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Shibuya N, McAlister JE, Prissel MA, Piraino JA, Joseph RM, Theodoulou MH, Jupiter DC. Consensus Statement of the American College of Foot and Ankle Surgeons: Diagnosis and Treatment of Ankle Arthritis. J Foot Ankle Surg 2021; 59:1019-1031. [PMID: 32778440 DOI: 10.1053/j.jfas.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/20/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Naohiro Shibuya
- Professor, College of Medicine, Texas A&M University, Temple, TX.
| | | | - Mark A Prissel
- Faculty, Advanced Foot and Ankle Reconstruction Fellowship Program, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Jason A Piraino
- Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, University of Florida Health, Gainesville, FL
| | - Robert M Joseph
- Chairman, Department of Podiatric Medicine & Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University, North Chicago, IL
| | - Michael H Theodoulou
- Chief, Division of Podiatric Surgery, Cambridge Health Alliance, Instructor of Surgery, Harvard Medical School, Cambridge, MA
| | - Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Community, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX
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Jupiter DC, LaFontaine J, Barshes N, Wukich DK, Shibuya N. Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications. J Foot Ankle Surg 2021; 59:484-490. [PMID: 32354505 DOI: 10.1053/j.jfas.2019.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 02/03/2023]
Abstract
AIMS The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. METHODS Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. RESULTS Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. CONCLUSIONS Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.
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Affiliation(s)
- Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, TX; Research Associate, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX.
| | - Javier LaFontaine
- Professor, Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Neal Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Dane K Wukich
- Professor and Chairman, Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Naohiro Shibuya
- Professor, Texas A&M University, College of Medicine, Temple, TX; Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Department of Surgery, Baylor Scott & White Health, Temple, TX
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Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
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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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Ramanujam CL, Stuto AC, Zgonis T. Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review. J Wound Care 2020; 29:S19-S28. [PMID: 32530758 DOI: 10.12968/jowc.2020.29.sup6.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes. METHOD A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded. RESULTS A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction. CONCLUSION Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C Stuto
- LVPG Orthopedics and Sports Medicine, Lehigh Valley Health Network, Bethlehem, PA, US
| | - Thomas Zgonis
- Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
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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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Rettedal D, Parker A, Popchak A, Burns PR. Prognostic Scoring System for Patients Undergoing Reconstructive Foot and Ankle Surgery for Charcot Neuroarthropathy: The Charcot Reconstruction Preoperative Prognostic Score. J Foot Ankle Surg 2018; 57:451-455. [PMID: 29574036 DOI: 10.1053/j.jfas.2017.10.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy is a destructive process that occurs in patients with peripheral neuropathy, often due to poorly controlled diabetes mellitus. Surgical reconstruction can be necessary to provide a plantigrade foot that is wound free. A risk of major amputation exists after a Charcot event and after attempted reconstruction. We retrospectively reviewed the data from 34 patients (36 reconstructions) who had undergone reconstructive surgery for Charcot neuroarthropathy. The mean patient age was 56.44 years. The mean follow-up period was 56 months. We collected patient age, body mass index, presence of wound or osteomyelitis, anatomic location, activity of disease, and hemoglobin A1c. Using these data, each patient was given a score using our novel prognostic scoring system, the Charcot Reconstruction Preoperative Prognostic Score (CRPPS). Our primary outcome measure was no wound and no major amputation at the final follow-up visit. The limb salvage rate was 89% (32 of 36), and 78% (28 of 36) had no wound at the final follow-up examination. For patients without a wound or major amputation at the final follow-up visit, the mean CRPPS was 2.96 ± 1.23. The mean CRPPS for those with a wound or major amputation at the final follow-up visit was 4.33 ± 1.07 (p = .0024). Univariate logistic regression revealed 2 statistically significant predictors of wound and/or amputation: anatomic location (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.051 to 23.789; p = .043) and CRPPS (OR 2.724, 95% CI 1.274 to 5.823, p = .01). A CRPPS of ≥4 was also predictive of a negative outcome (OR 7.286, 95% CI 1.508 to 35.211; p = .013). This scoring system, with a sensitivity of 75%, specificity of 71%, and negative predictive value of 85%, is a potential starting point when educating patients and making treatment decisions in this exceptionally challenging group.
