Cost comparison: limb salvage versus amputation in diabetic patients with charcot foot

BACKGROUND

The negative impact on health-related quality of life in patients with Charcot foot has prompted operative correction of the acquired deformity. Comparative effectiveness financial models are being introduced to provide valuable information to assist clinical decision making.

METHODS

Seventy-six patients with Charcot foot underwent operative correction with the use of circular external fixation. Thirty-eight (50%) had osteomyelitis. A control group was created from 17 diabetic patients who successfully underwent transtibial amputation and prosthetic fitting during the same period. Cost of care during the 12 months following surgery was derived from inpatient hospitalization, placement in a rehabilitation unit or skilled nursing facility, home health care including parenteral antibiotic therapy, physical therapy, and purchase of prosthetic devices or footwear.

RESULTS

Fifty-three of the patients with limb salvage (69.7%) did not require inpatient rehabilitation. Their average cost of care was $56,712. Fourteen of the patients with amputation (82.4%) required inpatient rehabilitation, with an average cost of $49,251.

CONCLUSIONS

Many surgeons now favor operative correction of Charcot foot deformity. This investigation provides preliminary data on the relative cost of transtibial amputation and prosthetic limb fitting compared with limb salvage. The use of comparative effectiveness models such as this simple attempt may provide valuable information in planning resource allocation for similar complex groups of patients.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Treatment of osteomyelitis in charcot foot with single-stage resection of infection, correction of deformity, and maintenance with ring fixation

BACKGROUND

There is both increased interest and awareness in diabetes-associated Charcot foot arthropathy. The number of affected patients will likely increase as the incidence of both diabetes and morbid obesity increases. Many experts now favor surgical correction of the deformity rather than longitudinal management with accommodative bracing. In patients with open wounds and exposed bone and/or chronic osteomyelitis, it is controversial whether resolution of the bony infection should be achieved before attempting surgical correction of the acquired deformity.

METHODS

During a 78-month period, 178 patients underwent surgical correction of deformity with diabetes-associated Charcot foot or ankle arthropathy by a single surgeon. Seventy-three had evidence of osteomyelitis at the time of surgery. There were 41 males and 32 females. Their average age was 57.9 (range, 31 to 76) years, and body mass index was 36.9 (range, 21.8 to 60.9). The clinical diagnosis of osteomyelitis was made by (a) an open wound overlying the deformity with exposed bone and chronic drainage; (b) a history of biopsy-diagnosed osteomyelitis that was not currently draining, but had clinical and pathologic evidence of abnormal bone in the region of the previous infection; or (c) a history of previous wound overlying bony deformity with abnormal bone observed at the time of surgery. Surgery involved radical resection of the clinically infected bone, combined with acute correction of the deformity to a plantigrade foot. Parenteral culture-specific antibiotic therapy was administered and monitored by an infectious disease comanagement service. A three-level preconstructed static circular external fixator was applied to maintain the surgically obtained correction.

RESULTS

Sixty-eight of 71 patients (95.7%) achieved limb salvage and were able to ambulate with commercially available therapeutic footwear. One patient died shortly after removal of the external fixator from unrelated causes. Three patients required amputation. Resolution of infection and wound closure was achieved in five patients following a second surgical debridement. Two noninfected wounds were resolved with local soft tissue flaps. Two patients have persistent noninfected wounds that have been resistant to wound care therapy.

DISCUSSION

A plantigrade noninfected foot can be achieved in patients with infected diabetic Charcot foot deformity with single-stage radical resection of osteomyelitis, correction of the deformity, maintenance of the correction with static external fixation, and culture-specific antibiotic therapy.

2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

The development of a neuropathic ankle following successful correction of non-plantigrade charcot foot deformity

BACKGROUND

The treatment of Charcot foot arthropathy has traditionally involved immobilization during the acute phase followed by longitudinal management with accommodative bracing. In response to the perceived poor outcomes associated with nonoperative accommodative treatment, many experts now advise surgical correction of the deformity, especially when the affected foot is not clinically plantigrade. The significant rate of surgical and medical-associated morbidity accompanying this form of treatment has led surgeons to look for improved methods of surgical stabilization, including the use of the circular ring external fixation.

