To Cut or to Cast? An Evaluation of Demographics & Mortality in Operative, Conservative, and Failed- Conservative Management of Charcot Neuroarthropathy

Abstract

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) is a chronic, destructive disease linked with diabetic neuropathy that affects the bone structure, joints, and soft tissues of the foot. Treatment can vary from a conservative shoe modification to a below-the-knee amputation (BKA). With no evidence based guidelines for CN management, treatment regimens are physician specific and dependent on stage of CN, comorbidities, and ulceration status. Further, no previous literature has compared the mortality rates of patients that are treated with casting versus common surgical procedures for CN. Here, we provide demographic and all-cause mortality data for patients who underwent casting, arthrodesis, exostectomy, and amputation, to evaluate the outcomes and characterize the populations treated for Charcot neuroarthropathy of the foot. Methods: Institutional review board approval was obtained. A database of all patients from 1/1/2000 to 1/31/2022 with CPT and ICD codes indicating a diagnosis of Charcot neuroarthropathy who underwent exostectomy, arthrodesis, minor amputation, major amputation, and/or casting was created from the electronic medical record. Demographic and mortality data was collected, including date-of-birth, sex, race, and all-cause mortality. Procedure data was collected, which included date, code, and description. Major amputations include transtibial and trans-metatarsal, whereas minor amputations include toe and metatarsal. In the casting group, patients were separated into two groups: casting as the sole intervention and failed casting that ultimately went on to have surgery. Patients who had postoperative casting or multiple instances of casting and surgery were excluded. Descriptive statistics were conducted and single-factor ANOVA and Chi squared tests were used for analysis. Results: A total of 2,130 patients were identified; 546 had arthrodesis, 488 had exostectomy, 677 had minor amputations, 332 had major amputations, 64 had casting only, and 23 failed casting. Of the 23 patients who failed casting and went on to have surgery, 11 had arthrodesis, 5 had exostectomy, 4 had minor amputation, and 3 had major amputation. The average overall was 57.7 ± 13.9. Mortality rates were 10.3%, 11.3%, 34.0%, 32.2%, 7.8%, 17.4% in the arthrodesis, exostectomy, minor amputation, major amputation, casting only, and failed casting groups, respectively (Figures 1A and 1B). Of those that failed casting and then had surgery, arthrodesis was the most common procedure. Conclusion: Treatment options for patients with CN range from simple casting to invasive amputation. Overall, patients who underwent casting as their sole intervention had a significantly lower all-cause mortality (7.8%) compared to those who had amputation (34% for minor amputations and 32.2% for major amputations). There was no significant difference in all-cause mortality between casting only and failed casting groups. These findings demonstrate a significant disparity in outcomes between conservative and operative management for CN. Understanding the mortality of the various treatment options for CN can help optimize standards of care to improve patient outcomes.