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Skinner WC, Pattisapu N, Yeoh J, Grear BJ, Richardson DR, Murphy GA, Bettin CC. Surgical Outcomes in Charcot Arthropathy. Orthop Clin North Am 2024; 55:393-401. [PMID: 38782510 DOI: 10.1016/j.ocl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.
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Affiliation(s)
- William C Skinner
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Naveen Pattisapu
- Beth Israel Lahey Hospital, 41 Mall Road, Burlington, MA 01805, USA
| | - Jane Yeoh
- Nanaimo Orthopaedics, 201-1515 Dufferin Crescent, Nanaimo, British Columbia V9S5H6, Canada
| | - Benjamin J Grear
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - David R Richardson
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Garnett A Murphy
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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2
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Pinzur MS, Cho E, Schiff AP, Hamid K. Painful Nonunion in Patients With Clinically Plantigrade Diabetes-Associated Charcot Foot Arthropathy. Foot Ankle Int 2024:10711007241255128. [PMID: 38859676 DOI: 10.1177/10711007241255128] [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] [Indexed: 06/12/2024]
Abstract
BACKGROUND It has been assumed that diabetic patients with peripheral neuropathy should not have pain associated with Charcot foot arthropathy. METHODS During a 19-year period, 14 diabetic patients (15 feet) presented for treatment with pain following resolution of the acute phases of midfoot Charcot foot arthropathy. All were clinically plantigrade with plain radiographic evidence of bony union without deformity. Pain did not resolve with the use of appropriate therapeutic footwear. When used, CT scans uniformly demonstrated nonunion. RESULTS All 14 patients had resolution of their presenting pain following successful arthrodesis. Nonunion was confirmed at surgery in all of the patients. One patient developed a fatal pulmonary embolus following removal of the external fixator. Two required late exostectomy for bony overgrowth at the surgical site of fusion for nonunion. CONCLUSION This small series of patients would suggest that nonunion of the Charcot neuroarthropathy process was responsible for complaints of pain not able to be managed with therapeutic footwear. Successful arthrodesis resolved the pain. CT imaging may help identify a treatable source of pain in this population.
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Affiliation(s)
- Michael S Pinzur
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Elizabeth Cho
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Adam P Schiff
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Kamran Hamid
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Maywood, IL, USA
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3
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Rogero RG, Swamy S, Bettin CC. The Differentiation Between Infection and Acute Charcot. Orthop Clin North Am 2024; 55:299-309. [PMID: 38403375 DOI: 10.1016/j.ocl.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.
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Affiliation(s)
- Ryan G Rogero
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA
| | - Samhita Swamy
- University of Tennessee Health Science Center College of Medicine, 847 E Parkway S, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA.
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4
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Wukich DK, Frykberg RG, Kavarthapu V. Charcot neuroarthropathy in persons with diabetes: It's time for a paradigm shift in our thinking. Diabetes Metab Res Rev 2024; 40:e3754. [PMID: 38069459 DOI: 10.1002/dmrr.3754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 03/13/2024]
Abstract
The aim of this paper is to review the recent literature regarding the epidemiology and surgical management of Charcot neuro-osteoarthropathy (CNO). We propose that a fundamental change in the approach and assumptions regarding the historical treatment of active CNO should be considered. Although the true incidence and prevalence of CNO in the US population with diabetes are not known, we estimated the incidence to be 27,602 per year and the prevalence to be 208,880 persons. In persons with diabetes, the incidence of CNO is higher than that of prostate, lung, kidney, and thyroid cancer, and in the entire US population, the incidence of CNO is higher than that of multiple myeloma, soft tissue sarcoma, and primary bone sarcoma. In persons with diabetes, the incidence of CNO is higher than fractures of the femoral shaft, distal femur, tibia, talus, calcaneus and Lisfranc ligament injuries. Surgical techniques have evolved over the past half century, and surgery is the standard for treating displaced fractures and intra-articular injuries. Since CNO is a fracture, dislocation, or fracture dislocation in patients with neuropathy, why do we treat CNO differently? Elsewhere in the skeleton displaced osseous and ligament injuries are treated surgically. Based on the information presented in this manuscript, we suggest that it is time for a paradigm shift in the treatment of persons with CNO. While uncommon, CNO in persons with diabetes is not rare. Given the advances in surgical techniques, surgical intervention should be considered earlier in persons with CNO who are at risk for developing deformity related foot ulceration.
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Affiliation(s)
- Dane K Wukich
- University of Texas Southwestern Orthopaedic Surgery, Dallas, Texas, USA
| | - Robert G Frykberg
- Podiatric Medicine, Midwestern University Glendale, Glendale, Arizona, USA
| | - Venu Kavarthapu
- Orthopaedic Surgeon - King's College Hospital, London, UK
- Orthopaedic Lead, King's Diabetic Foot Unit, London, UK
- University of Southern Denmark, Odense, Denmark
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5
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Hoskins T, Patel J, Choi JH, Fitzpatrick B, Begley B, Mazzei CJ, Harrington CJ, Miller JM, Wittig JC, Epstein D. Mini-Open Achilles Tendon Repair: Improving Outcomes While Decreasing Complications. Foot Ankle Spec 2023; 16:363-369. [PMID: 35249403 DOI: 10.1177/19386400221078671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An acute rupture of the Achilles tendon is a traumatic injury that can cause considerable morbidity and reduced function. Nonoperative intervention may put patients at higher risk of rerupture, whereas surgical intervention carries risk of infection, wound complications, and iatrogenic nerve injury. The mini-open Achilles tendon repair technique has been popularized in helping decrease complications. The goal of this study was to examine and compare the functional outcomes and rate of complications in patients treated with a mini-open repair technique versus a traditional open repair for acute Achilles tendon ruptures. A retrospective review was performed of all patients with a complete Achilles tendon rupture that were treated by a single foot and ankle fellowship-trained surgeon. Functional outcome scores were assessed using the American Orthopaedic Foot and Ankle scoring system (AOFAS) and the Achilles Tendon Rupture Score (ATRS). Eighty-one patients with a complete Achilles tendon rupture underwent mini-open repair and 22 patients underwent traditional open repair surgery between 2013 and 2020. The mean follow-up was 38.40 months (range, 12-71). Mean preoperative AOFAS and ATRS improved in the mini-open group from 45.60 and 47.18 respectively, to 90.29 and 87.97 after surgery (p < .05). Mean preoperative AOFAS and ATRS scores for the traditional open repair (n = 22) cohort were 44.02 and 42.27, respectively. Postoperatively, the AOFAS and ATRS scores improved to 85.27 and 86.64 (P value < .05), respectively. There was no statistically significant difference in postoperative ATRS scores. However, the mini-open repair group showed a statistically higher postoperative AOFAS score (90.30) than the traditional open-repair group (85.27) (P value < .05). The overall complication rate for our study was 2.9% (2 mini-open repair and 1 traditional open repair). The complication rate in the mini-open repair group and traditional open repair cohort were 2.4% and 4.5%, respectively (P value > .05). One patient in the mini-open repair cohort (1.2%) reruptured his Achilles tendon 4 months postoperatively. A second patient in the mini-open repair group (1.2%) developed a superficial skin infection and suture irritation. One patient (4.5%) in the traditional open repair group developed a superficial skin infection. There were no sural nerve injuries in our series. The mini-open approach to repair a ruptured Achilles tendon is a viable treatment option to decrease the incidence rate of postoperative complications and rerupture rates while also producing a superior cosmetic result.Level of Evidence: 3 (retrospective cohort study N ≥ 30).
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Affiliation(s)
- Tyler Hoskins
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Jay Patel
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Joseph H Choi
- Department of Orthopaedic Surgery, St. Joseph's Medical Center, Paterson, New Jersey
| | - Brendan Fitzpatrick
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Brian Begley
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Chris J Mazzei
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Colin J Harrington
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Justin M Miller
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - James C Wittig
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - David Epstein
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
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6
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Pinzur MS. Republication of "An Evidence-Based Introduction to Charcot Foot Arthropathy". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231188128. [PMID: 37535332 PMCID: PMC10387697 DOI: 10.1177/24730114231188128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Affiliation(s)
- Michael S Pinzur
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Mehlhorn AT, Illgner U, Lemperle S, Hoerterer H, Krenn V, Walther M. Histopathological assessment of a two-stage reconstructive procedure of the infected Charcot foot. Arch Orthop Trauma Surg 2023; 143:1223-1230. [PMID: 34743216 DOI: 10.1007/s00402-021-04238-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Charcot neuropathic osteoarthropathy (CN) can be complicated by osteomyelitis (OM). Surgery is a standard procedure to treat OM including debridement and interposition of antibiotic-loaded cement (ABLC) spacer. The course of CN and OM was investigated on a histopathological level. MATERIALS AND METHODS Diabetic patients (n = 15) suffering from CN and midfoot OM underwent surgical debridement and interposition of ABLC was interposed. 6 weeks later, ABLC was removed and bone samples were taken again. Histopathological Charcot Score (HCS), Histopathological Osteomyelitis Evaluation Score (HOES) and microbiological assessment were used to evaluate osteomyelitic and neuroosteoarthropathic activity at both time points. RESULTS Interposition of ABLC leads to microbiological/histopathological eradication of OM in 73%/87% of patients. CN activity-measured by HCS-could be reduced from moderate to low activity by ABLC spacer and correlated with HOES. CONCLUSIONS CN activity could be reduced by surgery. It can be suggested that neuroosteoarthropathic activity measured by HCS is triggered by OM.
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Affiliation(s)
- Alexander T Mehlhorn
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany.
- Department of Orthopedics and Trauma Surgery, Medical Center, Albert-Ludwigs University of Freiburg, Freiburg, Germany.
| | - Ulrich Illgner
- Orthopädische Privatpraxis Seintsch Illgner, Koblenz, Germany
| | - Stefan Lemperle
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
| | - Hubert Hoerterer
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Veith Krenn
- MVZ-Zentrum Für Histologie, Zytologie Und Molekulare Diagnostik GmbH, Max-Planck-Str. 5, Trier, Germany
| | - Markus Walther
- Center of Foot and Ankle Surgery, Schönklinik München Harlaching, Harlachingerstrasse 55, 81549, Munich, Germany
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8
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The Modern Treatment of Charcot Foot Arthropathy. J Am Acad Orthop Surg 2023; 31:71-79. [PMID: 36580046 DOI: 10.5435/jaaos-d-22-00365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/28/2022] [Indexed: 12/30/2022] Open
Abstract
The National Institute of Health now estimates that there are well over 37 million persons with diabetes in the United States alone, a number well over 11 per cent of our population. The associated multiple organ system disease is responsible for more than 327 billion dollars in direct and indirect medical costs and more than 140,000 lower extremity amputations yearly in the United States. Because healthcare professionals have begun to appreciate the economic and pathologic burden that diabetes imparts on our society, there has been a growth in both the understanding and treatment of the responsible pathologic disorders. The goal of this monograph is to provide an evidence-supported foundation to better understand the pathophysiology that leads to the development of neuropathic (Charcot) foot arthropathy and provide insight into developing a treatment plan for addressing this complex disease process that presents in a highly comorbid patient population.
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9
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Romero-Collado À, Hernández-Martínez-Esparza E, Zabaleta-Del-Olmo E, Urpí-Fernández AM, Santesmases-Masana R. Patient-Reported Outcome Measures of Quality of Life in People Affected by Diabetic Foot: A Psychometric Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1602-1618. [PMID: 35659485 DOI: 10.1016/j.jval.2022.04.1737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/10/2022] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This psychometric systematic review aimed to identify the most suitable patient-reported outcome measures (PROMs) of quality of life (QoL) in people affected by diabetic foot. METHODS We performed a literature search in MEDLINE (PubMed), CINAHL (EBSCOhost), and PsycINFO (EBSCOhost) databases from inception to February 1, 2022. We also searched gray literature databases. Eligible studies were full-text reports developing a QoL condition-specific PROM or assessing one or more of its measurement properties in people affected by diabetic foot. We assessed the methodological quality of included studies independently using the "Consensus-Based Standards for the Selection of Health Measurement Instruments Risk of Bias" checklist. The measurement properties were evaluated using specific criteria. We graded the quality of the evidence using a "Grading of Recommendations Assessment, Development and Evaluation" approach modified by Consensus-Based Standards for the Selection of Health Measurement Instruments. RESULTS Forty-three reports (46 studies) providing information on the measurement properties of 10 different PROMs were included. We did not identify any instruments that could be recommended for use. We identified 2 PROMs that were not recommended for use and 8 that were potentially recommended but would require further investigation. Of these 8 PROMs, 4 had better evidence for content validity. CONCLUSIONS Available PROMs to measure QoL in people affected by diabetic foot have limited evidence for their measurement properties. There is no fully suitable PROM. Pending further evidence, 4 PROMs could potentially be recommended for use.
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Affiliation(s)
| | | | - Edurne Zabaleta-Del-Olmo
- Nursing Department, Faculty of Nursing, Universitat de Girona, Girona, Spain; Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Gerència Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain.
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10
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Miller R. NEMISIS: Neuropathic Minimally Invasive Surgeries. Charcot Midfoot Reconstruction, Surgical Technique, Pearls and Pitfalls. Foot Ankle Clin 2022; 27:567-581. [PMID: 36096552 DOI: 10.1016/j.fcl.2022.05.001] [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] [Indexed: 02/02/2023]
Abstract
The last decade has seen a significant development in early surgical intervention for patients with or at risk of ulceration owing to deformity resulting from the sequalae of diabetic foot disease. Midfoot Charcot neuroarthropathy is the most common deformity; its correction is enabled by specialized surgical implants designed to maintain surgical corrections. There has also been an increasing number of orthopedic foot and ankle surgeons, with a specific interest in diabetic foot disease who provide early surgical correction in patients identified as high risk. Minimally invasive surgery using percutaneous incisions completes the triumvirate, facilitating earlier surgical intervention to decrease reulcerations.
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Affiliation(s)
- Roslyn Miller
- NHS Lanarkshire Universities Hospitals, Lanarkshire, Scotland, UK; Glasgow Caledonian University, Glasgow, Scotland, UK; Department of Orthopaedics, Foot and Ankle Service Lead, Hairmyres University Hospital, 218 Eaglesham Road, East Kilbride, Glasgow G75 8RG, UK.
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11
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Evidence-based conservative limb preserving surgery for the diabetic foot complications: A systematic review of systematic reviews. Foot Ankle Surg 2022; 28:670-679. [PMID: 34479784 DOI: 10.1016/j.fas.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/17/2021] [Accepted: 08/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC. METHODS PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies' quality. RESULTS 22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82. CONCLUSIONS There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.
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Wukich DK, Raspovic KM, Jupiter DC, Heineman N, Ahn J, Johnson MJ, Liu GT, VanPelt MD, Lafontaine J, Lavery L, Kim P, Nakonezny PA. Amputation and infection are the greatest fears in patients with diabetes foot complications. J Diabetes Complications 2022; 36:108222. [PMID: 35717355 DOI: 10.1016/j.jdiacomp.2022.108222] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/30/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022]
Abstract
AIMS To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America.
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Daniel C Jupiter
- Department of Preventive Medicine and Population Health Office of Biostatistics, University of Texas Medical Branch Galveston, TX 77550, United States of America
| | - Nathan Heineman
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - George T Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Michael D VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Javier Lafontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Larry Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Paul Kim
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Paul A Nakonezny
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, United States of America
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13
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McGregor PC, Lyons MM, Pinzur MS. Quality of Life Improvement Following Reconstruction of Midtarsal Charcot Foot Deformity: A Five Year Follow-Up. THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:109-112. [PMID: 35821917 PMCID: PMC9210442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND There is increasing interest in reconstruction of diabetes-associated Charcot foot arthropathy with the goal of improving quality of life. METHODS Twenty-four patients who completed the Short Musculoskeletal Function Assessment (SMFA) at baseline and one year following Charcot foot reconstruction were contacted and asked to complete the survey at five years following surgery. RESULTS Fourteen of the 24 patients completed the SMFA preoperatively, one year following surgery and five years postoperatively. Two patients underwent below knee amputation in the interim. Improvement was noted in all domains measured by the SMFA, with a statistically significant improvement in difficulty with daily activities at five years. CONCLUSION Correction of non-plantigrade Charcot foot arthropathy results in clinically meaningful improvement in health-related quality of life at both one and five years postoperatively, including independence with daily activities. The improvement is maintained when reevaluated at five years. This supports the modern paradigm shift towards reconstruction of this deformity. Level of Evidence: III.
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Affiliation(s)
- Patrick Cole McGregor
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, Illinois, USA
| | - Madeline M. Lyons
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, Illinois, USA
| | - Michael S. Pinzur
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, Illinois, USA
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14
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Galhoum AE, Abd-Ella MM, Zahlawy HE, Tejero S, Valderrabano V, Trivedi V, ElGebeily M. Infected unstable Charcot ankle neuroarthropathy, any hope before amputation? A prospective study. INTERNATIONAL ORTHOPAEDICS 2022; 46:1481-1488. [PMID: 35449479 DOI: 10.1007/s00264-022-05400-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures, and instability. In this study, we present the results of salvage procedure of the ankle Charcot neuroarthropathy using aggressive debridement and Ilizarov frame fusion with early weight bearing. METHODS Twenty-three patients with severely infected ulcerated and unstable Charcot neuroarthropathy of the ankle were treated between 2013 and 2018. The mean age was 63.5 ± 7.9 years; 16 males and seven females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, was performed followed by external fixation with an Ilizarov frame along with early weight-bearing. The primary outcome was a stable plantigrade infection-free foot and ankle that allows weight-bearing in accommodative footwear. RESULTS Limb salvage was achieved in 91.3% of cases at the end of a mean follow-up time of 19 months (range: 17-29). Fifteen (71.4%) solid bony unions evident clinically and radiographically were achieved, while six (28.5%) patients developed stable painless pseudarthrosis. Two patients had below-knee amputations due to uncontrolled infection. CONCLUSION Aggressive debridement and arthrodesis using ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing, and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection.
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Affiliation(s)
- Ahmed E Galhoum
- George Eliot Hospital NHS Trust, Nuneaton, Warwickshire, UK.
| | | | | | - Sergio Tejero
- Hospital Virgen del Rocío, University of Seville, Seville, Spain
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Johnson MJ, Wukich DK, Nakonezny PA, Lavery LA, La Fontaine J, Ahn J, Truong DH, Liu GT, VanPelt M, Kim PJ, Raspovic KM. The Impact of Hospitalization for Diabetic Foot Infection on Health-Related Quality of Life: Utilizing PROMIS. J Foot Ankle Surg 2022; 61:227-232. [PMID: 34389216 DOI: 10.1053/j.jfas.2021.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/26/2020] [Accepted: 07/10/2021] [Indexed: 02/03/2023]
Abstract
Diabetic foot infections (DFI) are an increasingly common cause of hospitalizations. Once hospitalized with DFI, many patients require some level of amputation, often undergoing multiple operations. With increasing importance on patient-centered metrics, self-reported health-related quality of life (HRQOL) tools have been developed. This prospective cohort study aimed assessed the impact of DFI on HRQOL. Two hundred twenty-four patients completed the 29-item Patient-Reported Outcome Measurement Information System (PROMIS) and 12-Item Short Form (SF-12) survey. Secondary outcomes using the Foot and Ankle Ability Measures survey were obtained and included in the analysis. The study group was comprised of hospitalized patients with DFIs (n = 120), and the control group was comprised of patients with diabetes who were evaluated for routine outpatient foot care (n = 104); diabetic foot screening, wound care, onychomycosis, and/or callosities. Using this cohort, a propensity score-matched sample of hospitalized patients with DFI (n = 35) and control group patients (n = 35) was created for comparative analysis. The 2-independent sample t test was used to test for group differences on each of the PROMIS subscale outcomes. Using PROMIS, we found that hospitalized patients with DFI reported significantly worse HRQOL in 6 of 7 subscales (physical function, anxiety, depression, fatigue, social role, pain intensity; p value range: .0001-.02) compared to outpatients with diabetes evaluated for routine foot care. There was no significant difference between the 2 groups on sleep disturbance (p = .22). Patients hospitalized for DFI report lower HRQOL compared to patients with diabetes receiving routine outpatient foot care.
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Affiliation(s)
- Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul A Nakonezny
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - David H Truong
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - George Tye Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul J Kim
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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16
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Moon KC, Son JW, Han SK, Kim JY. Risk Factors for Major Amputation for Midfoot Ulcers in Hospitalized Patients With Diabetes: A Retrospective Study. J Wound Ostomy Continence Nurs 2021; 48:163-168. [PMID: 33690250 DOI: 10.1097/won.0000000000000735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this study was to investigate the risk factors for major amputation in persons hospitalized with diabetic foot ulcers involving the midfoot. DESIGN Retrospective study. SUBJECTS AND SETTING Between January 2003 and May 2019, a total of 1931 patients with diabetes were admitted to the diabetic wound center for the management of foot ulcers. Among the admitted patients, 169 patients with midfoot ulcers were included in this study. One hundred fifty-four patients (91%) healed without major amputation, while 15 patients (9%) healed post-major amputation. METHODS Data related to 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology, and serology were collected from patients in these 2 groups for comparison. Univariate and multivariate logistic regression analyses were performed to analyze risk factors for major amputation. RESULTS Among the 88 potential risk factors, 15 showed statistically significant differences between the 2 groups. Using univariate analysis of 88 potential risk factors, 8 showed statistically significant differences. Using stepwise multiple logistic regression analysis, 3 of the 8 risk factors remained statistically significant. Multivariate-adjusted odds ratios for deep ulcers invading bone, cardiac disorders, and Charcot foot were 26.718, 18.739, and 16.997, respectively. CONCLUSION The risk factors for major amputation in patients hospitalized with diabetic midfoot ulcers included deep ulcers invading the bone, cardiac disorders, and Charcot foot.
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Affiliation(s)
- Kyung-Chul Moon
- Kyung-Chul Moon, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Ji-Won Son, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Seung-Kyu Han, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Jae-Yeon Kim, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea
| | - Ji-Won Son
- Kyung-Chul Moon, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Ji-Won Son, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Seung-Kyu Han, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Jae-Yeon Kim, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea
| | - Seung-Kyu Han
- Kyung-Chul Moon, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Ji-Won Son, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Seung-Kyu Han, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Jae-Yeon Kim, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea
| | - Jae-Yeon Kim
- Kyung-Chul Moon, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Ji-Won Son, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Seung-Kyu Han, MD, PhD, Department of Plastic Surgery and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea.,Jae-Yeon Kim, RN, WOCN, Department of Nursing Service and Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea
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Lyons M, McGregor PC, Pinzur MS, Adams W, Wilkos-Prostran L. Risk Reduction and Perioperative Complications in Patients With Diabetes and Multiple Medical Comorbidities Undergoing Charcot Foot Reconstruction. Foot Ankle Int 2021; 42:902-909. [PMID: 33629589 DOI: 10.1177/1071100721995422] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Modern patient safety programs focus on medical optimization of patients prior to surgery, regional anesthesia when possible, and hospitalist-orthopedic co-management during the perioperative period. METHODS Eighty-five consecutive patients with diabetes and multiple medical comorbidities underwent surgical reconstruction for acquired deformities secondary to Charcot foot arthropathy with circular ring fixation between 2016 and 2019. All patients participated in a standardized risk reduction program that included medical optimization prior to surgery, regional anesthesia whenever possible, and hospitalist-orthopedic co-management during the perioperative period. Charts were retrospectively reviewed for medical comorbidities, complications, and length of stay. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator was used to retrospectively calculate their predicted perioperative risk. RESULTS On multivariable analysis, longer lengths of stay were associated with low preoperative hemoglobin values (rate ratio [RR], 1.36; P = .01) and congestive heart failure (RR, 1.42; P = .02). There were 22 (26%) complications, though only 10 (12%) were serious. These included acute kidney injury (n = 6), sepsis (n = 2), 1 cardiac event, and 1 pulmonary embolism. Overall, the accuracy of predicting a complication using the ACS NSQIP Risk Calculator was 74% (95% CI, 63%-85%), which was comparable to the accuracy of predicting a complication using only patients' congestive heart failure and pin-tract infection statuses (c = 74%, 95% CI, 62%-86%). DISCUSSION Medical optimization of patients with diabetes and multiple medical comorbidities prior to elective complex reconstruction orthopedic surgery allows the surgery to be performed with a predictable risk for perioperative complications. Preoperative anemia and congestive heart failure are associated with longer hospitalizations in this patient group. The ACS NSQIP Risk Calculator appears to be a reliable predictor of complications during the perioperative period. This study demonstrates that reconstructive surgery in this complex patient population can be accomplished with a reasonable exposure to perioperative risk. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Madeline Lyons
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Patrick Cole McGregor
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Diabetic foot disease: a systematic literature review of patient-reported outcome measures. Qual Life Res 2021; 30:3395-3405. [PMID: 34109501 DOI: 10.1007/s11136-021-02892-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Diabetic foot disease is one of the most serious and expensive complications of diabetes. Patient-reported outcome measures (PROMs) analyse patients' perception of their disability, functionality and health. The goal of this work was to conduct a systematic review regarding the specific PROMs related to the evaluation of diabetic foot disease and to extract and analyse the values of their measurement properties. METHODS Electronic databases included were PubMed, CINAHL, Scopus, PEDro, Cochrane, SciELO and EMBASE. The search terms used were foot, diabet*, diabetic foot, questionnaire, patient-reported outcome, self-care, valid*, reliabil*. Studies whose did not satisfy the Critical Appraisals Skills Programme (CASP) Diagnostic Study Checklist were excluded. The measurement properties extracted were: Internal Consistency, Test-retest, Inter-rater and Intra-rater, Standard Error of Measurement, Minimum Detectable Measurement Difference, Content Validity, Construct Validity, Criterion Validity and Responsiveness. RESULTS The PROMs selected for this review were 12 questionnaires. The Diabetic foot self-care questionnaire (DFSQ-UMA) and the Questionnaire for Diabetes Related Foot Disease (Q-DFD) were the PROMs that showed the highest number of completed measurement properties. CONCLUSION According to the results, it is relevant to create specific questionnaires for the evaluation of diabetic foot disease. It seems appropriate to use both DFSQ-UMA and Q-DFD when assessing patients with diabetic foot disease.
