Operative management of Charcot neuropathy of the foot and ankle: A retrospective cohort study of long-term outcomes

Category:Midfoot/Forefoot; Diabetes; OtherIntroduction/Purpose:Charcot neuroarthropathy (CN) is a complex disease process with progressive degeneration of normal bone architecture. Treatment options for CN include both conservative measures and operative management with the goal of achieving or maintaining a plantigrade ulcer-free foot. Operative treatment of CN varies widely with regards to timing and type of interventions. Surgical interventions include debridement, exostectomy, and complex reconstructions. The technique of intramedullary beaming with supplemental medial locking plate (referred to here as a Midfoot Nail Plate Construct (MNPC)) utilizes large diameter intramedullary screws linked to a medial locked plate for midfoot stabilization which is the focus of this study.Methods:Nineteen patients (20 limbs) with midfoot CN treated at our institution by a single surgeon between January 2017 - December 2021 met inclusion criteria and were included in our MNPC cohort. Retrospective chart review was performed to obtain demographic data, comorbidities, previous treatment data, ambulation status pre/post intervention, radiographic (Brodsky) classification, time to intervention, number of operations, and outcomes after operative management with MNPCs with a descriptive statistical analysis. Furthermore, post-intervention outcomes (rates of post-operative ulceration, post-operative infection, and amputation) were compared to the our previously studied institutional baseline data of post- surgical complications of CN in 58 patients treated between 2005-2016 with limited and reconstructive techniques without MNPCs.Results:The mean age of the MNPC cohort was 56.3 (range 37 - 73 years), mean BMI was 39.4, and 73.7% of patients had diabetes (mean A1c 7.34, A1c range 5.8 to 10.5). 43% had undergone previous non-operative management and 19% received prior operative treatment. Mean follow up was 19.9 months (range 3 - 47 months). Average time from presentation to intervention was 10.1 months (range 1 - 32 months). Post-intervention rates of ulceration, infection, and amputation for the MNPC cohort were 30%, 25%, and 15% respectively. Compared to our institutional baseline data of complications after limited and reconstructive surgical techniques without MNPCs from 2005-2017, MNPC had a lower rate of ulceration and amputation. Ulceration rate after limited, reconstructive, and MNPC were 34.4%, 42.3%, and 30% respectively. Infection rates were 25%, 42.3%, and 25%, with amputation rates of 21.9%, 23%, and 15% respectively.Conclusion:Despite continued innovation in surgical management of CN of the foot, post-intervention complication rates remain high. This study provides patient and outcome data for Midfoot Nail Plate Constructs as a treatment for CN in a large cohort with midterm follow up. Compared to our own institutional historical data prior to adoption of this technique, MNPCs have an equivalent infection rate and lower rate of ulceration and amputation at an average of 19 month follow-up.

