The Consequences of Complacency: Managing the Effects of Unrecognized Charcot Feet

• Presenter: Wenjay Sung, DPM

• Authors: Dane K. Wukich, MD, Wenjay Sung, DPM, Shelly A.M. Wipf, DPM, and David G. Armstrong.

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Overview

• Purpose• Methods• Statistical Analysis• Results• Discussion• Conclusions

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Purpose

• To report on the outcomes of patients with undetected early Charcot neuroarthropathy of the foot.– Two different health science centers– Reported findings included

• Any delay in diagnosis, ulcer formation, concomitant infection need for surgical intervention

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Methods

• From January 2005 – December 2009, we obtained medical records of patients diagnosed with diabetic Charcot neuroarthopathy (CN)– Diagnosis made in patients with diabetic sensory neuropathy

with perceived or unperceived insult• Localized redness, swelling, and warmth to foot and ankle complex.

– Patients that were treated elsewhere and had normal radiographs prior to presentation at our centers were also included in this study.

– 20 patients (22 feet)

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Methods

• We evaluated patients for progression to CN-related adverse events – Ulcer formation, infection,

progression into the active phase, and the need for surgical reconstruction.

– Group I, patients who did not progress to destructive CN, were compared to Group II, patients who did progress to destructive CN.

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Statistical Analysis

• All data are described as median ± standard deviation. • A Mann-Whitney non-parametric test was used to identify

any association between the two groups in terms of delayed treatment and clinical outcome.

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Results

• 20 patients (22 feet) referred by outside facilities

• Only 1 (5%) patient was properly diagnosed with stage 0 CN prior to referral

• Three (13.6%) had developed a foot ulcer prior referral

• Eleven (50%) ultimately required surgery.

• Outside diagnoses prior to referral

• Ankle sprain (6), cellulitis (4), osteomyletis (3), gout (3), septic arthritis (2), fracture (2), plantar fasciitis (2), venous thromboemboli (2), and complex regional pain syndrome (1).

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Results

• The median duration of follow-up was 21.7 months (23.6 ± 14.0).

• Active CN was eventually diagnosed in 15 of the 22 feet (68.2%).

• Group I had an average delay in treatment of 4.1 ± 0.7 weeks, while Group II had an average delay of 8.7 ± 6.8 weeks.

– Mann–Whitney U = 24.5, z = 1.94, n1 = 15, n2 = 7, P < 0.05

• Average time of progression from the onset of symptoms of stage 0 until active CN developed was 10.9 ± 7.5 weeks.

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Results

• Sixteen of the 22 (72%) feet developed a complication during treatment.

• In Group I, one patient (14.3%) developed a midfoot ulceration

• In Group II, ten of 15 feet (66.7%) developed other complications

– Mann–Whitney U = 25.0, z = 1.90, n1 = 15, n2 = 7, P < 0.05

• No patient required an amputation during our follow up period.

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Group I: Patients who did NOT progress to active CharcotGroup II: Patients who did progress to active Charcot

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Discussion

• A high index of suspicion is necessary to properly arrive at an early diagnosis.

• As illustrated in our series, a delay in diagnosis is significantly associated – with progression of Charcot neuroarthopathy into the

active destructive phase and an increased risk of complication.

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Discussion

• Limitations– Retrospective design

• Assessor bias – Non-standard treatment protocol

• Non responder bias• Small sample size

– No control group

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Conclusion

• In our study, patients with stage 0 Charcot who had a delay in diagnosis had a significantly higher rate of complication.

• The data from this study suggest that recognition and early management of stage 0 Charcot may reduce the rate of future complications.

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Take home

– $1.5 million settlement for failure to diagnosis Charcot foot

• Diabetic man alerted his physician of swollen feet

– Told he “would have to live with it.”

• Later, his podiatric physician diagnoses Charcot foot.

• Jury found in favor of the plaintiff.

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Thank you

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