Diabetic osteoartropatiya — a disease which is shown by destruction of bone and articulate tissue against the background of diabetic neuropathy. There is hypostasis, hyperaemia and pain in the field of a talocrural joint. Deformation of foot develops, mobility of joints is broken. Diagnostics is based on survey, a clinical picture, data of a X-ray analysis and tomography (foot MPT, KT). The basis of treatment is made by an immobilization of the injured extremity the special fixing bandages. Antirezorbtivny, anti-inflammatory, antibacterial means, vitamins and minerals are appointed. In the started cases it is carried out or removal of an affected area of a bone.
Diabetic osteoartropatiya (foot or Sharko's joint) - a serious illness of bone and articulate system which develops against the background of the long course of diabetes. The similar complication is characteristic of many diseases (neurosyphilis, a siringomiyeliya, injuries of a spinal cord, a leprosy, alcoholism, etc.) which are followed by the phenomena of peripheral neuropathy. In the middle of the XX century the American scientist Jordan described Sharko's joint at patients with diabetes. Prevalence of this complication in endocrinology makes 1-2%. The age of patients varies from 45 to 60 years, female persons mainly are surprised. Both feet are involved in 20% of cases in pathological process.
Reasons of a diabetic osteoartropatiya
Formation of a disease happens against the background of a polyneuropathy. When progressing diabetes myelin nervous fibers are surprised, bezmiyelinovy - keep the function. This phenomenon brings to insufficient a traffic and to reduction of durability of a bone. At violation of adequate blood circulation in the lower extremities any influence (surgery on foot, a bruise, sprain, dislocation of an ankle joint) causes strengthening of microcirculation in the struck zone. The cascade of the pathological reactions leading to development of destructive processes in a bone is started. The long current and frequent decompensations of diabetes, lack of adequate treatment, high level of glucose in blood, are capable to provoke emergence of an osteoartropatiya.
For an explanation of an etiopatogenez of a diabetic osteoartropatiya several hypotheses are offered:
- Neurotraumatic. Diabetic neuropathy leads to gradual easing of sensitivity, muscular weakness and fading of propriotseptivny reflexes. Motive function is broken, there are microinjuries and the strengthened load of separate joints. This mechanism intensifies development of osteoklast which cause demineralization and gradual destruction of bones. Loss of sensitivity leads to an unnoticed trauma and abnormal increase in volume of movements in joints.
- Neurovascular. Diabetic polyneuropathy causes violation of microcirculation and formation of the arteriovenozny shunt in the affected joint. In a bone tissue there is abnormally strengthened blood-groove, locally develops osteosinging and osteolysis, and then an osteopartropatiya.
- Synthetic. This concept assumes that violation of local blood circulation and loss of sensitivity, interacting with each other, equally lead to development of a disease. It is the most modern theory which in the best way explains the nature of development of pathology.
Symptoms of a diabetic osteoartropatiya
The disease is characterized by the gradual progressing development of symptomatology and irreversible destructive changes. More often the ankle joint and plusnepredplusnevy area of foot is surprised. During a disease allocate 4 stages:
- First stage (sharp). It is characterized by small hypostasis of foot, increase in local temperature, reddening of skin. There is no pain both when pressing a joint, and when walking. Radiological signs are insignificant, early symptoms of osteoporosis are noted.
- Second stage (subsharp). Puffiness accrues and extends, hyperaemia and a hyperthermia of foot decreases. There is a crunch in a joint, feeling of discomfort. At long bystry walking pain develops. Mobility of joints decreases. On the roentgenogram changes of a configuration of foot, fragmentation of bone structures appear.
- Third stage (chronic). There are irreversible changes of a bone skeleton, basic ability and mobility in a joint is lost. Valgusny deformation of an internal surface of foot as "foot rocking chair" is formed, toes take a kogteobrazny form. Bones become fragile, joints hyper mobile. There is pain, both when walking, and at rest. Radiological the expressed deformation of foot, is defined.
- The fourth stage (complicated). Violation of an innervation and food of soft fabrics leads to emergence of trophic ulcers and formation of diabetic foot. Patients cannot independently move, in attempt to rise there is sharp an ankle joint pain. Radiological generalized destruction of a bone tissue comes to light. This stage is irreversible and leads to full disability.
Decrease in sensitivity promotes increase in volume of free movements in a joint that involves emergence of chronic incomplete dislocations and dislocations of an ankle joint. Violation of a mineralization and blood supply of a bone tissue, formation of osteoporosis are the reasons is long not growing together changes. At a late stage of a diabetic osteoartropatiya infection of ulcers leads to development of phlegmon and an erysipelatous inflammation in the field of an ankle. At crushing purulent defeats there is osteomyelitis and gangrene of the affected extremity that is the indication for amputation.
Diagnostics of a diabetic osteoartropatiya is based on complex assessment of a clinical picture, visual survey of the struck foot, the anamnesis of a disease and inspections including the analysis of work of nervous, endocrine and musculoskeletal system. Treat the main methods:
1. A X-ray analysis of feet in 2 projections (direct and side). Reveals signs of discharge of a bone tissue, determines the level of a mineralization of bones.
2. Magnetic and resonant and computer tomography of feet. MRT of foot allows to visualize changes of soft fabrics, a microtrauma and a microcrack at initial stages of a disease. KT estimates extent of destruction of a bone, damage of a periosteum.
3. Stsintigrafiya of bones. On extent of accumulation of marked isotopes (Technetium-99m) it is possible to judge degree of activity of inflammatory process in joints and bones of foot.
4. Laboratory researches. Carry out the biochemical analysis with definition of markers of an inflammation and destruction of a bone tissue (alkaline phosphatase, hydroxyproline, , sialovy acids, etc.). In the general blood test in the sharp period of a disease the level of leukocytes and SOE increases.
5. Biopsy of a bone tissue. It is carried out for confirmation of the diagnosis in difficult and doubtful cases. Defines an etiology of bone changes.
Differential diagnostics of an osteoartropatiya against the background of diabetes is carried out with diseases of the musculoskeletal device (rheumatoid, gouty arthritis, osteoarthrosis), vessels of the lower extremities (sharp thrombophlebitis, the obliterating atherosclerosis of arteries of the lower extremities). In addition carry out UZDG of arteries and veins of the lower extremities, duplex scanning. At emergence of hypostases of feet the osteoartropatiya is differentiated with heart failure and limfostazy. Increase in local temperature and hyperaemia can indicate existence of infectious process (an erysipelatous inflammation).
Treatment of a diabetic osteoartropatiya
Main objective of treatment of foot of Sharko is the stop of destructive processes in extremities and prevention of trophic complications and changes. Treatment of a disease is carried out in several directions:
- Control of a glycemia. Regular measurement of level of sugar in blood on an empty stomach and in 2 hours after food is recommended to the patients having diabetes. For correction of hypoglycemic therapy by the patient visit of the endocrinologist of 1 times in 6 months is shown.
- Orthopedic correction. In a sharp phase of a disease carry out unloading of foot before disappearance of hyperaemia and hypostasis. Wearing the special orthopedic footwear reducing pressure upon feet when walking is recommended to patients. Carry the orthosis and an individual unloading bandage (Total Contact Cast) to additional methods of an immobilization of an extremity.
- Medicamentous therapy. At any stage of a disease purpose of antirezorbtivny medicines (bifosfonata, a calcitonin), derivative D3 vitamin and calcium is shown to patients. Nonsteroid resolvents are in addition applied to reduction of pain, hypostasis and anabolic steroids for restoration of a bone tissue. At development of infectious complications conduct an antibiotic treatment course.
- Surgical intervention. Expeditious treatment is applied at late stages of a diabetic osteoartropatiya at irreversible destructions of bones of feet, violation of basic and motive function. At patients with instability in foot creation of an artificial anchylosis of a joint is shown (). At development of osteomyelitis and not healing trophic ulcers carry out amputation of a finger or a part of foot with the subsequent performing physiotreatment.
- Additional methods. The physical therapy (magnetotherapy, laser therapy, an electrophoresis, a balneoterapiya) is applied to removal of pain, reduction of inflammatory process at all stages of a disease. These procedures it is also used during rehabilitation after surgery. At the initial stages of an osteoartropatiya physiotherapy exercises and gymnastics are shown.
Forecast and prevention
The forecast of a disease depends on degree of a diabetic osteoartropatiya. Early diagnostics and competent treatment are capable to stop process of destruction of a bone, in this case the forecast of a disease favorable. The progressing damage of a bone tissue with the advent of vascular complications leads to violation of motive function and an invalidization. Prevention of a disease includes timely visit of the endocrinologist and chiropodist, maintenance of normal level of a glycemia. In order to avoid bruises, dislocations and fractures of extremities to patients not to limit occupations to extreme sports.