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) is a complex disease process with degeneration of normal foot architecture. The goal of surgical treatment for CN is achieving and maintaining a plantigrade ulcer-free foot. Operative treatment options for CN vary widely including debridement, exostectomy, and complex reconstruction. The technique of intramedullary beaming of the metatarsals with a supplemental medial locking plate (referred to here as a midfoot beam-plate construct [MBPC]) utilizes large diameter intramedullary cannulated screws with a medial locked plate for midfoot stabilization. Outcomes of MBPC patients, both clinical and radiographic, were evaluated to establish the efficacy and longevity of this fixation strategy as it compares to other methods of surgical management of CN. Methods: Forty patients (41 limbs) with midfoot CN treated at our institution by five fellowship-trained foot and ankle surgeons between January 2014 and October 2023 met inclusion criteria and were included in our MBPC cohort. A retrospective chart review was performed to obtain demographic data, previous treatment data, radiographic (Brodsky) classification, time to intervention, number of re-operations, and clinical outcomes after operative management with MBPC. Lateral Meary’s angle was measured for MBPC patients pre-operatively, at first post-operative radiographs, and final radiographs to use as a proxy for surgical correction of midfoot Charcot deformity. Furthermore, post-intervention outcomes (rates of post-operative ulceration, post-operative infection, and amputation) were compared to our previously reported institutional baseline data of 58 CN patients treated from 2005-2014 with limited and reconstructive techniques other than MBPC. Results: The mean age of the MBPC cohort was 57.6 (range, 37-73) years, mean BMI was 38.0, 82.5% (33/40) of patients had diabetes, and 43.9% (18/41) had an ulcer present at time of surgery. Mean clinical follow-up was 28.6 (range, 4-80) months. 94.4% (17/18) of ulcers present at the time of surgery healed after a MBPC construct was utilized. 19/41 (46.3%) patients developed recurrent or new ulcerations. At final follow-up, 28/41 (68.3%) had a plantigrade, shoeable, ulcer-free foot. Only 6/41 (14.6%) patients in our cohort underwent a major amputation, lower than the rates for our historical limited (21.9%) and reconstructive technique (23.1%) cohorts. Pre-operative lateral Meary’s angle averaged -31 degrees, immediate post-operative measured -5.3 degrees (p< 0.001), and final post-operative was -14.4 degrees (p< 0.001). Conclusion: This study provides patient and outcome data for midfoot beam-plate constructs as a treatment for CN in a large cohort with midterm follow-up. Patients undergoing MBPCs had a relatively low rate of major amputation and more than 2/3 achieved a plantigrade, shoeable, ulcer-free foot at final follow-up. We have also shown that active ulceration is not a contraindication to open reconstructive surgery and that a high rate of ulcer healing can be achieved. Furthermore, surgical correction of midfoot deformity as measured by lateral Meary’s angle was improved and sustained at final radiographic follow-up, demonstrating durability of MBPCs for deformity correction.

Surgical Outcomes in Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Charcot foot is a serious complication that arises in the setting of combined peripheral neuropathy and trauma. This neurodegenerative disease is often associated with diabetes mellitus and other chronic comorbid diagnoses which can further lead to an increased risk of other injuries such as bone deformities and ulcerations. As there is no standard protocol for the management and treatment of Charcot neuroarthropathy (CN), casting, arthrodesis, exostectomy, and amputation can all be utilized. The understanding of the various comorbidities and management strategies for Charcot foot may allow further guidance for treatment options. The objective of our study was to compare the demographics, lab values, and clinical outcomes of patients who undergo various treatment modalities for CN and determine if there was correlation. Methods: A sample of patients at a single institution diagnosed with CN of the lower extremity and who underwent exostectomy, arthrodesis, amputation, and/or casting were identified through TriNetX. Demographics were collected for the study sample including age, sex, and race. Descriptive statistics in addition to historic and projected rate of arrival were conducted on each subgroup of patients. Relative risk with the associated confidence intervals were completed to assess comparative statistics among the groups for various organ system based comorbid diagnoses and complications. Results: Three-hundred and forty patients were identified; 120 underwent amputation, 130 underwent arthrodesis, 180 underwent exostectomy, and 160 underwent casting. The average age was 62 ± 12 years. Males accounted for 62%, with a higher percentage (66%) in the amputation and exostectomy groups. 85% of patients identified as white. The predicted rate of arrival at this institution for amputation, arthrodesis, exostectomy, and casting was 2.4, 0.7, 2.5, and 4.7 respectively. Amputation was overall associated with a higher percentage of comorbid diagnosis. When compared to the arthrodesis group, casting had a 1.35 times (95% CI: 1.086-1.689) risk of ulceration and was associated with a higher hemoglobin A1C (7.5±2.211 vs 7.22 ± 1.87, p=0.058). Conclusion: Among relatively comparable groups, casting, while effective and the least invasive, is associated with higher risks of ulceration and complications in the future. Complications of Charcot foot can involve skeletal deformities, which can reduce the quality of life for patients. With the expected projected arrival rate of newly diagnosed CN patients at this institution to be highest for casting and lowest for arthrodesis, the consideration for early surgical intervention such as arthrodesis could reduce the risk of complications and readmissions in the future progression of Charcot foot.

