Comparison of Arthrodesis with Total Contact Casting for Midfoot Ulcerations Associated with Charcot Neuroarthropathy

Abstract

Background Gross deformity of the foot in Charcot neuroarthropathy can lead to foot collapse and subsequent ulceration, infection, amputation, or premature death. Total-contact casting (TCC) is a well-established treatment for neuropathic diabetic plantar foot ulcers. It was hypothesized that arthrodesis plus TCC may have advantages over TCC alone. This pilot study compared the effectiveness of arthrodesis plus TCC with TCC alone for the prevention, treatment, and recurrence of midfoot ulcerations associated with Charcot neuroarthropathy. Material/Methods Twenty-one subjects with plantar ulcers associated with unilateral diabetic Charcot midfoot neuroarthropathy were randomly assigned to ADS or TCC groups. The ADS group underwent an extended medial column arthrodesis procedure and TCC; ulcers were sutured directly. The TCC group underwent TCC alone with dressing changes. All patients underwent nerve conduction studies and quantitative sensory testing at baseline and during follow-up (6 and 12 months). Healing time and ulcer relapse rate were evaluated. Result Compared with the TCC group, there were fewer lesions in the ADS group after treatment (P<0.05). Temperature testing and vibration perception threshold improved significantly after ADS (P<0.05). Although the number of patients positive for pinprick and light touch sensations increased after surgery, not all patients recovered these sensations. Healing time was not significantly different between the 2 groups (24.25±3.89 vs. 25.89±2.84 days, P>0.05). There was no ulcer recurrence after 12 months in the ADS group compared with 33.3% in the TCC group. Conclusions An extended medial column arthrodesis may partly improve sensory impairments and restore protective sensation in patients with Charcot neuroarthropathy.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review

“…We identified one RCT with high risk of bias randomising 21 patients with midfoot plantar ulcers associated with Charcot deformity to extended medial column arthrodesis in combination with TCC or to TCC alone and found similar time‐to‐healing (24 vs 26 days; P > .05) …”

“…Moderate Health Quality Ontario 2017, 12 Elraiyah et al 2016, 13 Morona et al 2013, 53 Metatarsal head resection(s) in combination with a removable offloading device seems more effective to heal a neuropathic plantar metatarsal head DFU than using a removable offloading device alone a Low Kalantar Motamedi et al 2017, 80 Armstrong et al 2012, 82 Armstrong et al 2005, 61 and Piaggesi et al 1998 72 Medial column arthrodesis in combination with a non-removable offloading device is not superior in healing a neuropathic plantar midfoot DFU associated with a Charcot deformity than using a non-removable offloading device alone a Low Wang et al 2015 69 First metatarsal-phalangeal joint arthroplasty in combination with non-removable offloading device may lead to shorter time-to-healing a neuropathic plantar hallux DFU than using a non-removable offloading device alone a Low Armstrong et al 2003 84 and Lin et al 2000 85 Osteotomy seems more effective to heal a metatarsal head DFU than conservative treatment (with or without offloading) alone…”

“…We identified one RCT with high risk of bias randomising 21 patients with midfoot plantar ulcers associated with Charcot deformity to extended medial column arthrodesis in combination with TCC or to TCC alone and found similar time-to-healing (24 vs 26 days; P > .05). 69 Evidence statement. Medial column arthrodesis in combination with a non-removable offloading device is not superior in healing a neuropathic plantar midfoot DFU associated with a Charcot deformity than using a non-removable offloading device alone.…”

“…The current evidence base for surgical offloading for healing plantar DFU is still limited, with very few controlled studies published 69,80 since our previous review 4 years ago. 11 Achilles tendon lengthening seems to have limited value in addition to a TCC alone in healing plantar forefoot ulcers.…”

Global recurrence rates in diabetic foot ulcers: A systematic review and meta‐analysis

“…One hundred eighty‐two full‐text articles were assessed for eligibility, and 133 (65 reviews, eight studies of duplicated population, and 60 studies with data that cannot be extracted) of them were removed since they did not meet our selection criteria. Finally, 49 articles were included in our meta‐analysis after full‐text review …”