Original article
Role of the General Surgeon in the Early Diagnosis and Treatment of Charcot’ Foot
Papel del cirujano general en el diagnóstico y tratamiento precoz del pie de Charcot
Rafael Sellés Dechent
, Camilo Rueda Alcárcel, Vicent Primo Romaguera, Asunción Martínez Caamaño, Francisco Asencio Arana
Corresponding author
Servicio de Cirugía General, Hospital Arnau de Vilanova, Valencia, Spain
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(b) X-ray showing Sanders’ Charcot Foot type <span class="elsevierStyleSmallCaps">II</span> affecting the Lisfranc joint. Prior amputation of the 5th toe.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Charcot Foot (CF) or Charcot's neuroarthropathy (CN) consists of a progressive deterioration of bones and joints, mainly in the ankle and foot, especially in patients with a severe neuropathy. Diabetes mellitus (DM) is currently the most frequent cause of neuropathic arthropathy.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> The great problem is that it can be confused with other processes, delaying proper diagnosis and treatment. This encouraged us to perform a retrospective study to record all diagnosed cases of CF amongst the diabetic population, and to highlight the importance of the role of the general surgeon in early detection and initial treatment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">A retrospective study was performed where the diagnosed cases of CF amongst the diabetic population of our Department of Health were recorded and the literature is reviewed. We collected data regarding age, gender, medical history, type of diabetes, surgical history and prior ailments of the foot, symptoms, average time of evolution, physical examination, vital signs, complementary tests, radiological information, anatomical classification, applied treatment, hospital stay and follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">From January 2008 to December 2012, 4965 patients were treated in the Emergency Room with a diagnosis of diabetic foot. During this period, 7 cases were diagnosed with CF (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), representing a prevalence of 1:710. The average age of the patients was 61.1 years old (minimum 48, maximum 73). As for gender, 100% of patients were male. All patients had DM for more than 10 years, 4 patients were type <span class="elsevierStyleSmallCaps">I</span> and 3 patients were type <span class="elsevierStyleSmallCaps">II</span>. In addition, 4 patients had high blood pressure, COPD, heart disease and dyslipidaemia. In all cases the right foot was affected, except for one patient (left foot). Three patients had surgical history of a toe amputation due to gangrene, and 6 of them also suffered from or had suffered from diabetic foot ulcers (DFUs). 100% of patients went to the Emergency Room. The symptoms for which all patients consulted were light pain and swelling of the foot. During clinical exploration, 4 patients showed oedema and erythema of the foot. In addition, 3 patients evidenced great deformity of the foot or toes along with DFUs. All patients showed signs of severe neuropathy in the lower limbs. Two of the patients had already been treated in the Emergency Room a month before, and they were diagnosed erroneously with cellulitis and treated with anti-inflammatory medication, antibiotics and rest for the limb. The average time of delay in diagnosis was 10 weeks (minimum 1, maximum 24). In the Emergency Room, all patients had a simple X-ray (Rx) of the foot done in 2 projections, blood tests and vital signs taken. No patient had leukocytosis, neutrophilia, or fever. Once admitted, magnetic resonance imaging (MRI) scans and blood tests were performed. None had altered parameters of C-reactive protein or erythrocyte sedimentation rate. The glycosylated haemoglobin (HbA1c) levels had increased in 100% of patients, the medium being 10.8% (minimum 7.9%; maximum 13.2%). The Endocrinology department was consulted to adjust blood sugar levels and the Orthopaedics department was consulted to agree on the type of orthosis. The most frequent radiological formation was the atrophic (5 patients) and then the hypertrophic (2 patients). The anatomical classification was recorded according to Sanders’ classification: 5 patients type <span class="elsevierStyleSmallCaps">I</span>, one patient type <span class="elsevierStyleSmallCaps">II</span> and a case simultaneously involving affecting zones <span class="elsevierStyleSmallCaps">II</span>, <span class="elsevierStyleSmallCaps">III</span> and <span class="elsevierStyleSmallCaps">IV</span>. The initial treatment consisted of the rest in bed with the limb elevated and immobilisation of the limb using a Denis Browne splint. For getting up, the patient used crutches or a wheelchair. Once the oedema decreased, a method of offload was used, according to the type of anatomy. Patients with Sanders’ CF type <span class="elsevierStyleSmallCaps">I</span> used an orthopaedic shoe with offload in the forefoot, and for the remaining patients (Sanders’ CF types <span class="elsevierStyleSmallCaps">II</span>, <span class="elsevierStyleSmallCaps">III</span> or <span class="elsevierStyleSmallCaps">IV</span>) a <span class="elsevierStyleItalic">controlled ankle movement</span> (CAM) Walker<span class="elsevierStyleSup">®</span> orthosis was placed. To compensate, an adapted shoe was placed in the other foot and crutches were used to facilitate mobility. The average stay was 14.8 days (minimum 7, maximum 33). The average follow-up time was 30 months (minimum 3, maximum 54). During the consultation, the physician carried out a physical examination and took the temperature of the feet with a thermometer, and X-rays or MRI scans were periodically requested to confirm the bone consolidation of the joint. The evolution was favourable in 5 patients, with consolidation of the joint and the maintenance of the stability of the foot with orthopaedic shoes; one patient required trans-metatarsal amputation due to a deterioration and another patient died due to acute heart disease.