Bone in diabetes mellitus is characterized by an altered microarchitecture caused by abnormal metabolism of bone cells. Together with diabetic neuropathy, this is associated with serious complications including impaired bone healing culminating in complicated fractures and dislocations, especially in the lower extremities, so-called Charcot neuroarthropathy (CN). The underlying mechanisms are not yet fully understood, and treatment of CN is challenging. Several in vitro and in vivo investigations have suggested positive effects on bone regeneration by modifying biomaterials with sulfated glycosaminoglycans (sGAG). Recent findings described a beneficial effect of sGAG for bone healing in diabetic animal models compared to healthy animals. We therefore aimed at studying the effects of low- and high-sulfated hyaluronan derivatives on osteoclast markers as well as gene expression patterns of osteoclasts and osteoblasts from patients with diabetic CN compared to non-diabetic patients with arthritis at the foot and ankle. Exposure to sulfated hyaluronan (sHA) derivatives reduced the exaggerated calcium phosphate resorption as well as the expression of genes associated with bone resorption in both groups, but more pronounced in patients with CN. Moreover, sHA derivatives reduced the release of pro-inflammatory cytokines in osteoclasts of patients with CN. The effects of sHA on osteoblasts differed only marginally between patients with CN and non-diabetic patients with arthritis. These results suggest balancing effects of sHA on osteoclastic bone resorption parameters in diabetes.

The role of genetic factors and monocyte-to-osteoclast differentiation in the pathogenesis of Charcot neuroarthropathy

To summarize the progress of clinical diagnosis and treatment of diabetic Charcot neuroarthropathy (CNO) of foot and ankle to provide reference for clinical treatment. The research literature on diabetic CNO of foot and ankle at home and abroad was widely reviewed, and the stages and classification criteria of CNO were summarized, and the treatment methods at different stages of the disease course were summarized. CNO is a rapidly destructive disease of bone and joint caused by peripheral neuropathy, which leads to the formation of local deformities and stress ulcers due to bone and joint destruction and protective sensory loss, which eventually leads to disability and even life-threatening. At present, the modified Eichenholtz stage is a commonly used staging criteria for CNO of foot and ankle, which is divided into 4 stages by clinical and imaging manifestations. The classification mainly adopts the modified Brodsky classification, which is divided into 6 types according to the anatomical structure. The treatment of diabetic CNO of foot and ankle needs to be considered in combination with disease stage, blood glucose, comorbidities, local soft tissue conditions, degree of bone and joint destruction, and whether ulcers and infections are present. Conservative treatment is mainly used in the active phase and surgery in the stable phase. The formulation of individualized and stepped treatment regimens can help improve the effectiveness of diabetic CNO of foot and ankle. However, there is still a lack of definitive clinical evidence to guide the treatment of active and stable phases, and further research is needed.

Introduction: Charcot neuroarthropathy (CAN) is a serious and often neglected complication of diabetes mellitus, especially type 2 diabetes, often associated with a lack of preparation on the part of the medical team, which results in late diagnosis and additional complications. NAC causes progressive joint destruction and is more common in patients with type 2 diabetes and peripheral neuropathy, which characterizes it as a highly serious condition. It manifests itself through bone and joint lesions, which may or may not be painful, in limbs that have lost sensory innervation. Objective: The aim of this study was to analyze clinical management strategies for CAN in patients with type 2 diabetes mellitus. Methods: Using the PRISMA protocol and a search of the last 5 years (2019–2024) in the PubMed, Cochrane Library, and SciELO databases, with the descriptors “Clinical Protocols,” “Neurogenic Arthropathy,” and “Diabetes Mellitus,” 45 studies were identified, 16 were screened, resulting in 5 eligible studies that addressed the clinical treatment of CAN associated with type 2 diabetes mellitus. Results: Early diagnosis of CAN is essential for effective management, as a delay in diagnosis of more than 6 months can increase the chance of irreversible deformities and serious complications by up to 50%. Factors such as inadequate capillary blood glucose control, inadequate foot hygiene, and lack of periodic self-assessment were identified as risk indicators. Conservative treatment, with immobilization and weight-bearing on the affected extremity, is crucial in the acute phase of ACN. Conclusion: The relationship between NAC and diabetes highlights the crucial importance of early detection and transdisciplinary management. Implementing preventive strategies and intensive treatment of vascular and neuropathic changes are essential to reduce risks in people with diabetes.

