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A Closer Look At Trends In The Research On Charcot Neuroarthropathy And Podiatric Implications

Charcot neuroarthropathy is an important diagnosis in contemporary medical practice with respect to early recognition, health-care resource utilization and patient function, morbidity and mortality. Although there is a clear interest in and association of this condition with foot and ankle specialists, Charcot neuroarthropathy represents a multidisciplinary diagnosis. Primary care physicians, endocrinologists, neurologists, radiologists, vascular surgeons, wound care specialists, hospital administrators and emergency medicine physicians all contribute to the diagnosis and treatment of this disease process. 

For foot and ankle specialists, there are many relevant facets to this condition including: the development of differential diagnoses utilizing both clinical and radiographic parameters; an understanding of the natural course and progression of deformity development; the underlying pathogenesis of the process; the effect of early intervention on outcome; medical versus surgical decision making; and, unquestionably of late, specific surgical techniques and available fixation options as they relate to reconstruction and functional limb salvage.1-4 

What The Literature Reveals About Quality Of Life In Patients With Charcot Neuroarthropathy 

One must also consider the entire patient in addition to the affected limb. Utilizing a variety of outcome measures (including the Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36, American Association of Orthopaedic Surgeons (AAOS) outcomes instrument and American Orthopaedic Foot and Ankle Society (AOFAS) score), several recent investigations have demonstrated that patients with Charcot neuroarthropathy have a relatively low quality of life at baseline in comparison to the general population.5-7 

Other researchers have performed a comparison between subsets of patients with varying comorbidities. For example, patients with Charcot neuroarthropathy reportedly have a lower quality of life than patients with diabetes and no pedal problems.5-7 However, these studies found no significant quality of life differences between those with Charcot neuroarthropathy and foot ulcerations and those with Charcot neuroarthropathy but no foot ulcerations. 

Other studies looked at Charcot neuroarthropathy more broadly in terms of expectations. Wukich and colleagues found that patients with Charcot neuroarthropathy feared amputation even more than facing the possibilities of dialysis, infection and even death.8 Amputation represents a valid and major concern in these patients. Saltzman and team observed a 31 percent major amputation rate in a cohort of patients with Charcot neuroarthropathy who were treated non-surgically and suffered from a recurrent ulceration.9 Further, in a retrospective review of over 1,000 patients with Charcot neuroarthropathy, Sohn and colleagues found a 28.3 percent five-year mortality rate with 63 percent of patients experiencing a foot ulceration.10 Pakarinen and coworkers also found a relatively high mortality rate (29 percent) at a mean follow-up of eight years.11 

Identifying Historical Trends In The Literature On Charcot Neuroarthropathy 

It is interesting to consider how many different facets of the disease process a foot and ankle specialist needs to be aware of in order to effectively treat these patients from start to finish. With this in mind, we recently performed a bibliometric inquiry into peer-reviewed publishing patterns related to Charcot neuroarthropathy, specifically as it relates to what podiatric physicians should be critically reading. To evaluate this, we performed a PubMed search with relevant search terms [(“Charcot” or “diabetes” or “diabetic” or “neuropathic”) and (“neuropathy” or “neuroarthropathy” or “osteopathy” or “fracture”)] and five-year date range blocks of publication starting with January 1, 1969 and ending December 31, 2018 (i.e. the first date range block was from January 1, 1969 to December 31, 1973). 

We then reviewed and judged the article abstracts from the search as to whether the article was “relevant to a podiatric professional working with Charcot neuroarthropathy.” The term relevant is obviously a relatively broad designation but this was our intention. We made an attempt to be relatively open-minded with respect to our definition of article relevance and to include (as opposed to excluding) potential studies. A basic definition of article relevance was any article that had the possibility of being beneficial or improving patient care with respect to lower extremity Charcot neuroarthropathy for a podiatric physician. We did exclude case reports from our analysis. Our team further categorized the included articles into the geographic area of publication and whether the article presented a surgical or more medical focus. 

First, we found that the total number of peer-reviewed publications related to Charcot neuroarthropathy appeared to exponentially increase from the 1969 to 1973 time block to the 2014 to 2018 time period (see the chart above). What started out as a single relevant article in the 1969 to 1973 block gradually increased to a maximum of 87 relevant articles in the 2009 to 2013 block. However, a slight decrease occurred in the 2014 to 2018 time period in comparison to the 2009 to 2013 block (87 versus 80 relevant articles), perhaps indicating the start of a potential plateau of relevant published pieces. It is too early to tell this, however, and time will reveal how publishing patterns continue through the end of this decade and into the future. 

Second, we found that the first surgically-themed relevant publications did not occur until the 1989 to 1993 time period and similarly increased to an apparent plateau, peaking during the 2009 to 2013 time block. Although the percentage of surgically themed articles appeared to gradually increase over time, there were more medically-themed articles than surgically-themed articles within each five-year block where surgically-themed articles appeared. 

Third, we found that 44.2 percent of relevant articles originated from the United States while the remainder were of international origin. Of the 44.2 percent originating from the U.S., we further found that 35.9 percent originated from the Northeast, 28.1 percent originated from the Midwest, 25.8 percent originated from the South and 10.2 percent originated from the West when considering the reported location of the corresponding author. 

Final Notes 

The results of this brief investigation provide some preliminary objective evidence as to publishing patterns as they relate to the diagnosis of Charcot neuroarthropathy and specifically as they relate to time, frequency and geographic location of published articles that we 

found relevant to podiatric physicians. It is clear that those physicians who see and treat Charcot neuroarthropathy have a lot of critical reading to do in order to stay abreast of the contemporary medical literature. Avenues of future investigation might additionally include how articles detailing the surgical reconstruction of lower extremity Charcot neuroarthropathy relate to the overall scientific picture as well as the intended audiences for specific published articles with respect to medical subspecialty and journal of publication. 

Dr. Dougherty is a third-year resident at the Temple University Hospital Podiatric Surgical Residency Program in Philadelphia. 

Dr. Kwaadu is a Clinical Assistant Professor in the Department of Podiatric Surgery at Temple University School of Podiatric Medicine in Philadelphia. 

Dr. Meyr is a Clinical Professor in the Department of Podiatric Surgery at Temple University School of Podiatric Medicine in Philadelphia. 

Diabetes Watch
By Matthew Dougherty, DPM, Kwasi Y. Kwaadu, DPM, FACFAS and Andrew J. Meyr, DPM, FACFAS

1. Sanders LE, Frykberg RG, Rogers LC. The diabetic Charcot foot: recognition, evaluation, and management. In: Armstrong DG, Lavery LA, eds. Clinical Care of the Diabetic Foot. 2nd ed. Alexandria, Va.: American Diabetes Association; 2010: 79-96. 

2. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129. 

3. Schneekloth BJ, Lowery NJ, Wukich DK. Charcot neuroarthropathy in patients with diabetes: an updated systematic review of surgical management. J Foot Ankle Surg. 2016;55(3):586-590. 

4. Petrova NL, Edmonds ME. Medical management of Charcot arthropathy. Diabetes Obes Metab. 2013;15(3):193-197. 

5. Sochocki MP, Verity S, Atherton PJ, et al. Health related quality of life in patients with Charcot arthropathy of the foot and ankle. Foot Ankle Surg. 2008;14(1):11-15. 

6. Raspovic KM, Wukich DK. Self-reported quality of life in patients with diabetes: a comparison of patients with and without Charcot neuroarthropathy. Foot Ankle Int. 2014;35(3):195-200. 

7. Raspovic KM, Hobizal KB, Rosario BL, Wukich DK. Midfoot Charcot neuroarthropathy in patients with diabetes: the impact of foot ulceration on self-reported quality of life. Foot Ankle Spec. 2015;8(4):255-259. 

8. Wukich DK, Raspovic KM, Suder NC. Patients with diabetic foot disease fear major lower-extremity amputation more than death. Foot Ankle Spec. 2018;11(1):17-21. 

9. Saltzman CL, Hagy ML, Zimmerman B, Estin M, Cooper R. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet? Clin Orthop Relat Res. 2005;435:185-190. 

10. Sohn MW, Lee TA, Stuck RM, Frykberg RG, Budiman-Mak E. Mortality risk of Charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone. Diabetes Care. 2009;32(5):816-821. 

11. Pakarinen TK, Laine HJ, Maenpaa H, Mattila P, Lahtela J. Long-term outcome and quality of life in patients with Charcot foot. Foot Ankle Surg. 2009;15(4):187-191.

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