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Jones PJ, Davies MJ, Webb D, Berrington R, Frykberg RG. Contralateral foot temperature monitoring during Charcot immobilisation: A systematic review. Diabetes Metab Res Rev 2023; 39:e3619. [PMID: 36728905 DOI: 10.1002/dmrr.3619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/07/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
AIMS Contralateral temperature difference (CTD) is a frequently used marker of healing in Charcot neuro-osteoarthropathy (CN). We aimed to determine whether there is a consistent approach to CTD measurement during healing and the decision-making process around cessation of immobilisation. MATERIALS AND METHODS Medline, Scopus, and Web of Science were searched until February 2022 for peer-reviewed studies using keywords, including (('arthropathy' OR 'osteoarthropathy' OR 'osteopathy' OR 'neuroarthropathy') AND 'Charcot' AND ('temperature')), which returned 789 results excluding duplicates. Included studies monitored CTD in those with active CN to (i) assess the healing process and (ii) assist in determining the transition from immobilisation. RESULTS Thirty four studies in total (n = 677 participants) were shortlisted and 19 were included after full paper review. Average CTD at presentation varied from 1.6 to 8.0°C with insufficient data to determine if CTD was proportional to severity of Charcot. Evidence of a relationship between CTD and radiographic or scintigraphy-based markers of healing varied depending on the methodology employed. Threshold CTD for the cessation of immobilisation ranged from <1°C to <2°C. Most frequently it was <2°C sustained for 2-3 visits. Temperature was monitored typically every 2-6 weeks using handheld thermometry at CN site(s) after resting the feet for 15 min. Device type, accuracy/reliability, and ambient temperature were rarely reported. CONCLUSIONS Further research on CTD and radiographic and radiotracer markers is needed involving larger cohorts. Standardisation in reporting of thermometry device type, accuracy and reliability, foot resting times, and ambient temperature controls is essential to facilitate the comparison of studies, meta-analysis, and evaluation of different immobilisation interventions.
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Affiliation(s)
- Petra J Jones
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - David Webb
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Rachel Berrington
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
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Gooday C, Game F, Woodburn J, Poland F, Sims E, Dhatariya K, Shepstone L, Barton G, Hardeman W. A randomised feasibility study of serial magnetic resonance imaging to reduce treatment times in Charcot neuroarthropathy in people with diabetes (CADOM). J Foot Ankle Res 2023; 16:2. [PMID: 36703174 PMCID: PMC9878485 DOI: 10.1186/s13047-023-00601-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/04/2023] [Indexed: 01/27/2023] Open
Abstract
AIM This study aims to explore the feasibility of using serial MRI without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot, in order to decide whether a large-scale trial is warranted. METHODS A multicentre, randomised, prospective, two arm, open, feasibility study (CADOM) of people with diabetes with a suspected or confirmed diagnosis of Charcot neuroarthropathy. Participants were randomised (1:1) to 'standard care plus', including repeated foot temperature measurements and X-rays, or the intervention arm, with additional three-monthly MRI, until remission of Charcot neuroarthropathy or a maximum 12 months (active phase). Participants were then followed-up for a further 6 months, post remission to monitor for relapse of the Charcot neuroarthropathy (follow-up phase). Feasibility outcomes were recruitment, retention, data completeness, adherence to study procedures and safety of the intervention MRI. We also collected clinical efficacy outcomes, this included time in cast/off-loading device which will be the primary outcome of a future definitive trial. Finally, we collected patient reported outcomes, and data on health and social care usage. RESULTS One-hundred and five people were assessed for eligibility at five sites. 64/105 potential participants meet the eligibility criteria to participate in the study. Forty-three participants were randomised: 20 to standard care plus and 23 to MRI intervention. The main reason for ineligibility was a previous episode of Charcot neuroarthropathy. Thirteen participants were withdrawn post-randomisation due to an alternative diagnosis being made. Of the remaining 30 participants, 19 achieved remission, 6 had not gone into remission at the end of the 12 month active phase so exited the study. Five participants were lost to follow-up. Of the MRIs that were not disrupted by COVID-19 pandemic 26/31 (84%) were completed. For the visits that were conducted face-to-face, completion rates of patient-reported outcome measures were between 71 and 100%. There were no safety incidents associated with the intervention MRI. As this was a feasibility study it was not designed to test the effectiveness of serial MRI in diagnosing remission. The time in cast/off-loading device was 235 (±108.3) days for the standard care plus arm compared to 292 (±177.4) days for the intervention arm. There was no statistical difference in the time in cast/off-loading device between the two arms of the study: Hazard Ratio (HR) 0.405 (95% CI 0.140-1.172), p = 0.096. DISCUSSION The findings support a definitive randomised controlled trial to evaluate the effectiveness of MRI in diagnosing remission in Charcot neuroarthropathy. The rates of recruitment, retention, data, and MRI completeness show that a definitive study is feasible. STUDY REGISTRATION ISRCTN, 74101606 . Registered on 6 November 2017.