Charcot neuroarthropathy (CN) is a chronic, destructive, and painless damage of the skeletal system that affects the life quality of patients. CN, with an unclear mechanism, is characterized with invasive destruction of bones and a serious abnormality of bone metabolism. Unfortunately, development of an effective prevention and treatment strategy for CN is still a great challenge. Of note, recent studies providing an insight into the molecular mechanisms of bone metabolism and homeostasis have propelled development of novel CN therapeutic strategies. Therefore, this review aims to shed light on the pathogenesis, diagnosis, and treatment of CN. In particular, we highlight the eminent role of the osteoprotegerin (OPG)-receptor activator of nuclear factor-κB (RANK)-RANK ligand (RANKL) system in the development of CN. Furthermore, we summarize and discuss the diagnostic biomarkers of CN as well as the potential pharmacological mechanisms of current treatment regimens from the perspective of bone metabolism. We believe that this review will enhance the current state of knowledge on the diagnosis, prevention, and therapeutic efficacy of CN.

Charcot neuroarthropathy (CN) was first described over 150 years ago. Despite this there remains uncertanity around the factors that contribute to its development, and progression. This article will discuss the current controversies around the pathogenesis, epidemiology, diagnosis, assessment and management of the condition. The exact pathogenesis of CN is not fully understood, and it is likely to be multifactorial, with perhaps currently unknown mechanisms contributing to its development. Further studies are needed to examine opportunities to help screen for and diagnose CN. As a result of many of these factors, the true prevalence of CN is still largely unknown. Almost all of the recommendations for the assessment and treatment of CN are based on low-quality level III and IV evidence. Despite recommendations to offer people with CN nonremovable devices, currently only 40–50% people are treated with this type of device. Evidence is also lacking about the optimal duration of treatment; reported outcomes range from 3 months to more than a year. The reason for this variation is not entirely clear. A lack of standardised definitions for diagnosis, remission and relapse, heterogeneity of populations, different management approaches, monitoring techniques with unknown diagnostic precision and variation in follow-up times prevent meaningful comparison of outcome data. If people can be better supported to manage the emotional and physical consequences of CN, then this could improve people’s quality of life and well-being. Finally, we highlight the need for an internationally coordinated approach to research in CN.

The treatment of Charcot neuroarthropathy in the feet of diabetic patients has undergone fundamental changes in the last few years. Formerly, treatment was almost exclusively limited to nonoperative measures; since the late 1990s, however, current practice has shifted to early, stage-appropriate surgical therapy. The objective of this prospective study was to investigate the value of two types of positron emission tomography (PET) in the preoperative evaluation of diabetic patients with Charcot foot deformities. Ring [(18)F]FDG (2-fluoro-2-deoxy-glucose) and hybrid PET were compared to magnetic resonance imaging (MRI). MRI, ring PET, and hybrid PET imaging were used as part of the preoperative evaluation of 16 patients with type II diabetes mellitus. The diagnosis of Charcot neuropathy of the foot requiring operative treatment had been made on the basis of clinical and radiographic criteria. Of 39 Charcot lesions confirmed at surgery, 37 were detected by ring PET, 30 by hybrid PET, and 31 by MRI. PET (ring or hybrid) can be used in the evaluation of patients with metal implants that would compromise the accuracy of MRI. Another advantage of PET is its ability to distinguish between inflammatory and infectious soft-tissue lesions, and between osteomyelitis and Charcot neuroarthropathy. The differentiation between Charcot neuroarthropathy and florid osteomyelitis provides the surgeon with important additional information that often is unavailable from MRI. Because it provides important additional data, ring PET may be preferable to radiography and MRI in the preoperative evaluation of patients with Charcot neuroarthropathy of the foot. Hybrid PET, because of its poorer resolution compared to ring PET, appears less suitable for routine clinical application.

