials. The first will be on healthy volunteers to set a robust...

Background There is inadequate evidence to advise clinicians on the relative merits of swabbing versus tissue sampling of infected diabetic foot ulcers (DFUs). Objectives To determine (1) concordance between culture results from wound swabs and tissue samples from the same ulcer; (2) whether or not differences in bacterial profiles from swabs and...

Background: Health-related quality of life (HRQoL) is poor in patients with persistent diabetic foot ulcers (DFUs) and poor HRQoL predicts worse outcome in these patients. Amputation is often considered treatment failure, which is why conservative treatment is generally preferred over amputation. However, it is unclear whether minor amputation neg...

The prevalence of diabetes (DM) is constantly increasing worldwide at an alarming rate. According to the International Diabetes Federation in 2015, an estimated 415 million people globally were suffering from this condition [1]. Complications of DM account for increased morbidity, disability, and mortality and represent a threat for the economies o...

Charcot neuroarthropathy is a disabling complication of diabetic neuropathy. Prolonged immobilization in a total contact cast (TCC) is among the main treatments. Education of health care professionals in the application of TCC together with well-conducted clinical trials are required to overcome its frequent underuse. There are no established pharm...

Category Diabetes Introduction/Purpose Charcot osteooarthropathy (CN) is a debilitating condition afflicting the bone, soft tissue and joints of foot and ankle and is related to pain insensitivity. Its pathogenesis and natural progression is poorly understood. In patients with high clinical suspicion, treatment with immediate off-loading and immob...

Category Diabetes Introduction/Purpose Charcot neuroarthropathy (CN) of the foot can cause severe bone and joint destruction. The aim of reconstruction is to correct the deformity and achieve bone fusion, in order to provide a plantigrade foot to ambulate with using accommodative footwear. Column beaming using the Medial Column Fusion Bolt (MCB) i...

Abstract on looking for temperature differences between left and right feet in healthy volunteers

Diabetes is a growing problem globally; approximately 387 million people are living with diabetes worldwide and it is estimated to rise to 592 million by 2035. In the UK, five million people will be living with diabetes by 2025, with foot related problems amongst diabetes sufferers currently costing the NHS around £650 million annually, projected t...

There are an estimated 3.3M people with diabetes in the UK, rising to >5M by 2025. Up to 50% experience foot neuropathy which can result in extensive skin damage, leading to ulceration, infection and amputation. This train of events is largely avoidable with an estimated 80% reduction in amputations if early preventative action is taken. It has be...

Diabetic foot ulcer (DFU) patients have a greater than twofold increase in mortality compared with nonulcerated diabetic patients. We investigated (a) cause of death in DFU patients, (b) age at death, and (c) relationship between cause of death and ulcer type. This was an eleven-year retrospective study on DFU patients who attended King’s College H...

The patient with a diabetic foot is extremely complex and vulnerable to tissue necrosis because three great pathologies come together in the diabetic foot: neuropathy, ischaemia and infection. As a result of neuropathy, the signs and symptoms of external physical insults and of infection may be minimal. Nevertheless, the pathology emanating from su...

In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 a...

Charcot neuro‐osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Ch...

The guest editors wish to thank all the authors who submitted their work for consideration for this special issue and the reviewers who evaluated the papers. Without their efforts and valuable contribution, this special issue would not have been published.

We hypothesised that tumour necrosis factor-α (TNF-α) may enhance receptor activator of nuclear factor-κβ ligand- (RANKL-) mediated osteoclastogenesis in acute Charcot osteoarthropathy. Peripheral blood monocytes were isolated from 10 acute Charcot patients, 8 diabetic patients, and 9 healthy control subjects and cultured in vitro on plastic and bo...

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we at...

Background Although great progress has been made in managing diabetic foot disease, it continues to carry significant morbidity and mortality. Obstructive sleep apnoea (OSA) and diabetes frequently coexist and recent studies suggest significant under-recognition of OSA in those with diabetes. There are no current reports on the direct clinical impa...

Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification...

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaestheti...

The mainstay of medical management of osteomyelitis of foot and ankle is the use of antimicrobials. However, the available literature on the medical treatment of osteomyelitis in the foot and ankle is inconclusive to determine the best agent, route, or duration of antibiotic therapy. This chapter aims to summarize the available guidelines on the me...

Because of the severe morbidity and mortality associated with diabetes, diabetic foot care is an essential component of a peripheral vascular service. The goal of this article is to describe the vascular diabetic foot care pathway and how the coordinated foot care service for diabetic patients is delivered at King's College Hospital, London.

AimsTo assess markers of inflammation and bone turnover at presentation and at resolution of Charcot osteoarthropathy.Methods We measured serum inflammatory and bone turnover markers in a cross-sectional study of 35 people with Charcot osteoarthropathy, together with 34 people with diabetes and 12 people without diabetes. In addition, a prospective...

The natural history of the diabetic foot is aggressive and complex. To counteract this, we describe the transformation of a Multidisciplinary Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit, which delivers an emergency open access system for patients, with a "one-stop," same day service in which investigations are performed, re...

This paper describes important aspects of the diabetic foot which the vascular surgeon needs to understand to efficiently manage the diabetic foot. Firstly, it emphasises the three main pathologies which come together in the diabetic foot, namely neuropathy, ischemia and immunopathy, the latter predisposing to infection. As a result of neuropathy,...

https://onlinelibrary.wiley.com/doi/epdf/10.1111/dme.12378_2

We hypothesized that newly formed osteoclasts from patients with acute Charcot osteoarthropathy can resorb surfaces of bone more extensively compared with controls. Peripheral blood monocytes, isolated from eight Charcot patients and nine controls, were cultured in vitro on 24-well plates and bovine bone discs in duplicate with macrophage colony-st...

Objective Low health-related quality of life (HRQoL) has been consistently reported to be associated with poor prognosis for a variety of health outcomes in various settings. We aimed to evaluate whether HRQoL in patients presenting with new diabetic foot ulcers has prognostic significance for ulcer healing, major amputation and death.Research desi...

OBJECTIVE To compare X-ray and MRI as diagnostic tests of active Charcot neuro-osteoarthropathy (CNO) in diabetes. RESEARCH DESIGN AND METHODS X-rays and MRI scans of 48 participants were rated for severity of fracture (0 = no fracture, 1 = fracture, 2 = collapse/fragmentation), and for absence/presence of bone marrow edema (BME) on MRI and absenc...

In November 1883, Jean-Martin Charcot and Charles Féré reported on bone and joint disease of the foot in cases of tabes dorsalis, and referred to the condition as 'pied tabétique'-a disabling neuropathic osteoarthropathy that we usually now refer to as the Charcot foot. Charcot had originally described neuropathic osteoarthropathy in more proximal...

Aim: To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors. Methods: A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-se...

Objective: This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI). Methods: Between 2004 and 2011, patients...

We hypothesised that tumour necrosis factor-í µí»¼ (TNF-í µí»¼) may enhance receptor activator of nuclear factor-í µí¼…í µí»½ ligand-(RANKL-) mediated osteoclastogenesis in acute Charcot osteoarthropathy. Peripheral blood monocytes were isolated from 10 acute Charcot patients, 8 diabetic patients, and 9 healthy control subjects and cultured in vitr...

Diabetic patients suffer a high rate of amputation. There are two main reasons; infection which can spread rapidly leading to overwhelming tissue destruction and severe peripheral arterial disease. Studies that have stratified patients according to the presence or absence of both peripheral arterial disease and infection have shown significantly wo...