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Prognostic Scoring System for Patients Undergoing Reconstructive Foot and Ankle Surgery for Charcot Neuroarthropathy: The Charcot Reconstruction Preoperative Prognostic Score

Published:March 22, 2018DOI:https://doi.org/10.1053/j.jfas.2017.10.021

      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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      References

        • Pinzur M.S.
        Surgical versus accommodative treatment for Charcot arthropathy of the midfoot.
        Foot Ankle Int. 2004; 25: 545-549
        • 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
        • Schneekloth B.J.
        • Lowery N.J.
        • Wukich D.K.
        Charcot neuroarthropathy in patients with diabetes: an updated systematic review of surgical management.
        J Foot Ankle Surg. 2016; 55: 586-590
        • Pinzur M.S.
        Neutral ring fixation for high-risk nonplantigrade Charcot midfoot deformity.
        Foot Ankle Int. 2007; 28: 961-966
        • Schaper N.C.
        Diabetic foot ulcer classification system for research purposes: a progress report or criteria for including patients in research studies.
        Diabetes Metab Res Rev. 2004; 20: 590-595
        • Eschler A.
        • Gradl G.
        • Wussow A.
        • Mittlmeier T.
        Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score.
        BMC Musculoskelet Disord. 2015; 16: 349
        • Sammarco V.J.
        Superconstructs in the treatment of Charcot foot deformity: plantar plating, locked plating, and axial screw fixation.
        Foot Ankle Clin. 2009; 14: 393-407
        • Stuck R.M.
        • Sohn M.W.
        • Budiman-Mak E.
        • Lee T.A.
        • Weiss K.B.
        Charcot arthropathy risk elevation in the obese diabetic population.
        Am J Med. 2008; 121: 1008-1014
        • Pinzur M.
        • Freeland R.
        • Juknelis D.
        The association between body mass index and foot disorders in diabetic patients.
        Foot Ankle Int. 2005; 26: 375-377
        • Finkler E.S.
        • Kasia C.
        • Kroin E.
        • Davidson-Bell V.
        • Schiff A.P.
        • Pinzur M.S.
        Pin tract infection following correction of Charcot foot with static circular fixation.
        Foot Ankle Int. 2015; 36: 1310-1315
        • Wukich D.K.
        • Lowery N.J.
        • McMillen R.L.
        • Frykberg R.G.
        Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus.
        J Bone Joint Surg Am. 2010; 92A: 287-295
        • Dalla Paola L.
        • Brocco E.
        • Ceccacci T.
        • Ninkovic S.
        • Sorgentone S.
        • Marinescu M.G.
        • Volpe A.
        Limb salvage in Charcot foot and ankle osteomyelitis: combined use single stage/double stage of arthrodesis and external fixation.
        Foot Ankle Int. 2009; 30: 1065-1070
        • Pinzur M.S.
        • Gil J.
        • Belmares J.
        Treatment of osteomyelitis in Charcot foot with single-stage resection of infection, correction of deformity, and maintenance with ring fixation.
        Foot Ankle Int. 2012; 33: 1069-1074
        • Ramanujam C.L.
        • Han D.
        • Zgonis T.
        Lower extremity amputation and mortality rates in the reconstructed diabetic Charcot foot and ankle with external fixation: data analysis of 116 patients.
        Foot Ankle Spec. 2016; 9: 113-126
        • Wukich D.K.
        • Raspovic K.M.
        • Hobizal K.B.
        • Sadoskas D.
        Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes.
        Diabetes Metab Rev. 2016; 32: 292-296
        • Jeng C.L.
        • Campbell J.T.
        • Tang E.Y.
        • Cerrato R.A.
        • Myerson M.S.
        Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle.
        Foot Ankle Int. 2013; 34: 1256-1266
        • Shanbhoque V.V.
        • Brixen K.
        • Hansen S.
        Age- and sex-related changes in bone microarchitecture and estimated strength: a three-year prospective study using HR-pQCT.
        J Bone Mineral Res. 2016; 31: 1541-1549
        • Jeffcoate W.
        Vascular calcification and osteolysis in diabetic neuropathy—is RANK-L the missing link?.
        Diabetologia. 2004; 47: 1488-1492
        • Guo S.
        • DiPietro L.A.
        Factors affecting wound healing.
        J Dent Res. 2010; 89: 219-229
        • Simon S.
        • Tejwani S.
        • Wilson D.
        • Santner T.
        • Denniston N.
        Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot.
        J Bone Joint Surg Am. 2000; 82: 939-950
        • Raspovic K.R.
        • Wukich D.K.
        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
        • Hastings M.K.
        • Johnson J.E.
        • Strube M.J.
        • Hildebolt C.F.
        • Bohnert K.L.
        • Prior F.W.
        • Sinacore D.R.
        Progression of foot deformity in Charcot neuropathic osteoarthropathy.
        J Bone Joint Surg Am. 2013; 95A: 1206-1213
        • Pinzur M.S.
        Surgical treatment of the Charcot foot.
        Diabetes Metab Rev. 2016; 32: 287-291
        • Wukich D.K.
        • Pearson K.T.
        Self-reported outcomes of trans-tibial amputations for non-reconstructable Charcot neuroarthropathy in patients with diabetes: a preliminary report.
        Diabet Med. 2013; 30: 87-90
        • Rogers L.C.
        • Frykberg R.G.
        • Armstrong D.G.
        • Boulton A.J.
        • Edmonds M.
        • Van G.H.
        • Hartemann A.
        • Game F.
        • Jeffcoate W.
        • Jirkovska A.
        • Jude E.
        • Morbach S.
        • Morrison W.B.
        • Pinzur M.
        • Pitocco D.
        • Sanders L.
        • Wukich D.K.
        • Uccioli L.
        The diabetic Charcot foot syndrome: a report of the joint task force on the Charcot foot by the American Diabetes Association and the American Podiatric Medical Association.
        Diabetes Care. 2011; 34: 2123-2129