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Powers NS, Leatham PR, Persky JD, Burns PR. Outcomes of Tibiotalocalcaneal Arthrodesis with a Femoral Nail. J Am Podiatr Med Assoc 2021; 111:466723. [PMID: 34144596 DOI: 10.7547/19-151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters. METHODS We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated. RESULTS At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection-related complications. CONCLUSIONS Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.
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20
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Pradana AS, Phatama KY, Mustamsir E, Cahyono GD, Oktafandi IGNAA, Hidayat M. Double posterior lateral plating arthrodesis for charcot ankle: A case series. Ann Med Surg (Lond) 2021; 65:102250. [PMID: 33996041 PMCID: PMC8091877 DOI: 10.1016/j.amsu.2021.102250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Ankle arthrodesis is one of the managements for a significantly unstable Charcot ankle. Some of the methods of internal fixation for ankle arthrodesis include the use of intramedullary nails, screws, and plates. Ankle arthrodesis using intramedullary nails has become more popular. However, studies evaluating the use of plate fixation, particularly double posterior lateral plating, are limited. We report the clinical and radiological outcomes of double posterior lateral plating ankle arthrodesis in three diabetic Charcot ankle patients. Presentation of case Three patients, aged 73, 67, and 65 years old, complained of ankle pain and with a history of type 2 diabetes mellitus. The physical examination revealed swelling and erythema without a sign of active infection. The radiological examination showed ankle deformity, and the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scores were 5, 10, and 0, respectively. All patients were diagnosed with a diabetic Charcot ankle and underwent ankle arthrodesis using double posterior lateral plating. Four months and six months follow up revealed talus union, improved ankle deformity, and improved AOFAS Ankle-Hindfoot scores to 70, 76, and 73, respectively. Discussion Various methods of ankle arthrodesis are retrograde intramedullary nails, screws, and plates. In this report, we opt for plate fixation because it allows for stable internal fixation, adequate compression, high angular stability, and a lower irreversible deformation in osteoporotic bone. Conclusion Double posterior lateral plating ankle arthrodesis provided satisfactory clinical and radiological outcomes. This method can be an alternative for patients with Charcot ankle requiring ankle arthrodesis. Double posterior lateral plating ankle arthrodesis is satisfactory. This method can be an alternative for patients with Charcot ankle. Plate fixation allows stable internal fixation and adequate compression.
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Affiliation(s)
- Ananto Satya Pradana
- Orthopaedic and Traumatology Department, Faculty of Medicine, Brawijaya University-Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Krisna Yuarno Phatama
- Orthopaedic and Traumatology Department, Faculty of Medicine, Brawijaya University-Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Edi Mustamsir
- Orthopaedic and Traumatology Department, Faculty of Medicine, Brawijaya University-Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Ganang Dwi Cahyono
- Orthopaedic and Traumatology Department, Faculty of Medicine, Brawijaya University-Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | | | - Mohamad Hidayat
- Orthopaedic and Traumatology Department, Faculty of Medicine, Brawijaya University-Saiful Anwar General Hospital, Malang, East Java, Indonesia
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21
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Ferreira RC. Diabetic Foot. Part 2: Charcot Neuroarthropathy. Rev Bras Ortop 2020; 55:397-403. [PMID: 32904836 PMCID: PMC7458761 DOI: 10.1055/s-0039-3402460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/13/2019] [Indexed: 12/02/2022] Open
Abstract
Charcot neuroarthropathy (CN) is an unfortunate and common complication of patients with diabetes, most likely resulting from a lack of proper understanding of the disease, which leads to late diagnosis. It is commonly misdiagnosed as infection and treated with antibiotics and a frustrated attempt of surgical drainage, which will reveal only debris of the osteoarticular destruction. Proper education of diabetic patients and of the health care professionals involved in their treatment is essential for the recognition of the initial signs of CN. The general orthopedic surgeon is usually the first to treat these patients in the early stages of the disease and must be aware of the signs of CN in order to establish an accurate diagnosis and ensure proper treatment. In theory, this would make it possible to decrease the morbidity of this condition, as long as proper treatment is instituted early.
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Affiliation(s)
- Ricardo Cardenuto Ferreira
- Grupo de Cirurgia do Pé e Tornozelo, Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
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Abstract
Charcot neuropathic arthropathy (CN) is a devastating condition resulting in non-reducible foot deformity that places patients with distal peripheral neuropathy at risk for the development of chronic neuropathic foot ulcers, major lower extremity amputation, and even death. The condition is often misdiagnosed early in its presentation because of a lack of knowledge among members of the medical community. Consequently, initial therapies for the condition are fewer and patients who present in more advanced stages of the condition are more difficult to manage. We now understand that CN is a multifactorial process resulting in unregulated osteoclastogenesis and bony destruction. Classically, the patient will present with an edematous, erythematous foot with increased temperature. These non-specific findings lead to a multitude of differential diagnoses. However, there are no diagnostic biomarkers or pathognomonic clinical signs to distinguish this condition from other common foot ailments seen in the context of peripheral neuropathy. Advancing our understanding of this condition, while educating the medical community about its devastating impact, is needed to advance and improve outcomes for patients affected by CN.
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Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48106, USA.
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Abstract
It is now well accepted that diabetic patients with clinically and radiographically nonplantigrade Charcot foot arthropathy are best managed with correction of the acquired deformity. Several investigations have demonstrated a high probability for a favorable clinical outcome when the deformity is in the midfoot. Unstable deformity at the subtalar or ankle joints portends a far worse clinical outcome. The goal of this discussion was to describe the author's approach to this highly challenging clinical problem.
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Yammine K, Assi C. Intramedullary nail versus external fixator for ankle arthrodesis in Charcot neuroarthropathy: A meta-analysis of comparative studies. J Orthop Surg (Hong Kong) 2020; 27:2309499019836012. [PMID: 30894064 DOI: 10.1177/2309499019836012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Ankle Charcot neuroarthropathy presents a great challenge for treatment. While conservative treatments yield poor results, arthrodesis is considered the treatment of choice for unstable Charcot ankles. There are two methods used for ankle fusion: retrograde intramedullary nail (IMN) and external fixator (EF). Literature reports inconclusive results on which method is better for arthrodesis. METHODS The aim of this meta-analysis is to look for significant difference between the two techniques in terms of fusion rate and complications. Four comparative studies including 117 patients (117 interventions) were located and analyzed. RESULTS IMN was found to yield double fusion rate than EF ( p = 0.2) with 5 weeks less time to heal ( p = 0.4). While no significance was noted for revision surgery and amputation rates, EF yielded higher rates of hardware infection ( p = 0.01) and wound infection ( p = 0.01). The IMN method seems to offer quicker and better fusion rate when compared to EF with significantly lower postoperative infection rates. CONCLUSION In the clinical context of high-risk patients such as the diabetic population, IMN technique could be a better option in the case of ulcer-free ankles/feet or in the presence of medial/lateral ulcers. In case of presence of plantar ulcers, EF might be a better choice to avoid the plantar approach for nail insertion. Future research with bigger sample sized and randomized studies are warranted for validation.
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Affiliation(s)
- Kaissar Yammine
- 1 Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon.,2 School of Medicine, Lebanese American University, Byblos, Lebanon.,3 Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,4 Diabeti Foot Clinic, Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon
| | - Chahine Assi
- 1 Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon.,2 School of Medicine, Lebanese American University, Byblos, Lebanon.,3 Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
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Ha J, Hester T, Foley R, Reichert IL, Vas PR, Ahluwalia R, Kavarthapu V. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma 2020; 11:357-368. [PMID: 32405193 PMCID: PMC7211810 DOI: 10.1016/j.jcot.2020.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
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Affiliation(s)
- Joon Ha
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Thomas Hester
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Robert Foley
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Ines L.H. Reichert
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Prashanth R.J. Vas
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom,King’s Diabetic Foot Clinic, King’s College College Hospital, London
| | - Raju Ahluwalia
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom,Corresponding author.
| | - Venu Kavarthapu
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
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The minimum detectable measurement difference for the Scoliosis Research Society-22r in adolescent idiopathic scoliosis: a comparison with the minimum clinically important difference. Spine J 2019; 19:1319-1323. [PMID: 30986576 DOI: 10.1016/j.spinee.2019.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The minimal clinically important difference (MCID) is the smallest change in an outcomes instrument deemed relevant to a patient. MCID values proposed in spine research are limited by poor discriminative abilities to accurately classify patients as "improved" or "not improved." Furthermore, the MCID should not compare relative effectiveness between two groups of patients, though it is frequently used for this. The minimum detectable measurement difference (MDMD) is an alternative to the MCID in outcomes research. The MDMD must be greater than the MCID for the latter to be of value and the MDMD can compare change between groups. PURPOSE The purpose of this study was to determine the MDMD for the Scoliosis Research Society-22r (SRS-22r) in adolescent idiopathic scoliosis (AIS) patients treated with surgery. STUDY DESIGN Retrospective cohort study from multi-center registry. PATIENT SAMPLE Patients treated surgically for AIS. OUTCOME MEASURES Self-reported SRS-22r. METHODS An observational cohort of surgically treated AIS patients was queried for patients with complete baseline, 1-year, and 2-year SRS-22r data. The MDMD was calculated for SRS-22r domain and subscores. Effect size (ES) and standardized response mean were calculated to measure responsiveness of the SRS-22r to change. MDMD values were compared with MCID values. Research grants were received from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive, and Zimmer Biomet to Setting Scoliosis Straight Foundation. RESULTS One thousand two hundred and eighty-one AIS patients (1,034 female, 247 male, mean age 14.6 years) were analyzed. MDMD values were between 0.23 and 0.31. SRS-Pain MDMD was 0.3, greater than the MCID of 0.2. SRS-Activity MDMD was 0.24, greater than the MCID of 0.08. SRS-self-image MDMD was 0.3, less than the MCID of 0.98. Sixty-four percent of those with baseline SRS-self-image>4.0 improved MDMD or more, whereas only 14% improved beyond the MCID. ES and standardized response mean were highest for subscore and self-image. CONCLUSIONS The MDMD can compare the relevance of change in SRS-22r scores between groups of AIS patients. SRS-pain and SRS-activity MDMD values are greater than the MCID and should serve as the threshold for clinically relevant improvement. MDMD may help evaluate change in patients with baseline self-image>4.0.
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AlSadrah SA. Impaired quality of life and diabetic foot disease in Saudi patients with type 2 diabetes: A cross-sectional analysis. SAGE Open Med 2019; 7:2050312119832092. [PMID: 30815259 PMCID: PMC6385329 DOI: 10.1177/2050312119832092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/29/2019] [Indexed: 12/31/2022] Open
Abstract
Objectives: This study aimed to assess the overall health-related quality of life in type 2 diabetes mellitus patients with diabetic foot disease compared to diabetic patients without diabetic foot and to identify the clinical utility of this assessment. Methods: A total of 250 consecutive patients with type 2 diabetes mellitus (100/150 with/without diabetic foot, respectively) were interviewed. The questionnaires of the 36-item short-form survey and region-specific foot and ankle ability measure were applied. Wagner–Meggitt wound classification was used for foot-ulcer evaluation. Follow-up of patients for 3–6 weeks was done to identify the potential clinical short outcomes of diabetic foot ulcers. Results: Type 2 diabetes mellitus patients with diabetic foot exhibited poor mental and physical health consequences. Females had more prevalence of forefoot lesions, larger ulcer size, advanced Wagner grade, and higher frequency of unhealed ulcers. Receiver operating characteristic curve analysis demonstrated high value of foot and ankle ability measure and 36-item short-form questionnaires to discriminate type 2 diabetes mellitus patients with and without diabetic foot at cutoff values of 66 and 49.6, respectively. Foot and ankle ability measure questionnaire also showed high performance for differentiating the clinical outcome of foot ulcer. Total foot and ankle ability measure subscale score above the cutoff value of 65.5 could discriminate patients with complete healing and unhealed ulcer lesions at a high sensitivity and specificity. Conclusion: The current findings confirm the impact of diabetic foot disease on type 2 diabetes mellitus overall health-related quality of life reflected in 36-item short-form questionnaire and foot and ankle ability measure questionnaire which showed high discriminative values for type 2 diabetes mellitus patient sub-grouping. Their application in routine clinical health assessment with continuous medical education programs is highly recommended to achieve a better health-related quality of life.
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Affiliation(s)
- Sana A AlSadrah
- Department of Preventive Medicine, Governmental Hospital Khobar, Health Centers in Khobar, Ministry of Health, Khobar, Saudi Arabia
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Harkin EA, Schneider AM, Murphy M, Schiff AP, Pinzur MS. Deformity and Clinical Outcomes Following Operative Correction of Charcot Ankle. Foot Ankle Int 2019; 40:145-151. [PMID: 30526048 DOI: 10.1177/1071100718805076] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Deformity associated with Charcot foot arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following operative correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot foot arthropathy involving the ankle joint. METHODS: Fifty-six consecutive patients underwent operative reconstruction of Charcot foot deformity involving the ankle joint by a single surgeon over a 14-year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single-stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years. RESULTS: One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty-eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between pre- or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome. CONCLUSIONS: Operative correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly comorbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques. LEVEL OF EVIDENCE: Level IV, case series.
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Affiliation(s)
- Elizabeth A Harkin
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Andrew M Schneider
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | | | - Adam P Schiff
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Labovitz JM, Shapiro JM, Satterfield VK, Smith NT. Excess Cost and Healthcare Resources Associated With Delayed Diagnosis of Charcot Foot. J Foot Ankle Surg 2019; 57:952-956. [PMID: 29937337 DOI: 10.1053/j.jfas.2018.03.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Indexed: 02/03/2023]
Abstract
The purpose of the present study was to demonstrate the effect of a delayed diagnosis of Charcot foot on acute care cost and usage. We used International Classification of Disease, Ninth Revision, Clinical Modification codes, and the California Office for Statewide Health Planning and Development 2009 to 2012 public patient discharge files to identify patients with type 2 diabetes mellitus and Charcot foot. The costs and length of stay were compared for those with a diagnosis of Charcot foot on admission compared with those who received a delayed diagnosis of Charcot foot before discharge. Patient demographic data, diagnoses often mistaken for Charcot foot, and procedures often performed for Charcot foot were assessed to determine the potential effect on costs and length of stay in Charcot foot subjects. A delayed Charcot foot diagnosis was associated with 10.8% greater inpatient costs and 12.1% longer length of stay. These patients required greater resource usage owing to the significantly greater number of procedures performed. A significantly greater number of patients underwent lower extremity amputation when the diagnosis was delayed, resulting in a 30.4% increase in costs and 31.6% longer length of stay. A greater rate of diabetic foot ulcers, foot infections, and osteomyelitis was also observed; however, the cost was only affected by osteomyelitis, and the length of stay was not significantly affected. A delayed diagnosis of Charcot foot at admission resulted in significantly increased acute care costs and longer lengths of stay.
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Affiliation(s)
- Jonathan M Labovitz
- Professor, Western University of Health Science, College of Podiatric Medicine, Pomona, CA.
| | - Jarrod M Shapiro
- Associate Professor, Western University of Health Science, College of Podiatric Medicine, Pomona, California
| | - V Kathleen Satterfield
- Professor, Western University of Health Science, College of Podiatric Medicine, Pomona, CA
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Ortega-Avila AB, Cervera-Garvi P, Ramos-Petersen L, Chicharro-Luna E, Gijon-Nogueron G. Patient-Reported Outcome Measures for Patients with Diabetes Mellitus Associated with Foot and Ankle Pathologies: A Systematic Review. J Clin Med 2019; 8:jcm8020146. [PMID: 30691204 PMCID: PMC6407033 DOI: 10.3390/jcm8020146] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background: Diabetes mellitus (DM) is a chronic and complex disease, which is a major cause of morbidity and mortality and affects all age groups. It commonly produces secondary effects on the foot, often making daily activities impossible. Patient-reported outcome measures (PROMs) provide a standardised method of obtaining patients’ outlooks on their functional status and wellbeing. Although many instruments have been proposed for obtaining data on persons with DM whose feet are affected by the disease, in many cases the psychometric properties of the instrument have yet to be established. The principal objective of our review was to identify PROMs specific for patients with DM affecting the foot and ankle and to evaluate the psychometric properties and methodological quality of these instruments. Methods: In this systematic review, we investigate studies (published in English or Spanish) based on the use of one or more PROMs specific to foot and ankle pathologies for patients with DM (type I or II). To do so, the databases PubMed, Scopus, CINAHL, PEDro and Google Scholar were searched for studies that analysed psychometric or clinimetric properties in this respect. These were assessed according to Terwee or COSMIN criteria. Results: Of the 1016 studies identified in the initial search, only 11 were finally included in the qualitative review. Analysis according to Terwee and COSMIN criteria showed that the Foot Health Status Questionnaire (FHSQ) presented the greatest number of positive values. Conclusions: The FHSQ is the highest-quality PROM currently available for the foot and ankle, for patients with DM.