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">The CF was first described by Charcot<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> in patients with Tabes dorsalis due to neurosyphillis, but the link between CF and diabetes was made by Jordan,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> which is today the most frequent cause, although other neurological processes can present it, such as siringomielia, leprosy, heavy metal deposits or peripheral nerve injury.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Diabetic foot, together with its complications, like CF, is a multidisciplinary disease that must be handled by different specialists, but the general surgeon plays a very important role, since the patient goes to the Emergency Room whenever he/she has any problem, and there, the general surgeon assesses and performs a diagnosis for the initial treatment of the patient, before irreversible complications are caused, which may involve amputation of the limb. In fact, there are authors who define CF as a “medical emergency”.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> When we reviewed the literature, we noticed that CF publications are in medical journals of diabetes, Rheumatology, Rehabilitation, Traumatology, Vascular Surgery, and so on, but they are not in journals of General Surgery. All of this encouraged us to perform a retrospective study of all patients diagnosed with CF in our hospital in the last 5 years, and above all, to try to disseminate it in a General Surgery publication.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite the fact that the incidence and prevalence of CF is unknown, because patients are erroneously or belatedly diagnosed, it is estimated that CF affects 0.8%–8% of diabetic patients. The incidence is 3–11.7/1000 patients a year.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> From 2008 to 2012, 7 cases have been diagnosed at our centre, which represent a prevalence of 1/710, approximate to the literature. Up to 25% of the cases are bilateral<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>; in our series, 100% are unilateral. It is more common in type <span class="elsevierStyleSmallCaps">I</span> diabetic patients in their 50s or 60s who have had DM for more than 10 years.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,7</span></a> In our study, the average age of the patients was 61.1 years; 4 suffered from DM type <span class="elsevierStyleSmallCaps">I</span> and 3 suffered from DM type <span class="elsevierStyleSmallCaps">II</span>. The pathogenesis is unknown but it is probably a combination of traumatic and vascular factors due to peripheral neuropathy. There are 2 hypotheses: neurovascular (French) and neurotraumatic (German) which, although they differ in the initial cause, they agree that the changes in the bone structure determine an anomalous load distribution that favours the appearance of ulcers, fractures, and calluses. Inflammatory Cytokines that stimulate the formation of osteoclasts<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,6–9</span></a> have recently been incorporated. In terms of gender, there are no differences between men and women,<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,10</span></a> although our series featured all males. Having reviewed the literature, we found that some patients attended the Emergency Room,<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,11</span></a> others to offices for other reasons<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> and in most cases, there is no evidence.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10,13–15</span></a> All our patients went to the Emergency Room, none went to outpatient clinics, which means that all patients were assessed by the general surgeon on call.</p><p id="par0030" class="elsevierStylePara elsevierViewall">CF during the acute phase is characterised by “hot foot”, with erythema, oedema and mild pain on a neuropathic basis. The skin temperature raises 2–6 degrees compared to the skin in the other foot.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,6,7,16</span></a> In the chronic phase, the erythema and elevated temperature disappear and deformities develop.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> In our series, everyone was diagnosed in the acute phase. CF must be suspected for a diabetic patient with a long history of oedema, warm temperatures and unilateral flushing of the foot, absence or mild pain and deformity and instability of the joint (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Two of our patients were diagnosed erroneously with cellulitis. The average time of delay in diagnosis in our series was 10 weeks (minimum 1, maximum 24). In a study of Pakarinen,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> the diagnosis was delayed an average of 29 weeks.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">CF diagnosis is essentially clinical<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a>; a differential diagnosis should be made, especially against cellulitis, osteomyelitis, DVT, gout and arthritis.