SLR - October 2015 - Melissa Hurwitz
Reference: Wang Y, Zhou J, Yan F, Li G, Duan X, Pan H, He J. Comparison of Arthrodesis with Total Contact Casting for Midfoot Ulcerations Associated with Charcot Neuroarthropathy. Med Sci Monit. 2015 Jul 24; 21:2141-8.Scientific Literature Review
Reviewed By: Melissa Hurwitz, DPM
Residency Program: The Mount Sinai Hospital, Icahn School of Medicine, New York, NY.
Podiatric Relevance: Diabetic foot care is a major component of podiatric practices across the country. Although total contact casting is considered to be the gold standard for management, it can impede a patient’s functionality when utilized for extended periods of time. In addition, progression of the pathology in the setting of chronic ulcerations with severe deformity and instability often warrants surgical treatment. While medial column arthrodesis can be effective at realigning the patient’s joints, preventing ulcer formation and restoring stability, it also poses risks, which need to be taken into account for planning. This article provides insight into the decision making process for these patients by comparing the outcomes of patients treated concomitantly with total contact casting and medial column arthrodesis to those with total contact casting and conservative care alone.
Methods: Twenty-one patients with a fixed unilateral medial column deformity, radiographic evidence of arthropathy, and a limb threatening ulceration were included in this study. The only exclusion criteria in this group of patients were radiographic evidence of osteomyelitis. The subjects were randomly assigned to either receiving medial column arthrodesis with total contact casting or total contact casting alone for treatment. Both groups received ulcer debridement before treatment; with the surgical subjects receiving primary closure of the ulcer and the conservatively treated subjects receiving serial dressing changes every two days. Nerve conduction velocity as well as quantitative sensory tests was conducted two weeks before surgery, six months after and 12 months after surgery. Wound healing according to treatment was also measured throughout the study.
Results: Although there was no statistical difference between the healing times of the two treatment approaches, the rate of ulcer recurrence was higher for the group treated with total contact casting alone at a rate of 33.3 percent for 12 months. The use of arthrodesis with total contact casting resulted in no recurrences at 12 months. Also, tibial and peroneal nerve function, temperature, and vibratory perception were noted to be improved in the surgical group, with no change seen in the group treated with total contact casting alone.
Conclusions: These findings suggest that the combination of an extended medial column arthrodesis with total contact casting could possibly reduce the recurrence of Charcot neuro-arthropathy associated ulcerations by improving tibial and peroneal nerve function. Although the study does not refute the use of total contact casting alone, it suggests a better prognosis may be achieved when including a medial column arthrodesis. Limitations to this study include the small number of patients studied, which were from a single center and operated on by a single orthopedic surgeon. It is suggested that larger multicenter clinical trials be performed to ascertain a higher level of evidence to confirm the conclusions drawn from this study.