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

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.

Contralateral foot temperature monitoring during Charcot immobilisation: A systematic review

“…Body mass index (BMI) was reported only in three studies 21,26,37 and only one study reported ethnicity 38 (Table ). CN location was reported using either the Sanders–Frykberg classification ( n = 10), 23–30,32,39 and Brodsky classification ( n = 1), 34 in detail, 22 available only for those in remission 38 or unreported ( n = 6) 21,31,33,35–37 (Table 1).…”

“…Frequency of CTDs monitoring varied from every week 31 to every 12 weeks ( n = 2) 33,39 (Table 2). Usually, CTD monitoring took place every one to six weeks during immobilisation in the majority (14 of 19) of studies (see Table 2) 21–27,31,32,34–38 and as frequent as every 1–3 weeks ( n = 8) 21,23–25,31,32,37,38 .…”

“…Frequency of CTDs monitoring varied from every week 31 to every 12 weeks ( n = 2) 33,39 (Table 2). Usually, CTD monitoring took place every one to six weeks during immobilisation in the majority (14 of 19) of studies (see Table 2) 21–27,31,32,34–38 and as frequent as every 1–3 weeks ( n = 8) 21,23–25,31,32,37,38 . The frequency of temperature monitoring was sometimes event‐linked; for example, reduced from 1 week to every 2 weeks after oedema had stabilised 31 or after 12 weeks had elapsed 21 …”

“…Contralateral temperature difference was measured at the CN location in half (10 of 19) of immobilisation studies 21–23,26,27,34,35,37–39 (see Table 1). In other studies, CTD was measured at the hottest point on the Charcot affected foot, 33 unspecified 36 or at multiple foot locations ( n = 7) 24,25,28–32 . In these studies, the number of measurement sites ranged from two 28–30 to 10 sites 31 and location varied but sites common to more than one study included the first metatarsal head ( n = 4), 24,25,31,32 third and fifth metatarsal heads ( n = 3), 24,25,31 and hallux ( n = 3) 24,25,32 (Table 1).…”

“…One study used the three closest of seven sites to the CN location 32 . In another study, the resolution of CN was determined by a CTD less than 2°C at all 10 anatomical testing sites 31 . In the other studies, it is unclear whether the multiple temperature differences were averaged or whether all measuring sites had to be below the specified CTD threshold 24,25,28–30 …”