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Affiliation(s)
| | - Alissa Parker
- Foot and Ankle Surgeon, Washington Foot and Ankle Specialists, Washington, PA; Faculty, Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Adam Popchak
- Research Assistant Professor, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Patrick R Burns
- Assistant Professor, Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Director, Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA; Chief, Podiatry Section, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA
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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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Wukich DK, Ahn J, Raspovic KM, Gottschalk FA, La Fontaine J, Lavery LA. Comparison of Transtibial Amputations in Diabetic Patients With and Without End-Stage Renal Disease. Foot Ankle Int 2017; 38:388-396. [PMID: 28103735 DOI: 10.1177/1071100716688073] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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 purpose of this retrospective study was to report on a consecutive series of 102 patients with diabetes mellitus (DM) who underwent transtibial amputation (TTA) for chronic infections and nonreconstructable lower extremity deformities. A secondary aim was to compare the outcomes of TTA patients with end-stage renal disease on dialysis (ESRD) to patients without ESRD, and to identify risk factors for mortality after TTA. METHODS This cohort involved a consecutive series of patients who were treated by a single surgeon. The TTA patients were divided into 2 groups for analysis. The study group included those patients with ESRD who underwent TTA, and the control group included those patients who did not have ESRD. RESULTS At the time of final follow-up, 64 of 102 patients were ambulatory with a prosthesis. There was a significant improvement in ambulatory status after amputation (preoperatively 45.1%, postoperatively 62.7%, P = .02). Wound healing complications (infection and/or dehiscence) occurred in 31 of 102 patients and led to a transfemoral amputation in 4 patients. After TTA patients with ESRD were significantly more likely to die (52.4% vs. 23.5%, p <0.05) and significantly less like to ambulate (42.9% vs. 67.9%, p <0.05) than patients without ESRD. Contralateral foot problems after the TTA occurred in 33 of 97 patients and resulted in 10 patients undergoing a contralateral transtibial amputation. Excluding patients with bilateral amputations (5 prior to and 10 after the index amputation), 64 of 87 patients with successful unilateral transtibial amputations were able to ambulate with a prosthesis. Thirty of 102 patients (29.4%) died during the follow-up period, and 6 of these deaths occurred during the perioperative period (within 30 days of surgery). There were no significant differences between the 2 groups with regard to the use of staged TTA, need for transfemoral amputation, or wound healing problems at the amputation site. Patients who were unable to walk postoperatively had a calculated 5-year survival rate of 30.1%, whereas those who were ambulatory had a 5-year survival rate of 68.8%. Cox proportional hazards model demonstrated a 62% reduced risk of mortality in patients who were able to ambulate after LEA compared with those patients who were not able to ambulate. CONCLUSION TTA in patients with diabetes was associated with substantial morbidity and mortality. Risk factors that were significantly associated with an increased rate of mortality were the presence of ESRD, age ≥56 years, and inability to ambulate postoperatively. LEVEL OF EVIDENCE Level III, retrospective case controlled study.
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Affiliation(s)
- Dane K Wukich
- 1 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Junho Ahn
- 1 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katherine M Raspovic
- 2 Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Frank A Gottschalk
- 1 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Javier La Fontaine
- 3 Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Larry A Lavery
- 3 Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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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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What Role Does Function Play in Deciding on Limb Salvage versus Amputation in Patients With Diabetes? Plast Reconstr Surg 2016; 138:188S-195S. [DOI: 10.1097/prs.0000000000002713] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Labovitz JM, Shofler DW, Ragothaman KK. The impact of comorbidities on inpatient Charcot neuroarthropathy cost and utilization. J Diabetes Complications 2016; 30:710-5. [PMID: 26850144 DOI: 10.1016/j.jdiacomp.2016.01.004] [Citation(s) in RCA: 16] [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: 10/01/2015] [Revised: 01/05/2016] [Accepted: 01/07/2016] [Indexed: 01/15/2023]
Abstract
AIMS The purpose of this study was to portray the impact of comorbidities on inpatient cost and utilization in Charcot neuroarthropathy (CN) patients. METHODS Two cohorts, CN and diabetic peripheral neuropathy (DPN), were identified by ICD-9 codes in the California Office for Statewide Health Planning and Development 2009-2012 public patient discharge files. DPN and CN costs and length of stay (LOS) were compared adjusting for the number of chronic conditions. The impact of the Elixhauser comorbidity measures and other comorbidities on costs and LOS in CN subjects was evaluated. RESULTS CN was associated with 17.2% higher costs and 1.4 days longer LOS compared to DPN alone. Adjusting for 0.71 additional chronic conditions in CN patients accounted for 79.8% of variance and estimated a 13.9% cost difference between cohorts. Subjects averaged 4.5 Elixhauser comorbidities with higher scores corresponding to increased cost, LOS, and inpatient mortality. Other diabetic foot risk factors demonstrated that foot ulcers, foot infections, and osteomyelitis had significantly higher costs. Patients with foot ulcers, osteomyelitis, and depression had significantly increased LOS. CONCLUSIONS Systemic and local comorbidities significantly impact the cost, utilization, and inpatient mortality in inpatient management of Charcot foot.