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,6,7,11,16</span></a> Brodsky<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,19,20</span></a> described a procedure that involves raising the affected limb for 10<span class="elsevierStyleHsp" style=""></span>min with the patient in prone position; in the case of a CF, the oedema and erythema vanish, whereas the infection remains. Laboratory analyses are not diagnostic of CF but they can help to differentiate it from other infections.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">.</span><a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> In our study, everyone had normal levels of white blood cells, C-reactive protein and the erythrocyte sedimentation rate. In early stages, the X-ray can be normal.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,11,21</span></a> As the disease progresses, radiographic findings appear. Bone changes associated with the neuroarthropathy are classified radiographically into atrophic and hypertrophic. The hypertrophic form is the most common: it occurs in the midfoot, hindfoot and ankle, and is characterised by fragmentation, destruction of joints, bone luxations, fractures and bone spurs. The atrophic form is not so common; it is located in the forefoot and is characterised by bone resorption and small fracture lines. The metatarsals have a radiographic image that resembles a “pencil point” or “skinny sugar cane”.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,7,14,20</span></a> In our patients, the atrophic form was the most frequent (5 cases) and the hypertrophic form occurred in 2 patients. MRI can detect changes in early stages and is the test most frequently used; it is also useful to differentiate it from osteomyelitis.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,11</span></a> In CF, the bone lesion is usually multiple, the cortex is not compromised and the lesion is self-limited. On the other hand, in osteomyelitis, it is usually unique, the cortex is compromised and the lesion is not self-limited.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> There is no definitive diagnostic test to distinguish CF from osteomyelitis; however, the 3-phase bone scan with Tc-99m, followed by In-111 with marked leukocytes, has shown a high sensitivity and specificity.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,8</span></a> The PET-CT scan is also very reliable to differentiate CF from osteomyelitis.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,8,11</span></a> The MRI scan is available at our centre; the rest of the tests have to be requested to the reference Hospital centre and are therefore, more difficult to obtain.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The evolution of CF usually follows a clinical–radiological pattern that was described by Eichenholtz in 3 stages: fragmentation, coalescence and reconstruction. There is a previous stage (stage 0) described by other authors,<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11,20,23</span></a> characterised by a “hot foot” with normal radiological findings, which may be confused with an infection. The “hot foot” also happens in stage <span class="elsevierStyleSmallCaps">I</span>, but the X-ray shows osteopenia, subluxations, fractures, and peri-articular fragmentation. Stage <span class="elsevierStyleSmallCaps">II</span> is characterised by decreased oedema and warm temperature; radiographically, it shows bone resorption, fusion of bone fragments and sclerosis. In stage <span class="elsevierStyleSmallCaps">III</span> there is an absence of inflammation and a more stable foot, though often deformed; radiologically, it shows osteophytes, subchondral sclerosis and a decrease of space joint.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,10,11,16,17,20</span></a> All patients in our series were diagnosed in stage <span class="elsevierStyleSmallCaps">I</span>. Sanders and Frikberg<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> made a classification of CF depending on the anatomic area affected: type <span class="elsevierStyleSmallCaps">I</span> affects the forefoot, namely the metatarsal-phalangeal and interphalangeal joints, and can be confused with osteomyelitis or osteoarthritis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Type <span class="elsevierStyleSmallCaps">II</span> affects the Lisfranc joint, which is the joint most commonly affected in this disease (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Type <span class="elsevierStyleSmallCaps">III</span> affects the Chopart joint and the typical “rocking-chair foot” may occur, as well as type <span class="elsevierStyleSmallCaps">II</span>, due to midfoot sinking, which causes a predisposition to ulcerations (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). Type <span class="elsevierStyleSmallCaps">IV</span> affects the ankle and type <span class="elsevierStyleSmallCaps">V</span> affects the heel bone.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,10,17,24,25</span></a> As for our patients, the most frequent was type <span class="elsevierStyleSmallCaps">I</span> (5 patients). A patient showed symptoms of type <span class="elsevierStyleSmallCaps">II</span> and another patient had several areas affected at once (types <span class="elsevierStyleSmallCaps">II</span>–<span class="elsevierStyleSmallCaps">IV</span>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The initial treatment for CF in acute phases (stages 0 and <span class="elsevierStyleSmallCaps">I</span>) is the immobilisation and offload of the affected limb, to prevent the disease from progressing and deformities from occurring. The total contact cast (TCC) is the <span class="elsevierStyleItalic">gold standard</span> for the initial treatment of the foot offload.