METHODS

Over a 7-year period, a single surgeon performed surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a statically applied circular external fixator. Following successful correction, five patients developed a neuropathic deformity of the ipsilateral ankle after removal of the external fixator and subsequent weight bearing total contact cast.

RESULTS

Three of the five patients progressed to successful healing of the neuropathic (Charcot) ankle arthropathy following treatment with a series of weightbearing total contact casts. Two underwent successful ankle fusion with retrograde locked intramedullary nailing.

DISCUSSION

This unusual clinical scenario likely represents either a progression of the disease process in the foot or a complication associated with surgical correction of the original neuropathic foot deformity. A better understanding of this observation will likely become apparent as we acquire more experience with this disorder.

Executive Summary: 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.

Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

The relationship between knee arthroplasty and foot loading

Surgeons have questioned whether foot deformity applies abnormal loading on a knee implant. A total of 24 patients with mild knee deformity underwent a static recording of foot loading prior to and at 3 months following knee replacement. Of these patients, 13 had a preoperative varus deformity. The recorded postoperative to preoperative loading in all 6 geographic sites was decreased by an average of 10%. The largest changes were observed in the hallux and lesser toe masks, whereas the postoperative to preoperative foot pressure ratio in the metatarsal head (lateral and medial), heel, and midfoot masks was 0.94. This preliminary investigation reveals a minimal change in geographic foot loading following total knee arthroplasty in patients with mild knee deformity.

Charcot foot: a surgical algorithm

The historic treatment of Charcot foot has entailed non-weight-bearing immobilization during the acute active phase, followed by longitudinal management with accommodative bracing. This treatment plan yields poor outcomes, even in cases classified as successful. An appreciation of poor outcomes convinced experts to attempt correction of the resultant deformities. Early attempts at surgical correction of the acquired deformities in patients with medical comorbidities were complicated by infection, wound failure, and mechanical loss of correction. New surgical techniques have been designed to obtain and maintain correction and minimize the risks for complications and poor outcomes in this complex patient population.

Diabetic peripheral neuropathy

Diabetic peripheral neuropathy likely affects up to one-third of adults with diabetes. All diabetic patients are likely to develop peripheral neuropathy if they live sufficiently long. Recognition is crucial for initiation of the preventive strategies that have been demonstrated to decrease the potential risk for the development of diabetic foot ulcers, foot infection, Charcot foot, or amputation. The mainstay of current treatment is optimal glucose and hemoglobin A(1C) control. Drug therapy has limited potential for controlling the associated pain. Alternative methods of treatment have thus far demonstrated limited success.

Syme's ankle disarticulation

The Syme's ankle disarticulation is an end-bearing amputation level that provides stable walking, requires minimal physical therapy gait training, and rarely requires hospitalization on a rehabilitation unit. This article discusses patient selection, surgical technique, and rehabilitation of an underused rehabilitation amputation level.

Circular fixation for the nonplantigrade Charcot foot

Diabetes-associated neuropathic osteoarthropathy (Charcot foot) is increasingly being recognized as a destructive disease process that frequently leads to severe disability and is responsible for a severe negative impact on health-related quality of life. In addition, this diabetes-specific disease process creates a similar negative impact on the health care system by consuming health care resources for multiple surgical procedures, often leading to lower extremity amputation and premature death. There is growing interest among orthopedic foot and ankle surgeons to address surgical correction of the acquired deformities, with a goal of improving walking independence, which appears to reverse the impaired quality of life of affected individuals. Reconstructive surgery in this patient population is fraught with a substantial potential for unique complications, as many of the patients are morbidly obese, have large wounds overlying substantial bony deformity, have impaired immunity due to diabetes, and have underlying chronic osteomyelitis with poor bone quality. This review is focused on the applications of the principles of Ilizarov for providing surgical stabilization following correction of deformities. This application is best reserved for patients who are at the highest risk for complications or have failed with standard orthopedic methods of internal fixation.

