Top

Journal of Foot and Ankle Research

Published in:

Open Access 01-12-2021 | Research

Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

Authors: Danielle A. Griffiths, Michelle R. Kaminski

Published in: Journal of Foot and Ankle Research | Issue 1/2021

Abstract

Background

Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies.

Methods

This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher’s exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated.

Results

Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants.

Conclusions

The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.

Available only for authorised users

Christensen TM, Gade-Rasmussen B, Pedersen LW, Hommel E, Holstein PE, Svendsen OL. Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker. J Diabetes Complicat. 2012;26(5):430–4. https://doi.org/10.1016/j.jdiacomp.2012.05.006.CrossRef

Game FL, Catlow R, Jones GR, Edmonds ME, Jude EB, Rayman G, et al. Audit of acute Charcot's disease in the UK: the CDUK study. Diabetologia. 2012;55(1):32–5. https://doi.org/10.1007/s00125-011-2354-7.CrossRefPubMed

Milne TE, Rogers JR, Kinnear EM, Martin HV, Lazzarini PA, Quinton TR, et al. Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review. J Foot Ankle Res. 2013;6(1):30. https://doi.org/10.1186/1757-1146-6-30.CrossRefPubMedPubMedCentral

Frykberg RG, Belczyk R. Epidemiology of the Charcot foot. Clin Podiatr Med Surg. 2008;25(1):17–28. https://doi.org/10.1016/j.cpm.2007.10.001.CrossRefPubMed

Rogers LC, Frykberg RG, Armstrong DG, Boulton AJ, Edmonds M, Van GH, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123–9. https://doi.org/10.2337/dc11-0844.CrossRefPubMedPubMedCentral

Varma AK. Charcot neuroarthropathy of the foot and ankle: a review. J Foot Ankle Surg. 2013;52(6):740–9. https://doi.org/10.1053/j.jfas.2013.07.001.CrossRefPubMed

Markakis K, Bowling FL, Boulton AJ. The diabetic foot in 2015: an overview. Diabetes Metab Res Rev. 2016;32(Suppl 1):169–78. https://doi.org/10.1002/dmrr.2740.CrossRefPubMed

Boulton AJM, Whitehouse RW. The diabetic foot. [updated 15 mar 2020]. In: Feingold KR, Anawalt B, Boyce a, et al., editors. Endotext [internet]. South Dartmouth: MDText.com, Inc.; 2000. https://www.ncbi.nlm.nih.gov/books/NBK409609/. Accessed 14 Jul 2020

Wukich DK, Sung W, Wipf SA, Armstrong DG. The consequences of complacency: managing the effects of unrecognized Charcot feet. Diabet Med. 2011;28(2):195–8. https://doi.org/10.1111/j.1464-5491.2010.03141.x.CrossRefPubMed

10.

Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int. 2006;27(5):324–9. https://doi.org/10.1177/107110070602700503.CrossRefPubMed

11.

de Souza LJ. Charcot arthropathy and immobilization in a weight-bearing total contact cast. J Bone Joint Surg Am. 2008;90(4):754–9. https://doi.org/10.2106/JBJS.F.01523.CrossRefPubMed

12.

Vopat ML, Nentwig MJ, Chong ACM, Agan JL, Shields NN, Yang SY. Initial diagnosis and management for acute Charcot neuroarthropathy. Kans J Med. 2018;11(4):114–9. https://doi.org/10.17161/kjm.v11i4.8709.CrossRefPubMedPubMedCentral

13.

van Netten JJ, Prijs M, van Baal JG, Liu C, van der Heijden F, Bus SA. Diagnostic values for skin temperature assessment to detect diabetes-related foot complications. Diabetes Technol Ther. 2014;16(11):714–21. https://doi.org/10.1089/dia.2014.0052.CrossRefPubMed

14.

McGill M, Molyneaux L, Bolton T, Ioannou K, Uren R, Yue DK. Response of Charcot's arthropathy to contact casting: assessment by quantitative techniques. Diabetologia. 2000;43(4):481–4. https://doi.org/10.1007/s001250051332.CrossRefPubMed

15.

Moura-Neto A, Fernandes TD, Zantut-Wittmann DE, Trevisan RO, Sakaki MH, Santos AL, et al. Charcot foot: skin temperature as a good clinical parameter for predicting disease outcome. Diabetes Res Clin Pract. 2012;96(2):e11–4. https://doi.org/10.1016/j.diabres.2011.12.029.CrossRefPubMed

16.

Rosenbaum AJ, DiPreta JA. Classifications in brief: Eichenholtz classification of Charcot arthropathy. Clin Orthop Relat Res. 2015;473(3):1168–71. https://doi.org/10.1007/s11999-014-4059-y.CrossRefPubMed

17.

Bates M, Petrova NL, Edmonds ME. How long does it take to progress from cast to shoes in the management of Charcot osteoarthropathy? Diabet Med. 2006;23(Suppl 2):1–30.

18.