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,4,6,7,10,11,16,20</span></a> This will change as oedema of the leg reduces until it disappears and radiological changes of coalescence are seen. A disadvantage is that it requires specialised personnel to make it and put it on, which is why alternatives are currently being sought out, such as pneumatic offload orthoses that allow for greater mobility, hygiene, and they can be pulled out at night.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> There is no experience with TCC at our centre, so physicians opted to indicate limb rest in bed with a Denis Browne splint and, once the oedema diminishes, an offload orthosis was placed according to the anatomical type. In CF type <span class="elsevierStyleSmallCaps">I</span> (5 patients), an orthopaedic shoe was placed with offload in the forefoot (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A), and for the rest of the patients with CF types <span class="elsevierStyleSmallCaps">II</span>, <span class="elsevierStyleSmallCaps">III</span> or <span class="elsevierStyleSmallCaps">IV</span> (2 patients) a CAM (Controlled Ankle Movement) Walker<span class="elsevierStyleSup">®</span> orthosis was placed (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B). The other limb must be protected with a crutch or an adapted shoe, so that the healthy limb does not suffer.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> Tests were made with intravenous biophosphonates in the acute phase: although there are improvements in the clinical phase, there is no benefit in time to total immobilisation.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18,26,27</span></a> Once the patient is in stage <span class="elsevierStyleSmallCaps">II</span>, the TCC is replaced by a <span class="elsevierStyleItalic">Charcot restraint orthotic walker</span> (CROW) orthosis or similar for a month period, which will depend on the location and the extent of the destruction. At phase <span class="elsevierStyleSmallCaps">III</span>, the patient will wear an orthopaedic shoe for mobility.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,6,10,11,16,20,28</span></a> Surgical treatment is indicated when soft tissue is affected, when the foot is unstable, or when it cannot be suited for footwear. There are various options, such as exostectomy, Arthrodesis and Achilles tendon section. When all treatment options have failed or if there are complications, the option should be below-knee amputation.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,10,28–30</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">CF is a more common disease than we believe, and we should be aware in order to diagnose it in early stages and prevent irreversible stages. Within the multidisciplinary management of CF, the general surgeon is the anchor for diagnosis and initial treatment, since he/she is this person who initially “faces” the patient most of the time. Therefore, in the presence of inflammation and oedema of the foot in a patient with diabetes and severe neuropathy, once cellulitis, osteomyelitis, and DVT are discarded, a CN should be considered.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres483550" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec505632" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres483549" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec505633" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-16" "fechaAceptado" => "2013-04-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec505632" "palabras" => array:3 [ 0 => "Charcot neuroarthropathy" 1 => "Charcot foot" 2 => "Diabetes" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec505633" "palabras" => array:3 [ 0 => "Neuroartropatía de Charcot" 1 => "Pie de Charcot" 2 => "Diabetes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The Charcot Foot (CF) consists of a progressive deterioration of the bones and joints, most common in diabetic patients with advanced neuropathy. The great problem is that can be confused with other processes, delaying the diagnosis and specific treatment. The aim is to analyse the cases of CF diagnosed in our hospital and especially to highlight the role of the general surgeon.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of all registered cases diagnosed of CF between the diabetic population of our Department of Health. A review of the literature was performed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">From 2008 to 2012, there are 7 cases of CF were diagnosed (prevalence 1:710). Two of the patients were diagnosed erroneously of cellulitis. The average time of delay in the diagnosis was 10 weeks (minimum 1, maximum 24). The initial treatment was immobilisation of the extremity. Once the oedema was eliminated, an offload orthesis was placed according to Sanders's anatomical classification. Evolution was favourable in 5 patients, 1 patient needed amputation, and other one died of acute cardiac pathology.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The CF is a more frequent pathology than we believe. The general surgeon is the fundamental prop in the diagnosis and initial treatment. Before the presence of inflammation and oedema of the foot in a patient with diabetes and severe neuropathy, once cellulitis, osteomyelitis, and TVP are ruled out, Charcot neuroarthropathy should be considered.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El pie de Charcot (PC) consiste en un progresivo deterioro de los huesos y articulaciones, sobre todo en pacientes diabéticos afectos de neuropatía grave. El gran problema es que se puede confundir con otros procesos, retrasando el diagnóstico y tratamiento adecuados. El objetivo es analizar los casos de PC diagnosticados en nuestro hospital y, sobre todo, resaltar el papel del cirujano general.