SLR - January 2021 - Jorge L. Amaro

Surgical Treatment of Midfoot Charcot Neuroarthropathy with Osteomyelitis in Patients with Diabetes: A Systematic Review

Reference: Ramanujam CL, Stuto AC, Zgonis T. Surgical Treatment of Midfoot Charcot Neuroarthropathy with Osteomyelitis in Patients with Diabetes: A Systematic Review. J Wound Care. 2020 Jun 1;29(Sup6):S19-S28. 

Level of Evidence: Level I

Scientific Literature Review

Reviewed By: Jorge L. Amaro, DPM
Residency Program: Ascension St. Vincent Hospital – Indianapolis, IN

Podiatric Relevance: The most reported anatomical site of involvement for Charcot neuroarthropathy in diabetic patients is the midfoot. Diabetic patients with CN with concomitant osteomyelitis further complicates the diagnosis and carries increased lower extremity amputation and mortality risks. The medical or surgical management of CN with osteomyelitis depends on the location of the involvement, as the clinical presentation and treatment can vary if it involves the midfoot or if it involves the ankle. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot Neuroarthropathy with osteomyelitis in patients with diabetes. 

Methods: A systematic review of the literature was performed by three independent reviewers searching several databases. Studies were selected for analysis if they met the following criteria. For inclusion criteria, studies had to be in the English language, published between 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, postoperative follow up period of six months or more, healing rates, complications, need for revisional surgery, reulceration. Studies were excluded if they were entirely literature reviews, cadaveric studies, patients without diabetes, surgical treatment was proximal to the Chopart’s midtarsal joint.

Results: A total of 184 eligible studies were initially found. After inclusion and exclusion criteria, 171 studies were excluded. The remaining 13 studies had a total of 56 patients who had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis. The studies were composed of retrospective case series or case reports, and average follow up was approximately 23.1 months. All surgical treatments entailed some form of simple or staged debridement plus: 1) a simple exostectomy (two patients), 2) Arthrodesis with or without internal fixation and/or external fixation (48 patients), 3) Advanced soft tissue reconstruction with flaps (seven patients). Patients were treated with parenteral antibiotics. Major complications occurred in three patients (5.4 percent), minor complications in three patients (19.6 percent), revisional surgery in ten patients (17.9 percent). None reported a worsening of the Charcot Neuroarthropathy. 

Conclusions: The authors conclude that surgical intervention of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate (78.6 percent) for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal fixation or external fixation, and advanced soft tissue reconstructions. They attributed this high success rate of ambulation with osseous union or stable fibrous nonunion to the surgical debridement with wide resection of the infected soft tissue and bone, the use of IV antibiotics, and the strict restrictions for weight bearing status the patients followed postoperatively.   

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