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Affiliation(s)
- Catherine Gooday
- grid.8273.e0000 0001 1092 7967School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK ,grid.240367.40000 0004 0445 7876Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Frances Game
- grid.508499.9Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE UK
| | - Jim Woodburn
- grid.1022.10000 0004 0437 5432School of Health Sciences and Social Work, Griffith University, Southport, QLD 4222 Australia
| | - Fiona Poland
- grid.8273.e0000 0001 1092 7967Institute for Volunteering Research, Faculty of Medicine and Health Science, University of East Anglia, Norwich, NR4 7TJ UK
| | - Erika Sims
- grid.8273.e0000 0001 1092 7967Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Ketan Dhatariya
- grid.240367.40000 0004 0445 7876Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK ,grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Lee Shepstone
- grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Garry Barton
- grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Wendy Hardeman
- grid.8273.e0000 0001 1092 7967School of Health Sciences - Behavioural and Implementation Science Group, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
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Gooday C, Hardeman W, Poland F, Woodburn J, Dhatariya K. Controversies in the management of active Charcot neuroarthropathy. Ther Adv Endocrinol Metab 2023; 14:20420188231160406. [PMID: 37101723 PMCID: PMC10123890 DOI: 10.1177/20420188231160406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 02/11/2023] [Indexed: 04/28/2023] Open
Abstract
Charcot neuroarthropathy (CN) was first described over 150 years ago. Despite this there remains uncertanity around the factors that contribute to its development, and progression. This article will discuss the current controversies around the pathogenesis, epidemiology, diagnosis, assessment and management of the condition. The exact pathogenesis of CN is not fully understood, and it is likely to be multifactorial, with perhaps currently unknown mechanisms contributing to its development. Further studies are needed to examine opportunities to help screen for and diagnose CN. As a result of many of these factors, the true prevalence of CN is still largely unknown. Almost all of the recommendations for the assessment and treatment of CN are based on low-quality level III and IV evidence. Despite recommendations to offer people with CN nonremovable devices, currently only 40-50% people are treated with this type of device. Evidence is also lacking about the optimal duration of treatment; reported outcomes range from 3 months to more than a year. The reason for this variation is not entirely clear. A lack of standardised definitions for diagnosis, remission and relapse, heterogeneity of populations, different management approaches, monitoring techniques with unknown diagnostic precision and variation in follow-up times prevent meaningful comparison of outcome data. If people can be better supported to manage the emotional and physical consequences of CN, then this could improve people's quality of life and well-being. Finally, we highlight the need for an internationally coordinated approach to research in CN.
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Affiliation(s)
| | - Wendy Hardeman
- Behavioural and Implementation Science Group, School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Fiona Poland
- Institute for Volunteering Research, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Jim Woodburn
- School of Health Sciences and Social Work, Griffith University, Southport, QLD, Australia
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Gooday C, Hardeman W, Game F, Woodburn J, Poland F. A qualitative study to understand people's experiences of living with Charcot neuroarthropathy. Diabet Med 2022; 39:e14784. [PMID: 34985149 PMCID: PMC9305882 DOI: 10.1111/dme.14784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/09/2021] [Accepted: 01/03/2022] [Indexed: 12/16/2022]
Abstract
AIMS Charcot neuroarthropathy (CN) is a complication of neuropathy, in people with diabetes. Treatment requires the prolonged wearing of an offloading device, which can be challenging. The importance of understanding people's perspectives for promoting their engagement in self management is well known. However, no such studies have been done in CN. This qualitative study aimed to understand people's experiences of CN. METHODS Semi-structured interviews with a purposive sample of 14 participants with CN, recruited from a randomised controlled trial. We gathered opinions, thoughts and the meanings participants attributed to their experiences of CN and its physical, socio-economic and physiological effects and how this affected their families and relationships. We analysed the interviews using Inductive Thematic Analysis. RESULTS Four analytic themes were identified: (1) 'Trapped at home isolated and missing social life and daily life routines'; (2) 'Disruption to people's roles, responsibilities, relationships and mobility, which people adapted to try and address and manage'; (3) 'Pain which participants related to the direct or indirect consequences of wearing the cast or boot'; and (4) 'Blame for developing CN, attributed to themselves and healthcare professionals'. Participants described guilt about needing more support, expressing frustration, low mood and low self-esteem. CONCLUSION This study highlights experiential aspects of the previously unrecognised burden of CN. Its physical, social and emotional impacts on participants and their families are substantial and sustained. There is a need to raise clinical awareness of CN and its wider effects. TRIAL REGISTRATION ISRCTN74101606. Registered on 6 November 2017, http://www.isrctn.com/ISRCTN74101606?q=CADom&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search.
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Affiliation(s)
- Catherine Gooday
- School of Health Sciences, Faculty of Medicine and Health ScienceUniversity of East AngliaNorwichUK
| | - Wendy Hardeman
- School of Health Sciences – Behavioural and Implementation Science Group, Faculty of Medicine and Health SciencesUniversity of East AngliaNorwichUK
| | - Frances Game
- Department of Diabetes and EndocrinologyUniversity Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
| | - Jim Woodburn
- School of Health Sciences and Social WorkGriffith UniversitySouthportAustralia
| | - Fiona Poland
- School of Health Sciences ‐ Institute for Volunteering Research, Faculty of Medicine and Health ScienceUniversity of East AngliaNorwichUK
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Griffiths DA, Kaminski MR. Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study. J Foot Ankle Res 2021; 14:44. [PMID: 34130722 PMCID: PMC8204579 DOI: 10.1186/s13047-021-00477-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 04/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies. METHODS This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher's exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated. RESULTS Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants. CONCLUSIONS The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.
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Affiliation(s)
| | - Michelle R Kaminski
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia. .,Department of Podiatry, St Vincent's Hospital Melbourne, Melbourne, Victoria, 3065, Australia.
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Gooday C, Gray K, Game F, Woodburn J, Poland F, Hardeman W. Systematic review of techniques to monitor remission of acute Charcot neuroarthropathy in people with diabetes. Diabetes Metab Res Rev 2020; 36:e3328. [PMID: 32315511 DOI: 10.1002/dmrr.3328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/17/2020] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
AIM The management of acute Charcot neuroarthropathy relies on off-loading which is costly and time-consuming. Published studies have used monitoring techniques with unknown diagnostic precision to detect remission. We performed a systematic review of techniques for monitoring response to offloading in acute Charcot neuroarthropathy. MATERIALS AND METHODS We included studies of off-loading which evaluated or described monitoring techniques in acute Charcot neuroarthropathy. PubMed, EMBASE, CINAHL and Cochrane databases were searched (January1993-July 2018). We extracted data from papers including study design, setting, population, monitoring techniques and treatment outcomes. We also extracted information on the cost, clinical applicability, sensitivity and specificity, safety and participant acceptability of the monitoring techniques. RESULTS We screened 1205 titles, 140 abstracts and 45 full-texts, and included 29 studies. All studies were of low quality and at high risk of bias. In seven studies, the primary aim was to evaluate monitoring techniques: three evaluated magnetic resonance imaging, two thermography monitoring, one three-phase bone scanning and one Doppler spectrum analysis. The remaining 22 observational studies reported treatment outcomes and described the monitoring techniques used to assess the Charcot neuroarthropathy. Heterogeneity prevented the pooling of data. Very few studies included data on cost, clinical applicability, sensitivity and specificity, safety and patient acceptability of the monitoring techniques used. CONCLUSION Multiple techniques have been used to evaluate remission in acute Charcot neuroathropathy but uncertainty remains about their effectiveness. We recommend further research into the influences of different monitoring techniques on treatment outcomes.
