Guidelines on the diagnosis and treatment of active Charcot neuro‐osteoarthropathy in persons with diabetes mellitus (IWGDF 2023)

Wukich, Dane K.; Schaper, Nicolaas C.; Gooday, Catherine; Bal, Antonin; Bém, Robert; Chhabra, Avneesh; Hastings, Mary K.; Holmes, Crystal M.; Petrova, Nina L.; Araujo, Maria Gala Santini; Senneville, Éric; Raspovic, Katherine M.

doi:10.1002/dmrr.3646

Cited by 39 publications

(30 citation statements)

References 153 publications

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“…In a prospective study of 1666 people with diabetes, equinus deformity was present in 10.3% . Charcot arthropathy, defined as a foot fracture with possible joint dislocation in people with peripheral neuropathy, affects approximately 0.3% of people with diabetes, can lead to significant deformity, and increases the risk of a diabetic foot ulcer, particularly in the midfoot and ankle/hindfoot . Although approximately 40% of people with Charcot arthropathy have concomitant tissue loss, a unilateral red, hot, swollen foot without a wound or diagnosis of deep vein thrombosis may indicate Charcot arthropathy …”

Section: Screening For Risk Of Diabetic Foot Ulcersmentioning

confidence: 99%

Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

295

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ImportanceApproximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.ObservationsNeurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.Conclusions and RelevanceDiabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

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Section: Screening For Risk Of Diabetic Foot Ulcersmentioning

confidence: 99%

Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

295

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“…The only controlled study regarding joint arthrodesis in combination with offloading devices compared to offloading devices alone is based on a population of people with Charcot midfoot deformity and DFUs, and that study found little-to-no difference in healing. 43 That paper is included in the guideline on the Charcot foot, 32 and hence, we have considered a recommendation was not justified.…”

Section: Otherwise Please Refer To the Comments In Recommendation 5bmentioning

confidence: 99%

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Bus

Armstrong

Crews

et al. 2023

Diabetes Metabolism Res

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AimsOffloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes‐related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.Materials and MethodsWe followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient‐Intervention‐Control‐Outcome) format, undertaking a systematic review and meta‐analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.ResultsFor healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non‐removable knee‐high offloading device as the first‐choice offloading intervention. If contraindications or patient intolerance to non‐removable offloading exist, consider using a removable knee‐high or ankle‐high offloading device as the second‐choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third‐choice offloading intervention. If such a non‐surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non‐plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.ConclusionThese offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes‐related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

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“…Charcot neuro-osteoarthropathy is an inflammatory process in a person with peripheral neuropathy that results in injury to the bones, joints and soft tissues of the lower extremity. 48 CNO, one of the most F I G U R E 5 Halving the global diabetic foot burden from 2% to 1%. DFD, Diabetic foot disease; PAD, peripheral artery disease.…”

Section: Epidemiologymentioning

confidence: 99%

“…devastating complications from diabetes-related neuropathy, can occur in any person with underlying neuropathy. 48 When left untreated, CNO often results in significant foot or ankle deformity that drastically increases the risk of ulceration, infection and amputation. 49 Multiple studies have also demonstrated that these significant physical impacts also result in considerable QoL reductions.…”

Section: Epidemiologymentioning

confidence: 99%

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

Lazzarini,

Raspovic,

Meloni

et al. 2023

Diabetes Metabolism Res

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The 1989 Saint Vincent Declaration established a goal of halving global diabetes‐related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro‐osteoarthropathy is more prevalent than previously thought. Most cases respond well to non‐removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline‐based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.

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Guidelines on the diagnosis and treatment of active Charcot neuro‐osteoarthropathy in persons with diabetes mellitus (IWGDF 2023)

Cited by 39 publications

References 153 publications

Diabetic Foot Ulcers

Diabetic Foot Ulcers

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

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