Static measure of foot loading

Static and dynamic loading of the foot are important characteristics for understanding human walking in both health and disease. The goal of this investigation was to determine whether an objective measure of normal midstance loading of the foot could reliably be recorded using readily available disposable qualitative recording devices. Ten randomly selected normal volunteers were trained to step on Harris mat and Pressure Stat recording devices during normal walking. Each of the recordings was divided into 5 weight-bearing regions by 2 separate examiners. After outlining each foot, the recordings were digitized and compared. Interobserver reliability ranged from 0.81 to 0.96 for the Harris mat technique and 0.94 to 0.97 for the Pressure Stat technique. Data from a linear regression plot indicate high precision of calculations of the foot masks between the 2 examiners based on an R(2) value of 0.966 using the Pressure Stat method. These data plus a linear regression plot suggest that both qualitative recording devices, when digitized using a standardized format, appear to obtain a reliable objective measure of midstance loading during normal gait. The Pressure Stat device may be slightly more reliable. It is planned to use this standardized experimental model to compare objectively patterns of midstance loading in patients with injury or disease that is capable of altering normal walking.

Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery

The introduction of the hospitalist co-management model represents an opportunity to improve care by changing the system as it applies to a small group of patients. Eighty-six consecutive patients with multiple comorbidities were selectively enrolled in an academic medical center hospitalist-orthopedic surgery co-management patient care program. Patients were stratified by all patient refined diagnosis-related groups, severity of illness, and risk of mortality. Hospital length of stay, cost of care, in-hospital mortality, complications, and intensive care unit admissions were compared with a retrospectively constructed control group of 54 patients undergoing similar surgery during the period immediately preceding initiation of the program. The University Health System Consortium observed-to-expected ratio for hospital length of stay was 0.693 compared to 0.862 for the control group. The severity of illness and risk of mortality scores represented a relatively higher risk stratification in the study group. While the overall observed-to-expected cost of care remained virtually unchanged, the positive impact of the study model revealed an increased positive effect on the more severely affected severity of illness and risk of mortality patients. The results of this study suggest that a proactive, cooperative, co-management model for the perioperative management of high-risk patients undergoing complex surgery can improve the quality and efficiency metrics associated with the delivery of service to patients.

Use of platelet-rich concentrate and bone marrow aspirate in high-risk patients with Charcot arthropathy of the foot

BACKGROUND

Diabetic patients with Charcot arthropathy of the foot are at high risk for nonunion when undergoing arthrodesis. There is increasing evidence that cytokines identified in platelet rich concentrate and bone marrow aspirate may show equivalence to autologous bone graft in supporting arthrodesis.

MATERIALS AND METHODS

Prospectively, 44 high-risk diabetic patients with Charcot foot arthropathy underwent surgical correction of 46 feet through a limited surgical approach. The average age of the patients was 54.9 +/- 10.4 years. Their mean BMI was 38.0 +/- 9.7. Twenty-four were male and 20 were female. Twenty-eight had open wounds with chronic draining osteomyelitis. Surgical correction was maintained postoperatively with static circular ring fixation. At the time of wound closure, all of the patients had injection of autologous platelet rich concentrate and bone marrow aspirate.

RESULTS

Forty-two of the 46 feet had radiographic evidence of bony union at 26.2 +/- 12.2 months following surgery. One patient died of unrelated causes. Two underwent amputation for persistent infection. Six had recurrent ulcers which resolved with local treatment. One patient required a fifth ray resection for gangrene following surgery. There were three tibial stress fractures, with two requiring intramedullary nailing to achieve union.

CONCLUSIONS

Platelet-rich concentrate, when combined with a small amount of autologous bone marrow aspirate, may well be as effective as autologous bone grafting when performing arthrodesis of high risk diabetic patients with Charcot foot arthropathy.