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Affiliation(s)
- Catherine Gooday
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Katie Gray
- Podiatry Department, Derbyshire Community Health Services NHS Foundation Trust, Chesterfield, UK
| | - Frances Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jim Woodburn
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich, UK
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Gooday C, Game F, Woodburn J, Poland F, Sims E, Dhatariya K, Shepstone L, Hardeman W. A randomised feasibility study of serial magnetic resonance imaging to reduce treatment times in Charcot neuroarthropathy in people with diabetes (CADOM): a protocol. Pilot Feasibility Stud 2020; 6:85. [PMID: 32549996 PMCID: PMC7296621 DOI: 10.1186/s40814-020-00611-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/27/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complication of peripheral neuropathy associated with diabetes which most frequently affects the lower limb. It can cause fractures and dislocations within the foot, which may progress to deformity and ulceration. Recommended treatment is immobilisation and offloading, with a below knee non-removable cast or boot. Duration of treatment varies from six months to more than 1 year. Small observational studies suggest that repeated assessment with magnetic resonance imaging improves decision-making about when to stop treatment, but this has not been tested in clinical trials. This study aims to explore the feasibility of using serial magnetic resonance imaging without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot. A nested qualitative study aims to explore participants' lived experience of Charcot neuroarthropathy and of taking part in the feasibility study. METHODS We will undertake a two-arm, open study and randomise 60 people with a suspected or confirmed diagnosis of Charcot neuroarthropathy from five NHS, secondary care multidisciplinary Diabetic Foot Clinics across England. Participants will be randomised 1:1 to receive magnetic resonance imaging at baseline and remission up to 12 months, with repeated foot temperature measurements and X-rays (standard care plus), or standard care plus with additional three-monthly magnetic resonance imaging until remission up to 12 months (intervention). Time to confirmed remission of Charcot neuroarthropathy with off-loading treatment (days) and its variance will be used to inform sample size in a full-scale trial. We will look for opportunities to improve the protocols for monitoring techniques and the clinical, patient-centred and health economic measures used in a future study. For the nested qualitative study, we will invite a purposive sample of 10-14 people able to offer maximally varying experiences from the feasibility study to take part in semi-structured interviews to be analysed using thematic analysis. DISCUSSION The study will inform the decision whether to proceed to a full-scale trial. It will also allow deeper understanding of the lived experience of Charcot neuroarthropathy, and factors that contribute to engagement in management and contribute to the development of more effective patient-centred strategies. TRIAL REGISTRATION ISRCTN, ISRCTN74101606. Registered on 6 November 2017.
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Affiliation(s)
- Catherine Gooday
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Frances Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE UK
| | - Jim Woodburn
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, G4 0BA UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
| | - Erika Sims
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
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New Concepts in the Management of Charcot Neuroarthropathy in Diabetes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:391-415. [PMID: 32124412 DOI: 10.1007/5584_2020_498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Charcot Neuroarthropathy (CN) is an uncommon, debilitating and often underdiagnosed complication of chronic diabetes mellitus though, it can also occur in other medical conditions resulting from nerve injury. Till date, the etiology of CN remains unknown, but enhanced osteoclastogenesis is believed to play a central role in the pathogenesis of CN, in the presence of neuropathy. CN compromises the overall health and quality of life. Delayed diagnosis can result in a severe deformity that can act as a gateway to ulceration, infection and in the worst case, can lead to limb loss. In an early stage of CN, immobilization with offloading plays a key role to a successful treatment. Medical therapies seem to have limited role in the treatment of CN.In case of severe deformity, proper footwear or bracing may help prevent further deterioration and development of an ulcer. In individuals with a concomitant ulcer with osteomyelitis, soft tissue infection and severe deformity, where conservative measures fall short, surgical intervention becomes the only choice of treatment. Early diagnosis and proper management at an early stage can help prevent the occurrence of CN and amputation.