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Affiliation(s)
- Jonathan M Labovitz
- College of Podiatric Medicine, Western University of Health Sciences, 309 E Second Street, Pomona, CA 91766.
| | - David W Shofler
- College of Podiatric Medicine, Western University of Health Sciences, 309 E Second Street, Pomona, CA 91766.
| | - Kevin K Ragothaman
- College of Podiatric Medicine, Western University of Health Sciences, 309 E Second Street, Pomona, CA 91766.
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Wukich DK, Raspovic KM, Suder NC. Prevalence of Peripheral Arterial Disease in Patients With Diabetic Charcot Neuroarthropathy. J Foot Ankle Surg 2016; 55:727-31. [PMID: 27020760 DOI: 10.1053/j.jfas.2016.01.051] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy (CN) is a serious complication of diabetes mellitus (DM) that can lead to pedal ulceration, infection, hospitalization, and amputation. Peripheral arterial disease (PAD) is also found in patients with diabetic foot disease; however, its prevalence in patients with CN has not been extensively evaluated. The aim of the present study was to evaluate the prevalence of PAD in a group of patients with CN (with and without ulceration) and compare this to a group of patients with diabetic foot ulceration (DFU) and no CN. We compared the lower extremity noninvasive arterial testing results of 85 patients with DM and CN with those from a group of 126 patients with DFU and no CN. No statistically significant differences were found in age, gender, type of DM (1 versus 2), insulin use, duration of DM, or history of dialysis between our study and control groups. The prevalence of PAD in the patients with CN was 40%. Compared with patients with DFUs, the patients with CN were less likely to have PAD (odds ratio 0.48, 95% confidence interval 0.28 to 0.85; p = .0111), ischemia (odds ratio 0.33, 95% confidence interval 0.16 to 0.69; p = .0033), or the need for revascularization (odds ratio 0.27, 95% confidence interval 0.10 to 0.73; p = .0097). Critical limb ischemia (great toe pressure <30 mm Hg) was 82% less likely in patients with CN than in patients with DFU. PAD in patients with CN is not uncommon; however, ischemia and the need for revascularization were significantly less likely than in patients with DFU without CN.
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Affiliation(s)
- Dane K Wukich
- Professor, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, and Medical Director, UPMC Mercy Center for Healing and Amputation Prevention, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Katherine M Raspovic
- Assistant Professor, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Natalie C Suder
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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La Fontaine J, Lavery L, Jude E. Current concepts of Charcot foot in diabetic patients. Foot (Edinb) 2016; 26:7-14. [PMID: 26802944 DOI: 10.1016/j.foot.2015.11.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/20/2014] [Accepted: 11/12/2015] [Indexed: 02/04/2023]
Abstract
The Charcot foot is an uncommon complication of neuropathy in diabetes. It is a disabling and devastating condition. The etiology of the Charcot foot is unknown, but it is characterized by acute inflammation with collapse of the foot and/or the ankle. Although the cause of this potentially debilitating condition is not known, it is generally accepted that the components of neuropathy that lead to foot complications must exist. When it is not detected early, a severe deformity will result in a secondary ulceration, infection, and amputation. Immobilization in the early stages is the key for success, but severe deformity may still develop. When severe deformity is present, bracing may be attempted but often patients will need surgical intervention. Good success has been shown with internal and external fixation. In patients with concomitant osteomyelitis, severe deformity, and/or soft tissue infection, a high amputation may be the best treatment of choice.
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Affiliation(s)
- Javier La Fontaine
- UT Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, USA.
| | - Lawrence Lavery
- UT Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, USA
| | - Edward Jude
- Tameside Hospital NHS Foundation Trust, Lancashire, UK
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15
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Schneekloth BJ, Lowery NJ, Wukich DK. Charcot Neuroarthropathy in Patients With Diabetes: An Updated Systematic Review of Surgical Management. J Foot Ankle Surg 2016; 55:586-90. [PMID: 26810129 DOI: 10.1053/j.jfas.2015.12.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy (CN) of the foot and ankle is a demanding clinical dilemma, and surgical management can be very complicated. Historically, the evidence guiding surgical management of CN has been small retrospective case series and expert opinions. The purpose of the present report was to provide a systematic review of studies published from 2009 to 2014 and to review the indications for surgery. A Medline search was performed, and a systematic review of studies discussing the surgical management of CN was undertaken. Thirty reports fit the inclusion criteria for our study, including 860 patients who had undergone a surgical procedure for the treatment of CN. The surgical procedures included amputation, arthrodesis, debridement of ulcers, drainage of infections, and exostectomy. The midfoot was addressed in 26.9% of cases, the hindfoot in 41.6%, and the ankle in 38.4%. Of the 30 studies, 24 were retrospective case series (level 4), 4 were controlled retrospective studies (level 3), and 2 were level II studies. The overall amputation rate was 8.9%. The quality of the published data on the surgical management of CN has improved during the past several years. Evidence concerning the timing of treatment and the use of different fixation methods remains inconclusive.
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Affiliation(s)
- Brian J Schneekloth
- Podiatric Medicine and Surgery Residency Program, UPMC Mercy and University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Nicholas J Lowery
- Podiatric Medicine and Surgery Residency Program, UPMC Mercy and University of Pittsburgh School of Medicine, Pittsburgh PA; Washington Health System Wound and Skin Healing Center and Hyperbaric Medicine, Washington, PA
| | - Dane K Wukich
- Professor of Orthopaedic Surgery, University of Pittsburgh School of Medicine. Medical Director, UPMC Mercy Center for Healing and Amputation Prevention, Pittsburgh, PA.
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16
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Wukich DK, Raspovic KM, Hobizal KB, Sadoskas D. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:292-6. [PMID: 26452590 DOI: 10.1002/dmrr.2748] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality. SURGICAL MANAGEMENT The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality. CONCLUSION Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use.
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MESH Headings
- Ankle/pathology
- Ankle/surgery
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/pathology
- Arthropathy, Neurogenic/rehabilitation
- Arthropathy, Neurogenic/surgery
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Decision Trees
- Diabetic Foot/complications
- Diabetic Foot/pathology
- Diabetic Foot/rehabilitation
- Diabetic Foot/surgery
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/pathology
- Diabetic Neuropathies/rehabilitation
- Diabetic Neuropathies/surgery
- Evidence-Based Medicine
- External Fixators/adverse effects
- External Fixators/trends
- Foot Deformities, Acquired/complications
- Foot Deformities, Acquired/pathology
- Foot Deformities, Acquired/rehabilitation
- Foot Deformities, Acquired/surgery
- Heel/pathology
- Heel/surgery
- Humans
- Internal Fixators/adverse effects
- Internal Fixators/trends
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Precision Medicine
- Preoperative Care/adverse effects
- Preoperative Care/trends
- Quality of Life
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - David Sadoskas
- Fellow Reconstruction and Limb Salvage Surgery UPMC Mercy Hospital, Pittsburgh, PA, USA
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17
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Wukich DK, Sambenedetto TL, Mota NM, Suder NC, Rosario BL. Correlation of SF-36 and SF-12 Component Scores in Patients With Diabetic Foot Disease. J Foot Ankle Surg 2016; 55:693-6. [PMID: 27052155 PMCID: PMC5664160 DOI: 10.1053/j.jfas.2015.12.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Indexed: 02/03/2023]
Abstract
The assessment of patient outcomes is becoming increasingly important in all areas of medicine, including foot and ankle surgery. The Medical Outcomes Study Short Form 36-item (SF-36) is widely used as a generic measure of quality of life; however, patients often find answering 36 questions cumbersome. Consequently, the Short Form 12 (SF-12) was developed. We hypothesized that the agreement between the SF-12 and SF-36 component scores would be substantial in patients with diabetic foot disease. We retrospectively reviewed the data from 300 patients with diabetes mellitus (DM) and foot and ankle pathology who completed the SF-36 questionnaire. Of the 300 patients, 155 (51.7%) had problems directly related to complications of DM and 145 (48.3%) had routine foot complaints that were unrelated to complications of DM. The 12 questions of the SF-12 were abstracted from the SF-36. The overall median score for the SF-36 physical component summary was 34.70 compared with the overall SF-12 physical component summary of 36.75 (p = .04). The intraclass correlation coefficient was 0.93688. The overall median score for the SF-36 mental component summary was 52.40 compared with the overall SF-12 mental component summary of 51.25 (p = .34). The intraclass correlation coefficient was 0.95449. Substantial agreement was observed when comparing the component scores of the SF-12 and the SF-36. From our study results of 300 patients with DM, it appears that the SF-36 and SF-12 are comparable outcome instruments for use with patients with diabetic foot disease.
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Affiliation(s)
- Dane K. Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,University of Pittsburgh Medical Center Mercy Amputation Prevention Center, Pittsburgh, PA
| | - Tresa L. Sambenedetto
- University of Pittsburgh Medical Center Mercy Amputation Prevention Center, Pittsburgh, PA
| | - Natalie M. Mota
- University of Pittsburgh Medical Center Mercy Amputation Prevention Center, Pittsburgh, PA
| | - Natalie C. Suder
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Bedda L. Rosario
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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18
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Abstract
Charcot foot syndrome is an uncommon complication of diabetes but is potentially devastating in its consequences. Outcome is made worse by widespread professional ignorance leading to delayed diagnosis, but it is also hampered by lack of understanding of its causes and lack of treatments with proven effectiveness, other than offloading. There remains a desperate need for studies into its causes as well as comparative audit and trials designed to determine the best treatment for this difficult condition. Such work can probably only be effectively carried out through the establishment of multicentre networks. Nevertheless, improved understanding in recent years of the likely role of inflammatory pathways has raised awareness of the multiple ways in which the effects of neuropathy may be manifest in the development of the Charcot foot. This awareness is also leading to the realization that similar processes may conceivably contribute to the refractoriness of other foot diseases in diabetes, including both chronic unhealing ulcers and osteomyelitis.
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Affiliation(s)
- W J Jeffcoate
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, UK
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19
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Eschler A, Gradl G, Wussow A, Mittlmeier T. Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates. J Diabetes Res 2015; 2015:246792. [PMID: 26000309 PMCID: PMC4427061 DOI: 10.1155/2015/246792] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 04/02/2015] [Accepted: 04/09/2015] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates. MATERIALS/METHODS 21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis. RESULTS A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially. CONCLUSION Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.
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Affiliation(s)
- Anica Eschler
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
- *Anica Eschler:
| | - Georg Gradl
- Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Harlaching Clinic, Sanatoriumsplatz 2, 81545 Munich, Germany
| | - Annekatrin Wussow
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
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20
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Abstract
Foot infections in patients with diabetes mellitus (DM) are serious complications that can result in hospitalization, the need for amputation, and premature mortality. To the best of our knowledge, no published studies have specifically investigated the effect of diabetic foot infection (DFI) on patient quality of life. The aim of the present study was to compare the self-reported assessments of quality of life in patients hospitalized with DFIs with those from a group of patients without foot infections. We evaluated a study group of 47 patients who had been hospitalized with DFIs and a control group of 47 patients with DM who did not have any complaints referable to their foot or ankle. The self-reported outcomes were assessed using the Medical Outcomes Study short form 36-item health survey (SF-36) and the Foot and Ankle Ability Measurement. Patients hospitalized with DFIs had significantly reduced self-reported SF-36 scores in all 8 subscales compared with the cohort of patients with DM without foot complaints. The SF-36 physical component and mental component scores were significantly reduced in patients with DFIs, indicating a negative effect on overall health. Self-reported lower extremity function was also negatively affected with significantly lower Foot and Ankle Measurement activity of daily living and sports scores for patients with DFI. The present study has demonstrated the profoundly negative affect that moderate and severe DFIs have on self-reported quality of life, affecting both physical and mental well-being and lower extremity function.