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Affiliation(s)
- Ana Belen Ortega-Avila
- Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, Arquitecto Francisco Penalosa 3, Ampliación de Campus de Teatinos, 29071 Malaga, Spain.
| | - Pablo Cervera-Garvi
- Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, Arquitecto Francisco Penalosa 3, Ampliación de Campus de Teatinos, 29071 Malaga, Spain.
| | - Laura Ramos-Petersen
- Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, Arquitecto Francisco Penalosa 3, Ampliación de Campus de Teatinos, 29071 Malaga, Spain.
| | - Esther Chicharro-Luna
- Department of Behavioral Sciences and Health, Miguel Hernández University, San Juan de Alicante, 03550 Alicante, Spain.
| | - Gabriel Gijon-Nogueron
- Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, Arquitecto Francisco Penalosa 3, Ampliación de Campus de Teatinos, 29071 Malaga, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain.
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Nilsen FA, Molund M, Hvaal KH. High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot. J Foot Ankle Surg 2018; 57:301-304. [PMID: 29310882 DOI: 10.1053/j.jfas.2017.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Indexed: 02/03/2023]
Abstract
Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.
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Affiliation(s)
- Fredrik A Nilsen
- Surgeon, Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Østfold Hospital, Grålum, Norway.
| | - Marius Molund
- Surgeon, Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Østfold Hospital, Grålum, Norway
| | - Kjetil H Hvaal
- Surgeon, Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
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Galli M, Scavone G, Vitiello R, Flex A, Caputo S, Pitocco D. Surgical treatment for chronic Charcot neuroarthropathy. Foot (Edinb) 2018; 36:59-66. [PMID: 30368193 DOI: 10.1016/j.foot.2018.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/27/2018] [Accepted: 02/14/2018] [Indexed: 02/04/2023]
Abstract
Charcot Neuro-arthropathy (CN) is a condition characterized by a progressive derangement of the joints, in individuals affected with sensitive and autonomic neuropathy. The pathogenesis of CN is multifactorial as neuropathy is a necessary, but insufficient condition for the onset of the disease. The most important indication for surgical treatment of Charcot foot is a severe deformity that compromises the functionality of the limb, causing a high risk for ulceration, infection and amputation. The goal in Charcot foot treatment is to obtain and maintain the correction of a severe deformity and/or prevent its development. There are many surgical approach to the CN, such as exostectomy, arthrodesis with internal or external fixation and amputation. Every method has a different indication and specific complication. The right surgical approach in the CN is a real challenge for orthopedic surgeon that need a complete knowing of technique, material and complication.
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Affiliation(s)
- Marco Galli
- Università Cattolica del Sacro Cuore, Italy.
| | | | | | - Andrea Flex
- Università Cattolica del Sacro Cuore, Italy.
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Affiliation(s)
- Michael S. Pinzur
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Kroin E, Chaharbakhshi EO, Schiff A, Pinzur MS. Improvement in Quality of Life Following Operative Correction of Midtarsal Charcot Foot Deformity. Foot Ankle Int 2018; 39:808-811. [PMID: 29609479 DOI: 10.1177/1071100718762138] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with Charcot foot arthropathy report a poor quality of life following the development of deformity. Their quality of life is often not improved with "successful" historic accommodative treatment. There is increased current interest in operative correction of the acquired deformity with the stated goals of achieving both the traditional goals of resolution of infection and limb salvage as well as the desire to improve quality of life. The Short Musculoskeletal Functional Assessment (SMFA) outcomes instrument appears to be a valid tool for evaluating this complex patient population. METHODS Twenty-five consecutive patients undergoing operative reconstruction for nonplantigrade midtarsal Charcot foot arthropathy completed the SMFA patient-reported outcomes instrument prior to surgery, with 24 completing it at 1 year following the surgery. One patient died during the year following surgery from unrelated causes. RESULTS There was an 11.5-point (95% confidence interval [CI]: -19.7 to -3.2) decrease in the standardized functional index ( P = .01). Similarly, there was a 12.4-point (95% CI: -22.5 to -2.3) decrease in the standardized bother index ( P = .02). The standardized daily activity index demonstrated a 19.6-point decrease (95% CI: -30.5 to -8.6, P = .002), and there was a 14.7-point (95% CI: -24.1 to -5.3) decrease in the standardized emotion index ( P = .004). There was no meaningful change in the standardized arm/hand index ( P = .81). CONCLUSION The results of this investigation demonstrate that successful operative reconstruction of midtarsal Charcot foot arthropathy improved quality of life. This supports the modern paradigm shift from immobilization during the active phase of the disease process followed by simple accommodation of the acquired deformity to the modern interest in operative correction to allow the use of commercially available therapeutic footwear. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ellen Kroin
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | | | - Adam Schiff
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Michael S Pinzur
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Minimum Detectable Measurement Difference for Health-Related Quality of Life Measures Varies With Age and Disability in Adult Spinal Deformity: Implications for Calculating Minimal Clinically Important Difference. Spine (Phila Pa 1976) 2018; 43:E790-E795. [PMID: 29215503 DOI: 10.1097/brs.0000000000002519] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To investigate the minimum detectable measurement difference (MDMD) in the Scoliosis Research Society-22r (SRS-22r) outcomes instrument in adult spinal deformity (ASD) and to evaluate the effect of baseline data on measurable difference. SUMMARY OF BACKGROUND DATA The minimum clinically important difference (MCID) is the smallest, clinically relevant change observed and has been proposed for the SRS-22r instrument in ASD as 0.4. The MCID must be greater than the MDMD to be useful. The MDMD for the SRS-22r has not been calculated, nor have the effect of patient baseline values on MDMD. METHODS A prospective observation cohort was queried for patients treated both operatively and nonoperatively for ASD. Patients with baseline and 1-year, 2-year follow-up SRS-22r data were included in the analysis. The MDMD was calculated using classical test theory and item-response theory methods. Effect size and standardized response means were calculated. The effect of baseline data values was evaluated for MDMD. RESULTS A total 839 Patients were eligible for cohort inclusion with 428 (51%) eligible for analysis with complete data. MDMD for Pain (0.6) and Self-Image (0.5) were greater than 0.4. MDMD varied with age (highest for the youngest patients) and with disability (highest for SF-36 Physical Component Summary <28.6). MDMD was less than 0.4 for Activity (0.3), Mental Health (0.3), and Total Score (0.2). Gender and mental health did not affect MDMD for the SRS-22r instrument. CONCLUSION An MCID of 0.4 for the SRS-22r total score and domain scores may not be an appropriate value as the calculated MDMD is greater than 0.4 for both the Pain and Self-Image subscores. The MDMD for the SRS-22r instrument varied with age and baseline disability, making the assessment of clinically significant change more difficult using this tool. The MCID must be considered in the setting of the MDMD for instruments used to assess outcomes in ASD. LEVEL OF EVIDENCE 3.
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El-Mowafi H, El-Hawary A, Kandil Y. Functional pedal construct achieved by combined operative treatment in peritalar complex Charcot arthropathy: A prospective study of 38 feet. Foot Ankle Surg 2018; 24:236-241. [PMID: 29409253 DOI: 10.1016/j.fas.2017.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/21/2017] [Accepted: 02/14/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Charcot arthropathy of the peritalar complex carries a high risk of amputation if not properly managed. Our aim is to assess the functional outcome of severe Charcot arthropathy of the peritalar complex following enblock resection of the ulcer, massive debridement and stabilizing all the elements of the peritalar complex. METHODS We prospectively studied 38 feet in 35 patients with peritalar complex Charcot arthropathy. All Feet underwent intense debridement and fusion using a combination of (Ilizarov) external fixation, and (plate and locked nail) internal fixation. Thirty two feet were graded as Eichenholtz 2, and six feet were graded as Eichenholtz 3. The mean follow up was 35.9months. RESULTS The mean AOFAS score was significantly elevated from 25.4±9.1 preoperatively to 67.6±5.7 at the most recent follow-up (p<0.001). Complete bony fusion was achieved in 28 feet. Unsound bony fusion occurred in 8 feet. Two feet required below knee amputation. CONCLUSION Peritalar complex Charcot arthropathy is not uncommon variety. Such cases carry high risk of complications and amputation is not excluded. The proper timing of surgery is crucial. Massive debridement and rigid fixation with strict follow up is mandatory to achieve the ultimate goal of obtaining a plantigrade, stable, mechanically sound, painless and infection free pedal construct.