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo donde se registran los casos diagnosticados de PC entre la población diabética de nuestro Departamento de Salud y se hace una revisión de la literatura.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Desde 2008 hasta 2012 se han diagnosticado 7 casos de PC (prevalencia de 1:710). Dos de los pacientes fueron diagnosticados erróneamente de celulitis. El tiempo medio de demora en el diagnóstico ha sido de 10 semanas (mínimo 1, máximo 24). El tratamiento inicial fue inmovilización de la extremidad. Una vez desapareció el edema, se colocó ortesis de descarga según el tipo anatómico de la clasificación de Sanders. La evolución ha sido favorable en 5 pacientes, un paciente precisó amputación transmetatarsiana y otro fue exitus por enfermedad cardíaca aguda.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El PC es una enfermedad más frecuente de lo que creemos. El cirujano general es el pilar fundamental en el diagnóstico y tratamiento inicial. Ante la presencia de inflamación y edema del pie en un paciente con diabetes y neuropatía severa, una vez descartadas fundamentalmente la celulitis, la osteomielitis y la trombosis venosa profunda (TVP), se debe pensar en una neuroartropatía de Charcot.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sellés Dechent R, Rueda Alcárcel C, Primo Romaguera V, Martínez Caamaño A, Asencio Arana F. Papel del cirujano general en el diagnóstico y tratamiento precoz del pie de Charcot. Cir Esp. 2015;93:320–325.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1186 "Ancho" => 900 "Tamanyo" => 165425 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Acute Charcot Foot with ulcer and deformity. Prior amputation of the 5th toe.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 898 "Ancho" => 1001 "Tamanyo" => 77537 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) X-ray showing Sanders’ Charcot Foot type <span class="elsevierStyleSmallCaps">I</span> affecting the metatarsal–phalangeal joints. (b) X-ray showing Sanders’ Charcot Foot type <span class="elsevierStyleSmallCaps">II</span> affecting the Lisfranc joint. Prior amputation of the 5th toe.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 675 "Ancho" => 901 "Tamanyo" => 77996 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Charcot Foot with complete loss of the arch of the foot (rocking-chair foot).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 664 "Ancho" => 1002 "Tamanyo" => 48545 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">MRI showing Sanders’ Charcot Foot type <span class="elsevierStyleSmallCaps">II</span>.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 748 "Ancho" => 1000 "Tamanyo" => 91136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">(A) Orthopaedic shoe with forefoot offload, used in patients with Sanders’ Charcot Foot type <span class="elsevierStyleSmallCaps">I</span>. (B) Orthosis of arch offload (CAM Walker<span class="elsevierStyleSup">®</span>) used in patients with Sanders’ Charcot Foot types <span class="elsevierStyleSmallCaps">II</span>, <span class="elsevierStyleSmallCaps">III</span>or <span class="elsevierStyleSmallCaps">IV</span>.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">DM: diabetes mellitus; DFUs: diabetic foot ulcers; <span class="elsevierStyleSmallCaps">M</span>: male.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of DM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Medical history \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Radiological classification \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sanders’ Anatomic Classification \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Evolution \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amputation of 4th toe of the right foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forefoot offload shoe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amputation of 5th toe of the right foot+DFUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">II</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAM Walker<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DFUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forefoot offload shoe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trans-metatarsal amputation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amputation of the 3rd toe of the left foot+DFUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forefoot offload shoe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">II</span>+<span class="elsevierStyleSmallCaps">III</span>+<span class="elsevierStyleSmallCaps">IV</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAM Walker<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DFUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forefoot offload shoe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSmallCaps">M</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DFUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Type <span class="elsevierStyleSmallCaps">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forefoot offload shoe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab765082.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Cases diagnosed with Charcot foot (from January 2008 to December 2012).