SLR - March 2022 - Stephanie M. Guzelak
Reference: Wang BK, Wukich DK, Sambandam S. Complications from Ankle Arthrodesis in Diabetes-Related Charcot Foot Syndrome. J Diabetes Complications. 2021 Dec;35(12):108071.Level of Evidence: Level III – Cohort study
Scientific Literature Review
Reviewed By: Stephanie M. Guzelak, DPM
Residency Program: Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Podiatric Relevance: Charcot neuroarthropathy (CN) is a common, but often devastating complication amongst the diabetic and neuropathic population. It is known to cause bony destruction, dislocation and deformity adding further complexity to CN reconstructive surgery. In addition to the surgical complexity with aims to prevent and heal ulcerations as well as reduce amputation, there is a high associated risk and high rate of complications post-operatively. The goal of this study was to compare post-operative outcomes and assess complications rates after ankle arthrodesis in those with diabetes related CN, diabetics without CN, and non-diabetics without CN.
Methods: This retrospective cohort study queried the PearlDiver Patient Records Database from 1/2021 to 1/2019 based off CPT and ICD-10 codes for any patient undergoing ankle fusion. The included patients were required to have a minimum of one year post-operative follow-up. Factors evaluated included: overall nonunion, nonunion within one year, amputation, hardware removal, 90-day and 30-day surgical site infection (SSI), dehiscence, acute kidney injury, pneumonia, and 90-day myocardial infarction or deep venous thrombosis. Each group: ankle arthrodesis in those with diabetes related CN, diabetics without CN, and non-diabetics without CN, was analyzed for the odds and prevalence of each complication and compared.
Results: Ninety-six thousand three hundred seventy-seven (96,377) ankle arthrodesis patients were included in this study, with 3,815 patients in each of the three matched groups. There was noted increased rates of amputation, wound dehiscence, acute kidney injury, pneumonia, and SSI in those with diabetes related CN versus patients with diabetes but without CN. When comparing patients with diabetes without CN to non-diabetics without CN, higher rates of nonunion, amputation, SSI and acute kidney injury were observed in the diabetic group. Patients with diabetes related CN had a statistically significant shorter time to hardware removal when compared to non-diabetics without CN.
Conclusions: This study has demonstrated that diabetes itself poses significant challenges for limb salvage and reconstruction in ankle fusion candidates, especially when interposed with diabetes related CN. Charcot neuroarthropathy increases the risk of post-operative complications in-part due to microvascular, mechanical, and neurological manifestations. The striking finding of this study is that the increased odds of major amputation between those with diabetic related CN and non-diabetics without CN requiring ankle fusion is increased by 11.6-fold, and a 3.6-fold increase comparing diabetics with related CN and diabetics without CN. Multisystem involvement in diabetes related CN necessitates surgeons to properly assess other pre-operative risk factors as predictors for specific complications. Valuable data such as laboratory biomarkers, other medical diagnoses, and patient medications should be considered in an effort to minimize post-operative risk in necessitated ankle arthrodesis candidates.