Category: Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) has been associated with premature mortality, increased morbidity and reduced health related quality of life. The primary goal of treatment in patients with CN, whether surgical or non-surgical, is to achieve successful limb salvage. Traditionally, the quality of medical evidence guiding treatment has largely been based on expert opinion and uncontrolled case series. A systematic review (FAI 2012) reported that the mean and median number of patients reported in surgical studies of CN was 27 and 14 respectively. This retrospective study was performed to assess the outcomes of a consecutive series of diabetic patients with CN from a single surgeon academic practice. The primary aim was compare the major lower extremity rate (LEA) in patients with and without a preoperative ulcer Methods: This series was comprised of 256 diabetic patients with a mean age of 58.4 years (±10.1). The majority of patients were males (57%), had type 2 DM (78.5%) and used insulin (70.4%). The anatomic areas of CN involvement were midfoot (69.1%), ankle (25.1%), hindfoot (4.7%) and forefoot (0.1%). The majority of patients presented during Eichenholtz stage 3 (61%) followed by stage 1(27%) and stage 2 (12%). At the time of presentation, 144 patients (56%) had a foot ulcer and 58% of ulcer patients (N=84) had either a soft tissue infection or osteomyelitis. When comparing CN patients with and without ulcers, there were no significant differences between the two groups with regard to age, duration of DM, BMI, insulin use, serum glucose, Hbg A1C, serum creatinine, need for dialysis or PAD. Patients with foot ulcers were significantly more likely to be males and have lower levels of hemoglobin and albumin. Results: 75% of patients underwent some type of surgery and 25% were successfully managed without surgery. Major LEA was performed in 39 of 256 patients (15.2%). Three LEA (2.7%) were performed in patients (N=112) who did not have a preoperative ulcer compared to 36 LEA (25%) in patients (N=144) with ulcers (p < 0.0001). These 3 amputations occurred after reconstructive surgery in patients with PAD. Variables associated with major LEA included the presence of a preoperative ulcer [OR 12.1(95% CI 3.6-40.5), < 0.0001], preoperative infection [OR 4.5 (95% CI 2.1-9.8), < 0.0001] and male gender [OR 4.1(95% CI 1.7-9.7), 0.0007]. PAD [OR 1.3 (95% CI 0.6-2.7), 0.48] and dialysis [OR 1.3(0.4-3.6), 0.69] were not significantly associated with LEA. Thirty-seven of 256 patients (14.8%) died during the follow up period Conclusion: This study demonstrates that once an ulcer develops in patients with CN, the need for surgery, complications of surgery (i.e. surgical site infections) and risk of LEA increases significantly. Early treatment (non-surgical or surgical) should strive to prevent ulcer formation. Approximately one in six patients died during the follow up period, indicating that CN is likely a surrogate marker for cardiovascular and renal health. A major limitation of this study is that patients in this series were from an academic practice that receives tertiary referrals. Consequently, the relatively high rates of surgery and amputation may be due to selection bias.

Category:Diabetes, Midfoot/ForefootIntroduction/Purpose:Charcot neuroarthropathy (CN) is a complication of neuropathy secondary to diabetes mellitus (DM) and may involve multiple joints of the foot, in particular the midfoot. Patients with CN deformity associated with infection, ulceration or pre-ulceration are at risk of losing their limb. In these patients, reconstruction of the foot structure through beaming arthrodesis screws for stabilization is often required. In addition to midfoot beaming, previous reports have advocated for subtalar arthrodesis. Fixation of the subtalar joint restricts motion of the hindfoot. This rigid fixation has been hypothesized to offer greater stability and fewer hardware failures. The aim of this study was to describe failure of midfoot beaming screws after midfoot reconstruction of CN with and without subtalar arthrodesis.Methods:We retrospectively reviewed patients with DM diagnosed with CN. Patient radiographs were evaluated for type of midfoot Charcot reconstruction and hardware failure. Patients included in the study had follow up of 3 months or more. The main outcome variable of interest was hardware breakage.Results:Eighteen patients who underwent midfoot reconstruction for CN were included. The average age was 52.7 years (±8.4 years), 10 (55.6%) were male, and the average body-mass index (BMI) was 35.8 kg/m2 (±10.3 kg/m2). The average follow-up time was 6.5 months (±3.7 months). In the current series, thirteen out of 18 (72.2%) patients underwent subtalar fusion along with midfoot fusion. Screw breakage occurred in two patients, one at the 1st tarsometarsal joint and 2nd-4th tarsometarsal screws in another patient at 9 and 6 months respectively. Both patients with screw breakage had subtalar fusion. A third patient who had subtalar fusion subsequently developed collapse of their talus leading to subtalar screw removal 3 months after initial surgery.Patients without subtalar fusion did not experience screw breakage.Conclusion:An extended medial column fixation with subtalar arthrodesis has been previously proposed to provide better fixation after midfoot CN reconstruction with beaming screws as it restricts motion of the hindfoot. However, little to no evidence has been reported in favor of this technique. Our findings suggest that subtalar arthrodesis may result in fixation that is too rigid, which may place the beaming screws at higher risk of breakage. However, the number of observations is a limitation of our study, and further investigation comparing these techniques is needed to fully evaluate the effect of subtalar arthrodesis on midfoot beaming outcomes.