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Affiliation(s)
- Katherine M Raspovic
- Assistant Professor, Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC
| | - Dane K Wukich
- Professor of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Medical Director, UPMC Mercy Center for Healing and Amputation Prevention, Pittsburgh, PA.
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21
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Raspovic KM, Wukich DK. Self-reported quality of life in patients with diabetes: a comparison of patients with and without Charcot neuroarthropathy. Foot Ankle Int 2014; 35:195-200. [PMID: 24351658 DOI: 10.1177/1071100713517097] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous reports using the Short Form-36 as a generic measure of quality of life have demonstrated reduced quality of life in patients with Charcot neuroarthropathy (CN). The aim of this study was to assess self-reported quality of life using the SF-36 and a region-specific assessment (the Foot and Ankle Ability Measure [FAAM]), hypothesizing that patients with diabetes and CN would have lower self-reported scores than patients with diabetes and no foot disease. METHODS Fifty patients with diabetes and CN were included in the study group. Fifty-six patients with diabetes and no pedal complaints comprised the control group. Quality of life was assessed with the SF-36 and the FAAM. RESULTS Patients with CN were more likely to have type 1 diabetes mellitus, were more likely to use insulin, had greater duration of diabetes, and were more likely to be neuropathic than patients in the control group. Patients with CN reported mean FAAM activities of daily living (ADL) scores that were 2 standard deviations below the control group and sports scores that were 1 standard deviation lower. There was no notable difference between the SF-36 mental component summary scores between the CN and control groups. SF-36 physical component summary scores in patients with CN were notably lower than scores in the control group. CONCLUSION CN is associated with reduced quality of life as measured with the SF-36 and FAAM. To the best of our knowledge, this is the first study directly comparing self-reported outcome assessments in patients with both diabetes and CN and patients with diabetes without foot complaints. LEVEL OF EVIDENCE Level III, comparative series.
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Affiliation(s)
- Katherine M Raspovic
- University of Pittsburgh Medical Center, Mercy Center For Healing and Amputation Prevention, Pittsburgh, PA, USA
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Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon. J Am Acad Orthop Surg 2014; 22:183-92. [PMID: 24603828 DOI: 10.5435/jaaos-22-03-183] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.
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23
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Blume PA, Sumpio B, Schmidt B, Donegan R. Charcot neuroarthropathy of the foot and ankle: diagnosis and management strategies. Clin Podiatr Med Surg 2014; 31:151-72. [PMID: 24296023 DOI: 10.1016/j.cpm.2013.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This article reviews current literature discussing the etiology, pathophysiology, diagnosis and imaging, and conservative and surgical treatment of Charcot osteoarthropathy. The treatment of Charcot osteoarthropathy with concurrent osteomyelitis is also discussed.
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Affiliation(s)
- Peter A Blume
- Orthopedics and Rehabilitation, and Anesthesia, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA.
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24
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Abstract
Many surgical and nonsurgical options exist with the aim of improving quality of life and preventing amputation in patients with CN. A multidisciplinary approach is necessary to achieve the best outcomes in this high-risk group. Modern advanced diagnostic and imaging techniques have improved knowledge regarding the biomechanics, biology, and pathophysiology of CN. Despite these advances, surgical management has lagged behind and is based largely on retrospective case series and expert opinion. Although the surgeons of today are better equipped to manage CN, the optimal timing and specific method of surgical treatment have yet to be defined. Multicenter, prospective studies may be the best way to study this relatively uncommon problem.
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Affiliation(s)
- Wei Shen
- University of Pittsburgh Medical Center Comprehensive Foot and Ankle Center, Pittsburgh, PA, USA
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