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Affiliation(s)
- Hani El-Mowafi
- Mansoura University Hospital, Mansoura Faculty of Medicine, 35516 Mansoura, Egypt.
| | - Ahmed El-Hawary
- Mansoura University Hospital, Mansoura Faculty of Medicine, 35516 Mansoura, Egypt
| | - Yasser Kandil
- Mansoura University Hospital, Mansoura Faculty of Medicine, 35516 Mansoura, Egypt
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Affiliation(s)
- Sheldon S Lin
- Department of Orthopaedics, Rutgers New Jersey School of Medicine, Newark, New Jersey
| | - Omkar Baxi
- Department of Orthopaedics, Rutgers New Jersey School of Medicine, Newark, New Jersey
| | - Michael Yeranosian
- Department of Orthopaedics, Rutgers New Jersey School of Medicine, Newark, New Jersey
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Affiliation(s)
- Andrew Dodd
- Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Wukich DK, Raspovic KM. Assessing Health-Related Quality of Life in Patients With Diabetic Foot Disease: Why Is It Important and How Can We Improve? The 2017 Roger E. Pecoraro Award Lecture. Diabetes Care 2018; 41:391-397. [PMID: 29463665 DOI: 10.2337/dci17-0029] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patient-reported outcomes (PROs) have become an important subject in the area of diabetes-related foot complications. Self-reported health-related quality of life (HRQOL) surveys can provide a generic measure of overall health (global) and can be disease specific (i.e., diabetes) or even region specific (i.e., lower-extremity function). Analysis of PRO measures utilizing validated instruments allows health care providers to determine whether medical and surgical treatments are providing patients with the highest level of outcome possible and are actually improving HRQOL. The 36-item Short Form (SF-36), EuroQol five-dimension questionnaire (EQ-5D-5L), and Foot and Ankle Ability Measure (FAAM) are examples of commonly used HRQOL surveys. Low HRQOL has been associated with higher rates of hospital admission and mortality in patients with diabetes. Previous studies have demonstrated that patients with diabetes-related foot disease have low self-reported physical quality of life but do not typically report low mental quality of life. The impact of mental quality of life may be underestimated in these patients using the SF-36. In this article, we will discuss several widely used outcome instruments used to measure patient HRQOL and the impact of diabetic foot disease on HRQOL. As health care providers, we must continue to adjust and modify our treatments to achieve the best patient outcomes and associated high quality of life. Assessing PROs will become increasingly important as health care systems transition from a volume-based reimbursement model to a value-based model.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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Pinzur MS, Schiff AP. Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment. Foot Ankle Int 2018; 39:265-270. [PMID: 29172758 DOI: 10.1177/1071100717742371] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life. METHODS Over a 12-year period, 214 patients (9 bilateral) underwent reconstruction of the acquired deformity associated with midtarsal Charcot foot arthropathy. Over time, 3 patterns of deformity were observed based on weight-bearing pattern, relationship of the forefoot to the hindfoot, and integrity of the talocalcaneal joint. A valgus deformity pattern was present in 138, varus in 48, and dislocation of the talocalcaneal joint in 37. A consistent operative strategy was employed. Surgery included percutaneous tendon-Achilles lengthening, resection of infection when present, attempted correction of the structural deformity by wedge resection at the apex of the deformity, and immobilization with a 3-level static circular external fixator. Additional deformity pattern-specific procedures were added over time. Clinical outcomes were based on the historic metrics of limb salvage and resolution of infection and the functional metric of the ability to walk with commercially available therapeutic footwear. RESULTS Seven patients died within a year of surgery, and 15 underwent partial- or whole-foot amputation. Overall, 173 of 223 feet (77.6%) achieved a favorable clinical outcome. Patients with a valgus deformity pattern were most likely to achieve a favorable clinical outcome (120 of 138, 87.0%). Patients with a dislocation pattern were less likely to achieve a favorable clinical outcome (26 of 37, 70.3%), and those with a varus deformity pattern were least likely to achieve a favorable clinical outcome (27 of 48, 56.3%). CONCLUSIONS Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient population. This realistic appreciation of outcome expectations should both be helpful in counseling patients on the risk-benefit ratio associated with surgery and provide a benchmark to measure newer strategies of treatment. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Wukich DK, Raspovic KM, Suder NC. Patients With Diabetic Foot Disease Fear Major Lower-Extremity Amputation More Than Death. Foot Ankle Spec 2018; 11:17-21. [PMID: 28817962 DOI: 10.1177/1938640017694722] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to identify the most-feared complications of diabetes mellitus (DM), comparing those with diabetic foot pathology with those without diabetic foot pathology. METHODS We determined the frequency of patients ranking major lower-extremity amputation (LEA) as their greatest fear in comparison to blindness, death, diabetic foot infection (DFI), or end-stage renal disease (ESRD) requiring dialysis. We further categorized the study group patients (N = 207) by their pathology such as diabetic foot ulcer (DFU), Charcot neuroarthropathy, foot infection, or acute neuropathic fractures and dislocations. The control group (N = 254) was comprised of patients with diabetes who presented with common non-diabetes-related foot pathology. RESULTS A total of 461 patients were enrolled in this study and included 254 patients without diabetic foot complications and 207 patients with diabetic foot problems. When comparing patients with and without diabetic disease, no significant differences were observed with regard to their fear of blindness, DFI, or ESRD requiring dialysis. Patients with diabetic foot disease (61 of 207, 31.9%) were 136% more likely (odds ratio [OR] = 2.36; 95% CI = 1.51-3.70; P = .002] to rank major LEA as their greatest fear when compared with diabetic patients without foot disease (42 of 254, 16.5%) and were 49% less likely (OR = 0.51; 95% CI = 0.34-0.79; P = .002) to rank death as their greatest fear compared with patients without diabetic foot disease. CONCLUSION Patients with diabetic foot pathology fear major LEA more than death, foot infection, or ESRD. Variables that were associated with ranking LEA as the greatest fear were the presence of a diabetic-related foot complication, duration of DM ≥10 years, insulin use, and the presence of peripheral neuropathy. LEVELS OF EVIDENCE Level II: Prospective, Case controlled study.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (DKW).,Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC (KMR).,Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (NCS)
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (DKW).,Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC (KMR).,Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (NCS)
| | - Natalie C Suder
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (DKW).,Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC (KMR).,Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (NCS)
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Kroin E, Schiff A, Pinzur MS, Davis ES, Chaharbakhshi E, DiSilvio FA. Functional Impairment of Patients Undergoing Surgical Correction for Charcot Foot Arthropathy. Foot Ankle Int 2017; 38:705-709. [PMID: 28397549 DOI: 10.1177/1071100717701233] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Investigations using the Medical Outcomes Study Short Form 36 Healthy Survey (SF-36) and the American Orthopaedic Foot & Ankle Society Diabetic Foot Questionnaire (AOFAS-DFQ) have demonstrated a poor quality of life in patients with Charcot foot arthropathy. The Short Musculoskeletal Function Assessment (SMFA) questionnaire has been widely used in patients with a broad range of musculoskeletal disorders. METHODS Twenty-five consecutive patients undergoing operative correction for diabetes-related Charcot foot arthropathy of the midfoot completed the SMFA prior to undergoing surgery. There were 16 males and 9 females. The average body mass index (BMI) was 37.4 (range 25.8-50.2), and the average hemoglobin A1c was 7.5 (range 5.3-10.1) prior to surgery. RESULTS All 25 patients exhibited significant impairment in all 6 domains of the SMFA ( P < .0001) as compared to the normative data. There was a high correlation between each of the 6 domains of the SMFA, even after correcting for BMI. CONCLUSION Charcot foot severely impaired the quality of life in patients beyond the impact of morbid obesity. This impairment equally impacted all of the functional and emotional domains measured with the SMFA as compared with population norms. This investigation provides a benchmark for measuring the impact of operative correction of the deformity. In addition, the SMFA appears to be a valid tool for measuring impairment in this complex patient population. LEVEL OF EVIDENCE Level II, prospective comparative investigation.