The management of charcot neuroarthropathy, a severe disabling condition in diabetic patients with peripheral neuropathy, is currently inadequate with no specific pharmacological treatment available. We undertook a double-blind randomised controlled trial to study the effect of pamidronate, a bisphosphonate, in the management of acute diabetic Charcot neuroarthropathy. Altogether 39 diabetic patients with active Charcot neuroarthropathy from four centres in England were randomised in a double-blind placebo-controlled trial. Patients received a single infusion of 90 mg of pamidronate or placebo (saline). Foot temperatures, symptoms and markers of bone turnover (bone specific alkaline phosphatase and deoxypyridinoline crosslinks) were measured over the 12 months, in 10 visits. All patients also had standard treatment of the Charcot foot. Mean age of the study group (59 % Type II (non-insulin-dependent) diabetes mellitus) was 56.3 +/- 10.2 years. The mean temperature difference between active and control groups was 3.6 +/- 1.7 degrees C and 3.3 +/- 1.4 degrees C, respectively. There was a fall in temperature of the affected foot in both groups after 2 weeks with a further reduction in temperature in the active group at 4 weeks (active and placebo vs baseline; p = 0.001; p = 0.01, respectively), but no difference was seen between groups. An improvement in symptoms was seen in the active group compared with the placebo group (p < 0.001). Reduction in bone turnover (means +/- SEM) was greater in the active than in the control group. Urinary deoxypyridinoline in the pamidronate treated group fell to 4.4 +/- 0.4 nmol/mmol creatinine at 4 weeks compared with 7.1 +/- 1.0 in the placebo group (p = 0.01) and bone-specific alkaline phosphatase fell to 14.1 +/- 1.2 u/l compared with 18.6 +/- 1.6 u/l after 4 weeks, respectively (p = 0.03). The bisphosphonate, pamidronate, given as a single dose leads to a reduction in bone turnover, symptoms and disease activity in diabetic patients with active Charcot neuroarthropathy.

This prospective study was performed to compare calcaneal and lumbar bone mineral density (BMD) in individuals with and without diabetes mellitus. We compared bone density with the time from onset of Charcot's neuroarthropathy (CN) in patients with unilateral, nonoperative, reconstructive-stage CN. The final purpose was to investigate the role that sex, age, and serum vitamin D level may have in osseous recovery. Thirty-three individuals were divided into three groups: controls and patients with diabetes mellitus with and without CN. Peripheral instantaneous x-ray imaging and dual-energy x-ray absorptiometry were performed. The calcaneal BMD of patients with diabetes mellitus and CN was lower than that of the control group (P < .01) but was not significantly lower than that of patients with diabetes mellitus alone. There was no statistically significant difference in lumbar T-scores between groups. Women demonstrated lower BMD than did men (P = .02), but patients 60 years and older did not demonstrate significantly lower BMD than did patients younger than 60 years (P = .135). A negative linear relationship was demonstrated between time and BMD in patients with CN. The results of this study suggest that lumbar BMD does not reflect peripheral BMD in patients with diabetes mellitus and reconstructive-stage CN. This study has clinical implications when reconstructive osseous surgery is planned in patients with CN.