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Charcot foot in diabetes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.C. Rogers" 1 => "R.G. Frykberg" 2 => "D.G. Armstromg" 3 => "A.J.M. Boulton" 4 => "M. Edmonds" 5 => "G.H. Van" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Podiatr Med Assoc" "fecha" => "2011" "volumen" => "101" "paginaInicial" => "437" "paginaFinal" => "446" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21957276" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0160" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sur quelaques qui paraissent depender d’une lesión du cerveau oude la moele epiniere" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.M. Charcot" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Des Phyxiol Norm et Path" "fecha" => "1868" "volumen" => "1" "paginaInicial" => "161" "paginaFinal" => "171" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0165" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuritic manifestations in diabetes mellitus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "W.R. Jordan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Intern Med" "fecha" => "1936" "volumen" => "57" "paginaInicial" => "307" "paginaFinal" => "366" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0170" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuroartropatía diabética en fase aguda: un dilema diagnóstico. A propósito de dos casos y revisión de la bibliografía" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Vázquez Gutiérrez" 1 => "M.A. Mangas Cruz" 2 => "E. Cañas García-Otero" 3 => "R. Astorga Jiménez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2005" "volumen" => "205" "paginaInicial" => "549" "paginaFinal" => "552" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16324527" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0175" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute neuropathic joint disease: a medical emergency?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.L. Tan" 1 => "A. Greentein" 2 => "S.J. Jarrett" 3 => "D. Mc Gonagle" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2005" "volumen" => "28" "paginaInicial" => "2962" "paginaFinal" => "2964" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16306562" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0180" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot osteoarthropathy in diabetes: a brief review with an emphasis on clinical practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Gouveri" 1 => "N. Papanas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4239/wjd.v2.i5.59" "Revista" => array:6 [ "tituloSerie" => "World J Diabetes" "fecha" => "2011" "volumen" => "2" "paginaInicial" => "59" "paginaFinal" => "65" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21691556" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0185" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot foot – an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.P.K. Gupta" 1 => "V. Mohan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Assoc Physicians India" "fecha" => "2003" "volumen" => "51" "paginaInicial" => "367" "paginaFinal" => "372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12723651" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0190" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Asunción" 1 => "P.A. Valcarcel" 2 => "D. Poggio" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neuroatropatía de Charcot. 1.ª parte" "fecha" => "2011" "volumen" => "12" "paginaInicial" => "6" "paginaFinal" => "18" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0195" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The pathogenesis of Charcot neuroarthropathy: current concepts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.A. Larson" 1 => "P.R. Burns" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Diabet Foot Ankle" "fecha" => "2012" "volumen" => "3" "paginaInicial" => "1" "paginaFinal" => "4" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0200" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The diabetic Charcot foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.A. Slater" 1 => "Y. Ramot" 2 => "A. Buchs" 3 => "M.J. Rapoport" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Isr Med Assoc J" "fecha" => "2004" "volumen" => "6" "paginaInicial" => "280" "paginaFinal" => "283" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15151367" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0205" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Artropatía neuropática o pie de Charcot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Schinca" 1 => "J. Álvarez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Biomedicina" "fecha" => "2012" "volumen" => "7" "paginaInicial" => "44" "paginaFinal" => "51" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0210" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot neuroarthropathy: an often overlooked complication of diabetes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Botek" 1 => "M.A. Anderson" 2 => "R. Taylor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3949/ccjm.77a.09163" "Revista" => array:6 [ "tituloSerie" => "Cleve Clin J Med" "fecha" => "2010" "volumen" => "77" "paginaInicial" => "593" "paginaFinal" => "599" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20810870" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0215" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Artropatía de Charcot. Importancia del diagnóstico en fase aguda" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Concepción" 1 => "O. Rodríguez" 2 => "L. Illada" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rehabilitación" "fecha" => "2011" "volumen" => "45" "paginaInicial" => "75" "paginaFinal" => "77" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0220" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot foot osteoarthropathy of the foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.M. Perrin" 