Stark C, Murray T, Gooday C, Nunney I, Hutchinson R, Loveday D, et al. 5 year retrospective follow-up of new cases of Charcot neuroarthropathy - a single Centre experience. Foot Ankle Surg. 2016;22(3):176–80. https://doi.org/10.1016/j.fas.2015.07.003.CrossRefPubMed

19.

Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic. Diabet Med. 1997;14(5):357–63. https://doi.org/10.1002/(SICI)1096-9136(199705)14:5<357::AID-DIA341>3.0.CO;2-8.CrossRefPubMed

20.

Sinacore DR. Acute Charcot arthropathy in patients with diabetes mellitus: healing times by foot location. J Diabetes Complicat. 1998;12(5):287–93. https://doi.org/10.1016/S1056-8727(98)00006-3.CrossRef

21.

Chantelau E. The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture. Diabet Med. 2005;22(12):1707–12. https://doi.org/10.1111/j.1464-5491.2005.01677.x.CrossRefPubMed

22.

Pakarinen TK, Laine HJ, Honkonen SE, Peltonen J, Oksala H, Lahtela J. Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases. Scand J Surg. 2002;91(2):195–201. https://doi.org/10.1177/145749690209100212.CrossRefPubMed

23.

Chantelau EA, Antoniou S, Zweck B, Haage P. Follow up of MRI bone marrow edema in the treated diabetic Charcot foot - a review of patient charts. Diabet Foot Ankle. 2018;9(1):1466611. https://doi.org/10.1080/2000625X.2018.1466611.CrossRefPubMedPubMedCentral

24.

Kimmerle R, Chantelau E. Weight-bearing intensity produces Charcot deformity in injured neuropathic feet in diabetes. Exp Clin Endocrinol Diabetes. 2007;115(06):360–4. https://doi.org/10.1055/s-2007-970578.CrossRefPubMed

25.

Renner N, Wirth SH, Osterhoff G, Böni T, Berli M. Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients. BMC Musculoskelet Disord. 2016;17(1):504. https://doi.org/10.1186/s12891-016-1357-4.CrossRefPubMedPubMedCentral

26.

Ruotolo V, Di Pietro B, Giurato L, Masala S, Meloni M, Schillaci O, et al. A new natural history of Charcot foot: clinical evolution and final outcome of stage 0 Charcot neuroarthropathy in a tertiary referral diabetic foot clinic. Clin Nucl Med. 2013;38(7):506–9. https://doi.org/10.1097/RLU.0b013e318292eecb.CrossRefPubMed

27.

Zampa V, Bargellini I, Rizzo L, Turini F, Ortori S, Piaggesi A, et al. Role of dynamic MRI in the follow-up of acute Charcot foot in patients with diabetes mellitus. Skelet Radiol. 2011;40(8):991–9. https://doi.org/10.1007/s00256-010-1092-0.CrossRef

28.

Sämann A, Pofahl S, Lehmann T, Voigt B, Victor S, Möller F, et al. Diabetic nephropathy but not HbA1c is predictive for frequent complications of Charcot feet - long-term follow-up of 164 consecutive patients with 195 acute Charcot feet. Exp Clin Endocrinol Diabetes. 2012;120(6):335–9. https://doi.org/10.1055/s-0031-1299705.CrossRefPubMed

29.

Dixon J, Coulter J, Garrett M, Cutfield R. A retrospective audit of the characteristics and treatment outcomes in patients with diabetes-related Charcot neuropathic osteoarthropathy. N Z Med J. 2017;130(1467):62–7.PubMed

30.

Thewjitcharoen Y, Parksook W, Krittiyawong S, Porramatikul S, Sripatpong J, Mahaudomporn S, et al. A closer look at outcome of diabetic Charcot foot: Thailand's perspective. Diabetes Res Clin Pract. 2014;1:S63.CrossRef

31.

Jilbert EJ, Schoen DE, Trewben BC, Gurr JM. A retrospective audit of active Charcot neuroarthropathy in a tertiary hospital podiatry department. J Foot Ankle Res. 2011;4 Suppl 1:P30.CrossRef

32.

Eichenholtz SN. Charcot joints. Springfield, IL, USA: Charles C. Thomas; 1966.

33.

Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy. J Bone Joint Surg Am. 1990;72(5):749–56. https://doi.org/10.2106/00004623-199072050-00016.CrossRefPubMed

34.

Feng Y, Schlösser FJ, Sumpio BE. The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. J Vasc Surg. 2009;50(3):675–82. https://doi.org/10.1016/j.jvs.2009.05.017.CrossRefPubMed

35.

Armstrong DW, Tobin C, Matangi MF. The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease. Can J Cardiol. 2010;26(10):e346–50. https://doi.org/10.1016/S0828-282X(10)70467-0.CrossRefPubMedPubMedCentral

36.

Kaminski MR, Raspovic A, McMahon LP, Erbas B, Landorf KB. Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: study protocol for a prospective observational cohort study. J Foot Ankle Res. 2015;8(1):53. https://doi.org/10.1186/s13047-015-0110-9.CrossRefPubMedPubMedCentral

37.

