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Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment.
Foot Ankle Int. 2018 03; 39(3):265-270.FA

Abstract

BACKGROUND

The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life.

METHODS

Over a 12-year period, 214 patients (9 bilateral) underwent reconstruction of the acquired deformity associated with midtarsal Charcot foot arthropathy. Over time, 3 patterns of deformity were observed based on weight-bearing pattern, relationship of the forefoot to the hindfoot, and integrity of the talocalcaneal joint. A valgus deformity pattern was present in 138, varus in 48, and dislocation of the talocalcaneal joint in 37. A consistent operative strategy was employed. Surgery included percutaneous tendon-Achilles lengthening, resection of infection when present, attempted correction of the structural deformity by wedge resection at the apex of the deformity, and immobilization with a 3-level static circular external fixator. Additional deformity pattern-specific procedures were added over time. Clinical outcomes were based on the historic metrics of limb salvage and resolution of infection and the functional metric of the ability to walk with commercially available therapeutic footwear.

RESULTS

Seven patients died within a year of surgery, and 15 underwent partial- or whole-foot amputation. Overall, 173 of 223 feet (77.6%) achieved a favorable clinical outcome. Patients with a valgus deformity pattern were most likely to achieve a favorable clinical outcome (120 of 138, 87.0%). Patients with a dislocation pattern were less likely to achieve a favorable clinical outcome (26 of 37, 70.3%), and those with a varus deformity pattern were least likely to achieve a favorable clinical outcome (27 of 48, 56.3%).

CONCLUSIONS

Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient population. This realistic appreciation of outcome expectations should both be helpful in counseling patients on the risk-benefit ratio associated with surgery and provide a benchmark to measure newer strategies of treatment.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Authors+Show Affiliations

1 Loyola University Health System, Maywood, IL, USA.1 Loyola University Health System, Maywood, IL, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

29172758

Citation

Pinzur, Michael S., and Adam P. Schiff. "Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: a New Classification With Implications for Treatment." Foot & Ankle International, vol. 39, no. 3, 2018, pp. 265-270.
Pinzur MS, Schiff AP. Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment. Foot Ankle Int. 2018;39(3):265-270.
Pinzur, M. S., & Schiff, A. P. (2018). Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment. Foot & Ankle International, 39(3), 265-270. https://doi.org/10.1177/1071100717742371
Pinzur MS, Schiff AP. Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: a New Classification With Implications for Treatment. Foot Ankle Int. 2018;39(3):265-270. PubMed PMID: 29172758.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment. AU - Pinzur,Michael S, AU - Schiff,Adam P, Y1 - 2017/11/27/ PY - 2017/11/28/pubmed PY - 2019/2/23/medline PY - 2017/11/28/entrez KW - Charcot foot KW - deformity KW - diabetic foot SP - 265 EP - 270 JF - Foot & ankle international JO - Foot Ankle Int VL - 39 IS - 3 N2 - BACKGROUND: The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life. METHODS: Over a 12-year period, 214 patients (9 bilateral) underwent reconstruction of the acquired deformity associated with midtarsal Charcot foot arthropathy. Over time, 3 patterns of deformity were observed based on weight-bearing pattern, relationship of the forefoot to the hindfoot, and integrity of the talocalcaneal joint. A valgus deformity pattern was present in 138, varus in 48, and dislocation of the talocalcaneal joint in 37. A consistent operative strategy was employed. Surgery included percutaneous tendon-Achilles lengthening, resection of infection when present, attempted correction of the structural deformity by wedge resection at the apex of the deformity, and immobilization with a 3-level static circular external fixator. Additional deformity pattern-specific procedures were added over time. Clinical outcomes were based on the historic metrics of limb salvage and resolution of infection and the functional metric of the ability to walk with commercially available therapeutic footwear. RESULTS: Seven patients died within a year of surgery, and 15 underwent partial- or whole-foot amputation. Overall, 173 of 223 feet (77.6%) achieved a favorable clinical outcome. Patients with a valgus deformity pattern were most likely to achieve a favorable clinical outcome (120 of 138, 87.0%). Patients with a dislocation pattern were less likely to achieve a favorable clinical outcome (26 of 37, 70.3%), and those with a varus deformity pattern were least likely to achieve a favorable clinical outcome (27 of 48, 56.3%). CONCLUSIONS: Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient population. This realistic appreciation of outcome expectations should both be helpful in counseling patients on the risk-benefit ratio associated with surgery and provide a benchmark to measure newer strategies of treatment. LEVEL OF EVIDENCE: Level IV, retrospective case series. SN - 1944-7876 UR - https://www.unboundmedicine.com/medline/citation/29172758/Deformity_and_Clinical_Outcomes_Following_Operative_Correction_of_Charcot_Foot:_A_New_Classification_With_Implications_for_Treatment_ L2 - https://journals.sagepub.com/doi/10.1177/1071100717742371?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -