Foot & Ankle International - July 2018 - 810

810

Foot & Ankle International 39(7)

Table 1. Change in Short Musculoskeletal Functional Assessment Domains at 1 Year Following Surgical Correction of Charcot Foot
Deformity.a
Functional
Functional
Bother

Bother

Daily Activity

Emotion

Arm/Hand

Mobility

0.8 (<.0001)

0.9 (<.0001)

0.7 (<.0001)

0.6 (.0008)

0.9 (<.0001)

0.7 (.0002)

0.6 (.0043)

0.7 (.0003)

0.5 (.0201)

0.3 (.1088)

0.7 (<.0001)

0.5 (.0282)

0.7 (.0004)

Daily activity
Emotion
Arm/hand

0.5 (.0307)

N = 24 for all pairwise associations. Pearson partial correlation coefficients (r) are tabled with their significance (P) in parentheses.

decrease in the standardized emotion index (P = .004). There
was no meaningful change in the standardized arm/hand
index nor in the mobility index. The nonparametric sensitivity analyses revealed the same conclusions (Table 1).

Discussion
Several investigations using validated outcome instruments
have demonstrated that the historical accommodative treatment of the acquired deformity from diabetes-associated
Charcot foot arthropathy is not successful in reversing the
negative effects attributed to the disease process.3,5,8,11 This
appreciation has been the impetus for the current interest in
operative correction of the acquired deformity in this complex patient population. This is despite the substantial risk for
preoperative morbidity due to the high rate of medical comorbidities in this patient population. Surgeons believe that correction of the deformity will free these often morbidly obese
patients from having to use cumbersome custom accommodative orthotic devices used to allow safe walking.12
While the historic method of treatment has not been successful in reversing the negative effects on quality of life,
most reports of operative correction have not addressed
either functional or quality-of-life goals.12,15 We have
recently demonstrated that correction of the most common
midtarsal deformity appears to allow most patients to
resume safe walking with commercially available therapeutic footwear.10 This metric, much like the historical metric
of simple resolution of infection and limb salvage, must be
correlated with patient-reported outcomes methodology to
justify subjecting this complex, highly comorbid patient
population to the risks associated with surgery. Our results
would suggest that successful correction of the acquired
deformity of diabetes-associated Charcot foot arthropathy
is likely to substantially reverse the negative impact of the
disease process on quality of life.
This strength of this investigation, as well as the limitation, is the subjective nature of the patient-reported outcomes
methodology. It is hoped that the instrument that we selected
was sufficiently discriminative, and the power sufficiently

adequate, to address the issues in question. We did not do a
power analysis, arbitrarily selecting 25 consecutive patients.
We purposely chose to study the specific patient population
with isolated midtarsal deformity, as this is the most common
deformity pattern in this patient population and the most
likely to present for elective operative correction of deformity. The association of improved quality of life with correction of acquired deformity also provides credence for further
study in more complex deformities where the tibiotalar joint
is involved. This is a very complex patient population with
multiple medical comorbidities. Surgery subjects these individuals to substantial perioperative risk.4,12,17 This type of
information should be beneficial for both surgeons and
patients when addressing the risk-benefit ratio for elective
correction of these complex structural deformities in this
highly comorbid patient population.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
ICMJE forms for all authors are available online.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Michael S. Pinzur, MD,

https://orcid.org/0000-0003-4856-9792

Supplemental Material
A supplementary video is available online with this article.

References
1. Bevan WP, Tomlinson MP. Radiographic measure as a predictor of ulcer formation in diabetic Charcot midfoot. Foot
Ankle Int. 2008;29(6):568-573.
2. Brodsky J, Wagner FWW, Kwong P. Patterns of breakdown
in the Charcot tarsus of diabetes and relation to treatment.
Foot Ankle. 1986;6(5):353.

https://www.orcid.org/0000-0003-4856-9792

Table of Contents for the Digital Edition of Foot & Ankle International - July 2018