Charcot Reconstruction: Outcomes in Patients With and Without Diabetes

Cates, Nicole K.; Wagler, Emily C.; Bunka, Taylor J.; Elmarsafi, Tammer; Tefera, Eshetu; Kim, Paul J.; Liu, George T.; Evans, Karen K.; Steinberg, John S.; Attinger, Christopher E.

doi:10.1053/j.jfas.2020.05.019

Cited by 9 publications

(15 citation statements)

References 43 publications

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“…Our results must be interpreted with care by orthopaedic surgeons who favor realignment procedures early, because we attempted to prevent surgery in patients with CN whenever possible. There seem to be differences in functional outcome and fusion during surgical reconstruction between patients with diabetic CN and those without [6]. Further, smoking and peripheral artery disease were associated with diabetic CN in surgical interventions.…”

Section: Discussionmentioning

confidence: 99%

“…The anatomic distribution and frequency of bilateral involvement were compared with existing evidence on diabetic CN and they did not differ, while limb loss was less frequent in patients with idiopathic neuropathy [2]. A study comparing surgically reconstructed diabetic and nondiabetic CN found important differences: Patients with nondiabetic CN feet were more likely to return to ambulation and have delayed union [6]. A review from 2022 reinforced the lack of evidence on nondiabetic CN [31].…”

Section: Introductionmentioning

confidence: 99%

“…It therefore is important to ascertain whether there are differences in the clinical course of diabetic and nondiabetic CN when treated nonsurgically, analogous to research on the topic that has focused on surgical reconstruction [6]. Further, by using single-center data with treatment guided by a single orthopaedic surgeon, we sought to address another shortcoming when interpreting studies about the clinical course of CN; namely, the heterogeneity of treatment approaches.…”

Section: Introductionmentioning

confidence: 99%

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No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy

Waibel

Weber

Selman

et al. 2023

Clin Orthop Relat Res

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Background The cause of Charcot neuro-osteoarthropathy (CN) is diabetes in approximately 75% of patients. Most reports on the clinical course and complications of CN focus on diabetic CN, and reports on nondiabetic CN are scarce. No study, to our knowledge, has compared the clinical course of patients initially treated nonoperatively for diabetic and nondiabetic CN. Questions/purposes Among patients with CN, are there differences between patients with diabetes and those without in terms of (1) the frequency of major amputation as ascertained by a competing risks survivorship estimator; (2) the frequency of surgery as ascertained by a competing risks survivorship estimator; (3) frequency of reactivation, as above; or (4) other complications (contralateral CN development or ulcers)? Methods Between January 1, 2006, and December 31, 2018, we treated 199 patients for diabetic CN. Eleven percent (22 of 199) were lost before the minimum study follow-up of 2 years or had incomplete datasets and could not be analyzed, and another 9% (18 of 199) were excluded for other prespecified reasons, leaving 80% (159 of 199) for analysis in this retrospective study at a mean follow-up duration since diagnosis of 6 ± 4 years. During that period, we also treated 78 patients for nondiabetic Charcot arthropathy. Eighteen percent (14 of 78) were lost before the minimum study follow-up and another 5% (four of 78 patients) were excluded for other prespecified reasons, leaving 77% (60 of 78) of patients for analysis here at a mean of 5 ± 3 years. Patients with diabetic CN were younger (59 ± 11 years versus 68 ± 11 years; p < 0.01), more likely to smoke cigarettes (37% [59 of 159] versus 20% [12 of 60]; p = 0.02), and had longer follow-up (6 ± 4 years versus 5 ± 3 years; p = 0.02) than those with nondiabetic CN. Gender, BMI, overall renal failure, dialysis, and presence of peripheral arterial disease did not differ between the groups. Age difference and length of follow-up were not considered disqualifying problems because of the later onset of idiopathic neuropathy and longer available patient follow-up in patients with diabetes, because our program adheres to the follow-up recommendations suggested by the International Working Group on the Diabetic Foot. Treatment was the same in both groups and included serial total-contact casting and restricted weightbearing until CN had resolved. Then, patients subsequently transitioned to orthopaedic footwear. CN reactivation was defined as clinical signs of the recurrence of CN activity and confirmation on MRI. Group-specific risks of the frequencies of major amputation, surgery, and CN reactivation were calculated, accounting for competing events. Group comparisons and confounder analyses were conducted on these data with a Cox regression analysis. Other complications (contralateral CN development and ulcers) are described descriptively to avoid pooling of complications with varying severity, which could be misleading. Results The risk of major amputation (defined as an above-ankle amputation), estimated using a competing risks survivorship estimator, was not different between the diabetic CN group and nondiabetic CN group at 10 years (8.8% [95% confidence interval 4.2% to 15%] versus 6.9% [95% CI 0.9% to 22%]; p = 0.4) after controlling for potentially confounding variables such as smoking and peripheral artery disease. The risk of any surgery was no different between the groups as estimated by the survivorship function at 10 years (53% [95% CI 42% to 63%] versus 58% [95% CI 23% to 82%]; p = 0.3), with smoking (hazard ratio 2.4 [95% CI 1.6 to 3.6]) and peripheral artery disease (HR 2.2 [95% CI 1.4 to 3.4]) being associated with diabetic CN. Likewise, there was no between-group difference in CN reactivation at 10 years (16% [95% CI 9% to 23%] versus 11% [95% CI 4.5% to 22%]; p = 0.7) after controlling for potentially confounding variables such as smoking and peripheral artery disease. Contralateral CN occurred in 17% (27 of 159) of patients in the diabetic group and in 10% (six of 60) of those in the nondiabetic group. Ulcers occurred in 74% (117 of 159) of patients in the diabetic group and in 65% (39 of 60) of those in the nondiabetic group. Conclusion Irrespective of whether the etiology of CN is diabetic or nondiabetic, our results suggest that orthopaedic surgeons should use similar nonsurgical treatments, with total-contact casting until CN activity has resolved, and then proceed with orthopaedic footwear. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach. Level of Evidence Level III, prognostic study.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy

Waibel

Weber

Selman

et al. 2023

Clin Orthop Relat Res

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“…Charcot neuroarthropathy (CN) is characterized by chronic and progressive destruction of bone and joints that can lead to deformities, ulcerations, and even amputation [2, 3, 5, 7-10]. It is most commonly associated with peripheral neuropathy from diabetes mellitus [2, 3, 5, 7-10].…”

Section: Where Are We Now?mentioning

confidence: 99%

“…In another, more-recent study, the authors compared surgical treatment outcomes for patients with Charcot arthropathy caused by diabetes with those with Charcot arthropathy from other causes. The authors did a nice job of matching the groups and found that patients with nondiabetic Charcot arthropathy were much more likely to return to ambulation than patients with neuroarthropathy of the foot caused by diabetes [3].…”

Section: Where Are We Now?mentioning

confidence: 99%