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Fejfarová V, Pavlů J, Bém R, Wosková V, Dubský M, Němcová A, Jirkovská A, Sixta B, Sutoris K, Thieme F, Armstrong DG, Vrátná E, Hazdrová J, Lánská V. The Superiority of Removable Contact Splints in the Healing of Diabetic Foot during Postoperative Care. J Diabetes Res 2019; 2019:5945839. [PMID: 31637262 PMCID: PMC6766149 DOI: 10.1155/2019/5945839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/14/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Off-loading is one of the crucial components of diabetic foot (DF) therapy. However, there remains a paucity of studies on the most suitable off-loading for DF patients under postoperative care. The aim of our study was to evaluate the effect of different protective off-loading devices on healing and postoperative complications in DF patients following limb preservation surgery. METHODS This observational study comprised 127 DF patients. All enrolled patients had undergone foot surgery and were off-loaded empirically as follows: wheelchair+removable contact splint (RCS) (group R: 29.2%), wheelchair only (group W: 48%), and wheelchair+removable prefabricated device (group WP: 22.8%). We compared the primary (e.g., the number of healed patients, healing time, and duration of antibiotic (ATB) therapy) and secondary outcomes (e.g., number of reamputations and number and duration of rehospitalizations) with regard to the operation regions across all study groups. RESULTS The lowest number of postoperative complications (number of reamputations: p = 0.028; rehospitalizations: p = 0.0085; and major amputations: p = 0.02) was in group R compared to groups W and WP. There was a strong trend toward a higher percentage of healed patients (78.4% vs. 55.7% and 65.5%; p = 0.068) over a shorter duration (13.7 vs. 16.5 and 20.3 weeks; p = 0.055) in the R group, as well. Furthermore, our subanalysis revealed better primary outcomes in patients operated in the midfoot and better secondary outcomes in patients after forefoot surgery-odds ratios favouring the R group included healing at 2.5 (95% CI, 1.04-6.15; p = 0.037), reamputations at 0.32 (95% CI, 0.12-0.84; p = 0.018), and rehospitalizations at 0.22 (95% CI, 0.08-0.58; p = 0.0013). CONCLUSIONS This observational study suggests that removable contact splint combined with a wheelchair is better than a wheelchair with or without removable off-loading device for accelerating wound healing after surgical procedures; it also minimises overall postoperative complications, reducing the number of reamputations by up to 77% and the number of rehospitalizations by up to 66%.
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Affiliation(s)
- Vladimíra Fejfarová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jaroslav Pavlů
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Robert Bém
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Veronika Wosková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Andrea Němcová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Alexandra Jirkovská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Bedřich Sixta
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Karol Sutoris
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Filip Thieme
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), University of Southern California (USC), Los Angeles, USA
| | - Eliška Vrátná
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jitka Hazdrová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Věra Lánská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Bullen B, Young M, McArdle C, Ellis M. Charcot neuroarthropathy patient education among podiatrists in Scotland: a modified Delphi approach. J Foot Ankle Res 2018; 11:54. [PMID: 30258497 PMCID: PMC6154915 DOI: 10.1186/s13047-018-0296-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 09/12/2018] [Indexed: 11/10/2022] Open
Abstract
Background This evaluation sought to determine current Charcot neuroarthropathy (CN) diabetes patient education practices among Scottish National Health Service (NHS) and academic podiatrists and evaluate novel visual tools and develop expert consensus for future practice. Methods Questionnaires collected mixed qualitative and quantitative responses, analysed concurrently within a convergence coding matrix. Delphi methodology permitted member-checking and agreement of consensus over two rounds. Results Fourteen participants (16.28%) completed a Round One questionnaire, leading to the generation of four themes; Experience; Person-Centred Care and the Content and Context of CN patient education. Seven consensus statements were subsequently developed and six achieved over 80% agreement among 16 participants (18.60%) with a Round Two questionnaire. Respondents agreed CN patient education should be considered for all ‘At-risk’ individuals with diabetic peripheral neuropathy (DPN). Verbal metaphors, including the ‘rocker-bottom’ foot, soft or brittle bones, collapsing, walking on honeycomb and a shattering lightbulb were frequently employed. Visual tools, including visual metaphors and The Charcot Foot Thermometer, were positively evaluated and made available online. Conclusions Key findings included respondent’s belief that CN education should be considered for all individuals with DPN and the frequent use of simile, analogy and metaphor in CN education. The concept of ‘remission’ proved controversial due to its potential for misinterpretation. Electronic supplementary material The online version of this article (10.1186/s13047-018-0296-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benjamin Bullen
- 1NHS Lothian Diabetes Foot Service, New Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew Young
- 1NHS Lothian Diabetes Foot Service, New Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Carla McArdle
- 2Podiatry Department, School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Mairghread Ellis
- 2Podiatry Department, School of Health Sciences, Queen Margaret University, Edinburgh, UK
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