1 => "M.J. Gardner" 2 => "D. Murphy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Aust Fam Physician" "fecha" => "2010" "volumen" => "39" "paginaInicial" => "117" "paginaFinal" => "119" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20369111" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0225" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuroartropatía de Charcot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Aguilera" 1 => "J. Povedano" 2 => "A. García" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1699-258X(05)72749-2" "Revista" => array:6 [ "tituloSerie" => "Reumatol Clin" "fecha" => "2005" "volumen" => "1" "paginaInicial" => "225" "paginaFinal" => "227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21794269" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0230" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Mumoli" 1 => "A. Camaiti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Can Med Assoc J" "fecha" => "2012" "volumen" => "184" "paginaInicial" => "1392" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0235" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.K. Pakarinen" 1 => "H.J. Laine" 2 => "S.E. Honkonen" 3 => "J. Peltonen" 4 => "H. Oksala" 5 => "J. Lahtela" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Scand J Surg" "fecha" => "2002" "volumen" => "91" "paginaInicial" => "195" "paginaFinal" => "201" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12164523" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0240" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diabetic neuroarthopathic arthropaty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Lesley" 1 => "M.D. Hordon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Uptodate" "fecha" => "2003" "paginaInicial" => "9" "paginaFinal" => "23" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0245" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outpatient diagnosis and care of the diabetic foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.W. Brodsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Instr Course Lect" "fecha" => "1993" "volumen" => "42" "paginaInicial" => "121" "paginaFinal" => "139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8463660" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0250" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Charcot foot: the diagnostic dilemma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.C. Sommer" 1 => "T.H. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am Fam Physician" "fecha" => "2001" "volumen" => "64" "paginaInicial" => "1591" "paginaFinal" => "1598" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11730314" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0255" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current challenges in imaging of the diabetic foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.E. Sanverdi" 1 => "B.F. Ergen" 2 => "A. Oznur" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Diabet Foot Ankle" "fecha" => "2012" "volumen" => "3" "paginaInicial" => "18754" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0260" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Problemas en los pies de los pacientes con diabetes (segunda parte): evaluación y manejo de las infecciones" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Primerano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Evid Actual Pract Ambul" "fecha" => "2008" "volumen" => "11" "paginaInicial" => "115" "paginaFinal" => "119" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0265" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation and treatment of stage 0 Charcot's neuroarthropathy of the foot and ankle" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.V. Yu" 1 => "J.R. Hudson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Podiatr Med Assoc" "fecha" => "2002" "volumen" => "92" "paginaInicial" => "210" "paginaFinal" => "220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11961088" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0270" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diabetic neuropathic ostearthropathy: the Charcot foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.J. Sanders" 1 => "R.G. Frykberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "The high risk foot in diabetes mellitus" "paginaInicial" => "297" "paginaFinal" => "338" "serieFecha" => "1991" ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0275" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "German-Austrian consensus on operative treatment of Charcot neuroarthropathy: a perspective by the Charcot task force of the German Association for Foot Surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Koller" 1 => "R. Springfeld" 2 => "G. Engels" 3 => "R. Fiedler" 4 => "E. Orthner" 5 => "S. Schrinner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Diabet Foot Ankle" "fecha" => "2011" "paginaInicial" => "2" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0280" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilization of advanced modalities in the management of diabetic Charcot neuroarthropathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Pappalardo" 1 => "R. Fitzgerald" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Diabetes Sci Technol" "fecha" => "2010" "volumen" => "4" "paginaInicial" => "1114" "paginaFinal" => "1120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20920430" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0285" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of zoledronic acid on the clinical resolution of Charcot neuroarthropathy: a pilot randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T.K. Pakarinen" 1 => "H.J. Laine" 2 => "H. Mäenpää" 3 => "P. Mattila" 4 => "J. Lahtela" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2337/dc11-0396" "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2011" "volumen" => "34" "paginaInicial" => "1514" "paginaFinal" => "1516" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21593295" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0290" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biphosphonates in the treatment of Charcot neuroarthropathy: a double blind randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Jude" 1 => "P. Selby" 2 => "L. Buergess" 3 => "P. Lilleystone" 4 => "E.B. Marver" 5 => "S.R. Page" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s001250100008" "Revista" => array:6 [ "tituloSerie" => "Diabetología" "fecha" => "2001" "volumen" => "44" "paginaInicial" => "2032" "paginaFinal" => "2037" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11719835" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0295" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pie de Charcot: reconstrucción funcional y procedimientos de rescate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Noriega" 1 => "P. Villanueva" 2 => "S.T. Hansen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Ortop Traumatol" "fecha" => "2007" "volumen" => "51" "paginaInicial" => "164" "paginaFinal" => "172" ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0300" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of diabetic neuropathic foot and ankle malunions and nonunions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.J. Stapleton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Diabet Foot Ankle" "fecha" => "2011" "volumen" => "2" "paginaInicial" => "6287" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735077/0000009300000005/v2_201504260831/S2173507715000940/v2_201504260831/en/main.assets" "Apartado" => array:4 [ "identificador" => "7417" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735077/0000009300000005/v2_201504260831/S2173507715000940/v2_201504260831/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507715000940?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 27 | 5 | 32 |
| 2024 September | 50 | 2 | 52 |
| 2024 August | 43 | 3 | 46 |
| 2024 July | 27 | 4 | 31 |
| 2024 June | 26 | 3 | 29 |
| 2024 May | 31 | 5 | 36 |
| 2024 April | 37 | 16 | 53 |
| 2024 March | 35 | 3 | 38 |
| 2024 February | 65 | 9 | 74 |
| 2024 January | 92 | 1 | 93 |
| 2023 December | 77 | 4 | 81 |
| 2023 November | 58 | 3 | 61 |
| 2023 October | 86 | 8 | 94 |
| 2023 September | 58 | 2 | 60 |
| 2023 August | 62 | 0 | 62 |
| 2023 July | 76 | 6 | 82 |
| 2023 June | 63 | 6 | 69 |
| 2023 May | 75 | 2 | 77 |
| 2023 April | 54 | 1 | 55 |
| 2023 March | 69 | 4 | 73 |
| 2023 February | 59 | 1 | 60 |
| 2023 January | 57 | 4 | 61 |
| 2022 December | 50 | 6 | 56 |
| 2022 November | 58 | 11 | 69 |
| 2022 October | 65 | 9 | 74 |
| 2022 September | 69 | 10 | 79 |
| 2022 August | 68 | 13 | 81 |
| 2022 July | 56 | 11 | 67 |
| 2022 June | 43 | 7 | 50 |
| 2022 May | 48 | 11 | 59 |
| 2022 April | 55 | 8 | 63 |
| 2022 March | 68 | 16 | 84 |
| 2022 February | 99 | 6 | 105 |
| 2022 January | 118 | 12 | 130 |
| 2021 December | 104 | 14 | 118 |
| 2021 November | 72 | 11 | 83 |
| 2021 October | 68 | 13 | 81 |
| 2021 September | 58 | 16 | 74 |
| 2021 August | 76 | 8 | 84 |
| 2021 July | 46 | 10 | 56 |
| 2021 June | 51 | 15 | 66 |
| 2021 May | 66 | 23 | 89 |
| 2021 April | 114 | 21 | 135 |
| 2021 March | 110 | 6 | 116 |
| 2021 February | 49 | 6 | 55 |
| 2021 January | 54 | 13 | 67 |
| 2020 December | 45 | 7 | 52 |
| 2020 November | 50 | 12 | 62 |
| 2020 October | 42 | 8 | 50 |
| 2020 September | 40 | 14 | 54 |
| 2020 August | 42 | 3 | 45 |
| 2020 July | 35 | 1 | 36 |
| 2020 June | 34 | 11 | 45 |
| 2020 May | 67 | 15 | 82 |
| 2020 April | 37 | 3 | 40 |
| 2020 March | 46 | 5 | 51 |
| 2020 February | 43 | 5 | 48 |
| 2020 January | 37 | 3 | 40 |
| 2019 December | 38 | 12 | 50 |
| 2019 November | 33 | 5 | 38 |
| 2019 October | 45 | 8 | 53 |
| 2019 September | 48 | 1 | 49 |
| 2019 August | 24 | 2 | 26 |
| 2019 July | 39 | 19 | 58 |
| 2019 June | 62 | 20 | 82 |
| 2019 May | 141 | 47 | 188 |
| 2019 April | 83 | 14 | 97 |
| 2019 March | 24 | 2 | 26 |
| 2019 February | 28 | 5 | 33 |
| 2019 January | 28 | 9 | 37 |
| 2018 December | 20 | 5 | 25 |
| 2018 November | 35 | 7 | 42 |
| 2018 October | 32 | 2 | 34 |
| 2018 September | 53 | 7 | 60 |
| 2018 August | 48 | 11 | 59 |
| 2018 July | 25 | 2 | 27 |
| 2018 June | 30 | 0 | 30 |
| 2018 May | 30 | 3 | 33 |
| 2018 April | 44 | 0 | 44 |
| 2018 March | 30 | 0 | 30 |
| 2018 February | 27 | 1 | 28 |
| 2018 January | 24 | 0 | 24 |
| 2017 December | 22 | 1 | 23 |
| 2017 November | 25 | 0 | 25 |
| 2017 October | 21 | 7 | 28 |
| 2017 September | 32 | 2 | 34 |
| 2017 August | 39 | 2 | 41 |
| 2017 July | 26 | 2 | 28 |
| 2017 June | 27 | 3 | 30 |
| 2017 May | 56 | 4 | 60 |
| 2017 April | 46 | 4 | 50 |
| 2017 March | 53 | 15 | 68 |
| 2017 February | 144 | 1 | 145 |
| 2017 January | 37 | 0 | 37 |
| 2016 December | 41 | 6 | 47 |
| 2016 November | 46 | 4 | 50 |
| 2016 October | 71 | 11 | 82 |
| 2016 September | 78 | 7 | 85 |
| 2016 August | 51 | 6 | 57 |
| 2016 July | 37 | 2 | 39 |
| 2016 June | 37 | 13 | 50 |
| 2016 May | 36 | 12 | 48 |
| 2016 April | 58 | 12 | 70 |
| 2016 March | 57 | 21 | 78 |
| 2016 February | 28 | 12 | 40 |
| 2016 January | 13 | 11 | 24 |
| 2015 December | 24 | 11 | 35 |
| 2015 November | 21 | 2 | 23 |
| 2015 October | 21 | 7 | 28 |
| 2015 September | 31 | 6 | 37 |
| 2015 August | 12 | 7 | 19 |
| 2015 July | 0 | 1 | 1 |
| 2015 June | 0 | 1 | 1 |
| 2015 May | 1 | 2 | 3 |
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