Petrova NL, Moniz C, Elias DA, Buxton-Thomas M, Bates M, Edmonds ME. Is there a systemic inflammatory response in the acute Charcot foot? Diabetes Care. 2007;30(4):997–8. https://doi.org/10.2337/dc06-2168.CrossRefPubMed

38.

Sinacore DR, Hastings MK, Bohnert KL, Fielder FA, Villareal DT, Blair VP 3rd, et al. Inflammatory osteolysis in diabetic neuropathic (Charcot) arthropathies of the foot. Phys Ther. 2008;88(11):1399–407. https://doi.org/10.2522/ptj.20080025.CrossRefPubMedPubMedCentral

39.

Sanders LJ, Frykberg RG. The Charcot foot. In: Frykberg RG, editor. The high risk foot in diabetes mellitus. New York: Churchill Livingstone; 1991. p. 325–35.

40.

Kominsky SJ. The ambulatory total contact cast. In: Frykberg RG, editor. The high risk foot in diabetes mellitus. New York: Churchill Livingstone; 1991. p. 449–55.

41.

Sun P-C, Jao S-HE, Cheng C-K. Assessing foot temperature using infrared thermography. Foot Ankle Int. 2005;26(10):847–53. https://doi.org/10.1177/107110070502601010.CrossRefPubMed

42.

Dallimore SM, Puli N, Kim D, Kaminski MR. Infrared dermal thermometry is highly reliable in the assessment of patients with Charcot neuroarthropathy. J Foot Ankle Res. 2020;13(1):56. https://doi.org/10.1186/s13047-020-00421-z.CrossRefPubMedPubMedCentral

43.

Gooday C, Gray K, Game F, Woodburn J, Poland F, Hardeman W. Systematic review of techniques to monitor remission of acute Charcot neuroarthropathy in people with diabetes. Diabetes Metab Res Rev. 2020;36:e3328.

44.

Chantelau E, Kimmerle R, Poll LW. Nonoperative treatment of neuro-osteoarthropathy of the foot: do we need new criteria? Clin Podiatr Med Surg. 2007;24(3):483–503. https://doi.org/10.1016/j.cpm.2007.03.006.CrossRefPubMed

45.

Verity S, Sochocki M, Embil JM, Trepman E. Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole. Foot Ankle Surg. 2008;14(1):26–31. https://doi.org/10.1016/j.fas.2007.10.002.CrossRefPubMed

46.

Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complicat. 2009;23(6):409–26. https://doi.org/10.1016/j.jdiacomp.2008.09.004.CrossRef

47.

Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013;34(11):1541–7. https://doi.org/10.1177/1071100713500490.CrossRefPubMed

48.

Iagnocco A, Rizzo C, Gattamelata A, Vavala C, Ceccarelli F, Cravotto E, et al. Osteoarthritis of the foot: a review of the current state of knowledge. Med Ultrason. 2013;15(1):35–40. https://doi.org/10.11152/mu.2013.2066.151.ai1ofr2.CrossRefPubMed

49.

Bullen B, Young M, McArdle C, Ellis M. Charcot neuroarthropathy patient education among podiatrists in Scotland: a modified Delphi approach. J Foot Ankle Res. 2018;11(1):54. https://doi.org/10.1186/s13047-018-0296-8.CrossRefPubMedPubMedCentral

50.

Guyton GP. An analysis of iatrogenic complications from the total contact cast. Foot Ankle Int. 2005;26(11):903–7. https://doi.org/10.1177/107110070502601101.CrossRefPubMed

51.

Armstrong DG, Lavery LA. Monitoring healing of acute Charcot's arthropathy with infrared dermal thermometry. J Rehabil Res Dev. 1997;34(3):317–21.PubMed

52.

Bramham R, Wraight P, May K. Management of Charcot neuroarthropathy. Diabetic Foot J. 2011;14:163–70.

53.

Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care. 2003;26(9):2595–7. https://doi.org/10.2337/diacare.26.9.2595.CrossRefPubMed

Title: Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study
Authors: Danielle A. Griffiths
Michelle R. Kaminski
Publication date: 01-12-2021
Publisher: BioMed Central
Published in: Journal of Foot and Ankle Research / Issue 1/2021
Electronic ISSN: 1757-1146
DOI: https://doi.org/10.1186/s13047-021-00477-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2021

Differences in toe flexor strength and foot morphology between wheelchair dependent and ambulant older people in long-term care: a cross-sectional study

Validation of the Indonesian version of the foot and ankle score in patients with chronic lateral ankle instability

People with chronic ankle instability benefit from brace application in highly dynamic change of direction movements

The effectiveness of PROLOTHERAPY for recalcitrant Medial TIBIAL Stress Syndrome: a prospective consecutive CASE series

The biopsychosocial-digital continuum of foot orthosis practice and research: the VALUATOR model

Release of the National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary