Outcome nach operativer Intervention bei Charcot-Fuß-Deformität

Abstract

The diabetic neuropathic osteoarthropathy (DNOAP), named after the French neurologist, Jean-Martin Charcot, leads to severe deformities due to a non-infectious progressive destruction of the foot skeleton and upper ankle. The resulting deformities of the foot silhouette paired with a sensomotoric diabetic polyneuropathy (SDPNP) are predilection sites for the formation of ulcers and infections that can lead to minor and major amputations. Since the clinical picture can easily be confused with other pathologies, a delayed diagnosis and therapy initiation is often made. In addition, the decision for the indication of the surgical therapy is considerably difficult due to the lack of concerted recommendations. The present retrospective evaluation of the Tettnanger (city hospital in Germany) patient collective examines whether major amputations can be prevented by Charcot-stabilizing measures and whether these interventions can positively influence the ability to walk and optimize the quality of life. In order to investigate the therapeutic benefits of early-stage surgical measures, as advocated by some authors, postoperative outcomes are analyzed in patients with Eichenholtz stages 1 - 2 and stages 3 - 4. As a secondary question, the relationship between the intensity of polyneuropathic disease on the one hand and the grade of obesity based on the Body Mass Index (BMI) on the other hand and the need for surgical measures is investigated. Finally, the relationship between the expression of neuropathic disease and the degree of renal insufficiency in patients without diabetes is analyzed. 70 patients (17 women, 53 men) between 23 and 79 years (median = 62.5 years) were included. In 19 patients, surgery on both feet was necessary, so 89 surgical cases were analyzed. 51 patients with Diabetes mellitus (DM) type 1 and 6 patients with DM Type 2 presented a manifest polyneuropathy (PNP). 13 patients presented an idiopathic form of PNP. In 21 surgical cases there was an Eichenholtz stage 1-2 and in 68 cases a stage 3-4. Over a period of 30.5 months, the data was collected clinically and from the patient records by the author of the study as part of the regular outpatient or inpatient care. The statistical analysis was carried out retrospectively. In no case major amputation was necessary. Complete autonomy (Barthel Index = 100) was almost 76% and a selective need for help (Barthel Index = 85-95) was present in about 18.5% of patients. Only 5.7% of patients were in need of help in daily life. A resilient lower limb could be obtained in almost 98% and a walking distance > 50 m in about 93% of cases. No significant difference was found in the analysis of the postoperative outcome of patients with Eichenholtz stage 1 – 2 and stage 3 – 4. Similarly, no significant correlation could be found between the intensity of the PNP or the BMI and the need for surgical measures. Furthermore, there was no link between the degree of renal insufficiency and the intensity of PNP in people without diabetes. In conclusion, Charcot-stabilizing measures prevented major amputations in the patient collective studied and, for the most part, a high quality of life with a sufficient walking distance was achieved. A high BMI and a stronger form of the PNP did not have a significant influence on the type and number of operations. The studies also showed that there is no statistically significant difference in postoperative outcome in the Eichenholtz stage, which supports the indications for early surgical therapy.