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Affiliation(s)
- Ellen Kroin
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Adam Schiff
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Michael S Pinzur
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Elissa S Davis
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Edwin Chaharbakhshi
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Frank A DiSilvio
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Raspovic KM, Ahn J, La Fontaine J, Lavery LA, Wukich DK. End-Stage Renal Disease Negatively Affects Physical Quality of Life in Patients With Diabetic Foot Complications. INT J LOW EXTR WOUND 2017; 16:135-142. [PMID: 28682731 DOI: 10.1177/1534734617707081] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this study was to evaluate the impact of end-stage renal disease (ESRD) on health-related quality of life (QOL) in patients with diabetic foot disease. We compared a group of 30 diabetic patients with ESRD requiring dialysis to a group of 60 diabetic patients without ESRD. Both groups consisted of patients with active diabetic foot disease (ulcer, Charcot, infection) and were matched with regard to age and gender. Self-reported QOL was assessed using the Short Form-36 (SF-36) physical and mental component summary (PCS and MCS) scores and the region-specific Foot and Ankle Ability Measure (FAAM). Diabetic foot patients with ESRD requiring dialysis were found to have significantly higher creatinine levels, lower hemoglobin levels, lower albumin levels, higher rates of peripheral arterial disease, and lower rates of Charcot neuroarthropathy than patients without ESRD. The median PCS was significantly lower in the ESRD group; however, no significant difference was found when comparing the median MCS and FAAM. Patients who ultimately died had a tendency to report lower PCS scores at baseline compared with those patients who did not die ( P = .07). Patients who ultimately required major amputation also reported lower PCS scores at baseline. ESRD negatively affects physical QOL to a greater degree than mental QOL in patients with diabetic foot disease. The SF-36 may not be sensitive enough to capture impaired mental QOL because both groups had relatively high MCS scores. Low physical QOL may be associated with mortality and the eventual need for major amputation.
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Affiliation(s)
| | - Junho Ahn
- 2 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Larry A Lavery
- 2 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dane K Wukich
- 2 University of Texas Southwestern Medical Center, Dallas, TX, USA
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Wukich DK, Ahn J, Raspovic KM, La Fontaine J, Lavery LA. Improved Quality of Life After Transtibial Amputation in Patients With Diabetes-Related Foot Complications. INT J LOW EXTR WOUND 2017; 16:114-121. [DOI: 10.1177/1534734617704083] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The purpose of this study was to evaluate health-related quality of life after major lower-extremity amputation in a cohort of patients with diabetes mellitus. We evaluated 81 patients with diabetes and transtibial amputation (TTA) who had a minimum of 1 year of follow-up. Of these 81 patients, 50.6% completed the Short Form Survey (SF-36) and the Foot and Ankle Ability Measure (FAAM) preoperatively and postoperatively. Outcome measures before and after TTA were compared using Welch’s ANOVA for continuous variables and Fisher’s exact test for categorical variables. There was significant improvement in all 8 subscales of the SF-36, physical component summary (PCS) score, mental component summary (MCS) score, and the FAAM. The median SF-36 PCS score improved from 26.2 to 36.6 preoperatively versus postoperatively ( P < .0005). The postoperative PCS score improved in 75.6% of patients and worsened in 24.4%. The median SF-36 MCS score improved from 43.7 to 56.1 preoperatively versus postoperatively ( P < .0005). Both the FAAM activities of daily living (ADL; P < .005) and FAAM sports scores ( P < .05) improved significantly. The postoperative FAAM general/ADL score improved in 75.6% of patients and worsened in 24.4%. Patients who were nonambulatory postoperatively had significantly lower SF-36 general health subscale scores and lower FAAM scores than patients who were ambulatory postoperatively. In select patients with nonfunctional lower extremities resulting from instability and/or chronic infection, TTA can result in significant improvement in quality of life and lower-extremity function. We acknowledge that 25% of patients had a reduction in self-reported quality of life; however, 75% of patients improved their quality of life.
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Affiliation(s)
- Dane K. Wukich
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Junho Ahn
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Larry A. Lavery
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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A systematic review of measurement properties of patient-reported outcome measures for use in patients with foot or ankle diseases. Qual Life Res 2017; 26:1969-2010. [DOI: 10.1007/s11136-017-1542-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2017] [Indexed: 12/20/2022]
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Wukich DK, Sadoskas D, Vaudreuil NJ, Fourman M. Comparison of Diabetic Charcot Patients With and Without Foot Wounds. Foot Ankle Int 2017; 38:140-148. [PMID: 27923212 DOI: 10.1177/1071100716673985] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The primary aim of this study was to evaluate the outcomes of a series of patients with Charcot neuroarthropathy (CN) who were evaluated in a tertiary care setting. We hypothesized that those patients with CN who presented with a Charcot-related foot wound would have lower rates of successful limb salvage than patients who presented without a wound. METHODS Two hundred forty-five patients (280 feet) were identified with diabetic CN during the time period from January 1, 2005, to June 1, 2015. This consecutive cohort of patients was treated by a single surgeon and had a mean age of 57.9 ± 10.0 years. Our CN patients were divided into 2 groups for the purpose of our analysis. Our study group included those patients who presented to our clinic with a Charcot-related foot wound. Our control group was composed of CN patients who presented without a Charcot-related foot wound. RESULTS Overall, 78 feet (27.9%) were successfully treated nonoperatively and 202 feet (72.1%) required some type of surgery. Of the 202 feet that received surgery, 22 (10.9%) were not felt to be suitable for reconstruction and underwent a definitive transtibial amputation without an attempt at reconstruction. An additional 18 patients underwent soft tissue surgery, which included drainage of infection, posterior muscle group lengthening, or soft tissue reconstructive flap surgery. The remaining 162 feet underwent osseous surgery, which included ostectomies for osteomyelitis, exostectomies, osteotomies, and arthrodesis. Eighteen of the 180 limbs (10.0%) that underwent soft tissue or osseous reconstruction ultimately required a transtibial amputation, resulting in a successful limb salvage rate of 90.0%. Thirty-five amputations were performed in 164 feet (21.3%) with Charcot-related foot wounds compared with 5 amputations in 116 feet (4.5%) without Charcot-related foot wounds (OR 6.02, 95% CI 2.28-15.91, P < .0001). CONCLUSION The presence of a Charcot-related foot wound at presentation increased the likelihood of a major lower extremity amputation by a factor of 6. Other risk factors that were associated with major amputation in patients included active infection at presentation, nonunion/instability after reconstruction, and a postoperative wound problem. The overall rate of successful limb salvage in patients deemed reconstructive candidates was 90%. LEVEL OF CLINICAL EVIDENCE Level III, retrospective, case-control study.
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Affiliation(s)
- Dane K Wukich
- 1 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Sadoskas
- 2 Baylor Scott and White Healthcare System, Waco, TX, USA
| | - Nicholas J Vaudreuil
- 3 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mitchell Fourman
- 3 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Short DJ, Zgonis T. Circular External Fixation as a Primary or Adjunctive Therapy for the Podoplastic Approach of the Diabetic Charcot Foot. Clin Podiatr Med Surg 2017; 34:93-98. [PMID: 27865319 DOI: 10.1016/j.cpm.2016.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Numerous techniques have been described for surgical management of the diabetic Charcot foot. External fixation has become a main surgical tool for the reconstructive foot and ankle surgeon when dealing with the ulcerated diabetic Charcot foot. In the presence of an open wound and/or osteomyelitis, staged reconstruction with circular external fixation becomes ideal for salvage of the diabetic lower extremity. Also, circular external fixation can provide simultaneous compression and stabilization, correct the underlying osseous or soft tissue deformities, and surgically offload the diabetic Charcot foot. This article describes a variety of circular external fixation applications for the diabetic Charcot foot.
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Affiliation(s)
- Daniel J Short
- Reconstructive Foot and Ankle Surgery, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA
| | - Thomas Zgonis
- Reconstructive Foot and Ankle Surgery, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA.
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Petrova NL, Edmonds ME. Conservative and Pharmacologic Treatments for the Diabetic Charcot Foot. Clin Podiatr Med Surg 2017; 34:15-24. [PMID: 27865311 DOI: 10.1016/j.cpm.2016.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Charcot neuroarthropathy is a disabling complication of diabetic neuropathy. Prolonged immobilization in a total contact cast (TCC) is among the main treatments. Education of health care professionals in the application of TCC together with well-conducted clinical trials are required to overcome its frequent underuse. There are no established pharmacologic therapies to treat this condition; however, there is an overwhelming need for a new therapeutic approach. Novel targeted drug delivery systems are required to prevent the pathologic bone and joint destruction of the Charcot neuroarthropathy and this may lead to an improved outcome in diabetic patients with this condition.
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Affiliation(s)
- Nina L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.
| | - Michael E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
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Abstract
Charcot neuroarthropathy (CN) is a difficult problem for the foot and ankle surgeon. If surgery is required, little is known or available regarding the best methods and timing. When the initial attempt of reconstruction fails, revision of CN is even more demanding. One must take in to account all aspects, including nutrition, vascular status, infection control, short- and long-term blood glucose management, as well as other factors requiring laboratory monitoring and consult services. Once optimized, the biomechanics of the deformity can be addressed and decisions can be made on fixation devices.
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Affiliation(s)
- Patrick K Strotman
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Taylor J Reif
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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