Charcot Arthropathy Risk Elevation in the Obese Diabetic Population

doi:10.1016/j.amjmed.2008.06.038

The American Journal of Medicine

Volume 121, Issue 11, November 2008, Pages 1008-1014

https://doi.org/10.1016/j.amjmed.2008.06.038 Get rights and content

Abstract

Purpose

To examine the association of obesity, peripheral neuropathy, and other risk factors with the Charcot arthropathy incidence rate in a large diabetic population.

Methods

The Department of Veterans Affairs inpatient and outpatient administrative datasets were used to identify persons with diabetes in 2003. Logistic regressions were used to model the likelihood of a person developing Charcot arthropathy as a function of individual characteristics, obesity, peripheral neuropathy, diabetic control, and comorbidities.

Results

Of Veterans Affairs users with diabetes, 652 (0.12%) were newly diagnosed with Charcot arthropathy in 2003. Compared with persons without obesity or peripheral neuropathy, those with obesity alone were approximately 59% more likely, those with neuropathy alone were 14 times more likely, and those with both obesity and neuropathy were 21 times more likely to develop Charcot arthropathy. Ages 55 to 64 years, diabetes duration 6 years or more, hemoglobin-A1c 7% or more, renal failure, arthritis, and deficiency anemia also were associated with an increased incidence of Charcot arthropathy.

Conclusion

Obesity is significantly associated with an increased incidence of Charcot arthropathy independently of other risk factors. When obesity is combined with neuropathy, the Charcot arthropathy incidence rate increases multiplicatively. Prevention and detection of Charcot arthropathy should take the interaction between obesity and neuropathy into consideration.

Section snippets

Data and Study Sample

The Institutional Review Board at the Edward Hines Jr VA Hospital approved the study, including a Health Insurance Portability and Accountability Act waiver of authorization.

We used the Department of Veterans Affairs (VA) inpatient and outpatient datasets¹⁶ for the fiscal year 2003 (October of 2002 to September of 2003; all years henceforth are fiscal years) to identify patients in the study sample and those with Charcot arthropathy. These datasets contain administrative records of all

Results

The study sample consisted of 561,597 persons who had diabetes and had height and weight measured at least once in 2003. A total of 652 persons in the sample were newly diagnosed with Charcot arthropathy in 2003 with an incidence rate of 1.2 per 1000 persons. Its incidence rates were highest among those aged 55 to 64 years (1.9/1000) and decreased as patients became older, with those 65 years or older having an incidence rate less than 1.0 per 1000 patients (Table 1). Married persons had lower

Discussion

This study shows that obesity is significantly associated with an increased incidence of Charcot arthropathy and that its association is amplified in the presence of peripheral neuropathy. When obesity was present along with neuropathy, the risk of developing Charcot arthropathy increased more than would be expected from the sum of independent effects of these conditions in isolation. For example, obesity alone increased its incidence rates by 59% and neuropathy alone increased its incidence

Limitations

This study has several limitations. First, we did not have access to non-VA data, notably Medicare data for elderly veterans. To evaluate methodological robustness in identifying diabetics among VA users, we compared the VA diabetes prevalence with the estimated prevalence from the 2003 Behavioral Risk Factor Surveillance System, a large survey database on a sample representative of the US population that included questions about VA user status and whether the respondent had diabetes. We found

Conclusions

We have shown that obesity is an independent and significant risk factor for Charcot arthropathy. The obese diabetic patient with coexisting peripheral neuropathy is particularly at high risk for developing Charcot arthropathy. These patients need to be provided with increased vigilance in the assessment of lower-extremity injuries. Annual foot screening, special scrutiny, and education need to be provided to patients with multiple risk factors. Once screening has identified elevated risks,

Acknowledgments

We thank Jack Bates of the VHA Corporate Data Warehouse, for providing height and weight data for the study sample, and Lishan Cao and Huiyuan Zhang, for programming support. The corresponding author had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

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2022, The Essentials of Charcot Neuroarthropathy: Biomechanics, Pathophysiology, and MRI Findings
In this chapter, the readers find a comprehensive review of the worldwide epidemiology of diabetes mellitus type 2 (DMT2). The latest epidemiological data collected from different primary literature sources across the globe regarding DMT2 and Charcot neuroarthropathy are presented in a didactic manner. The epidemiology of diabetes-induced Charcot neuroarthropathy with emphasis on demographics is revisited. There is a broad analysis of the socioeconomic consequences of DMT2 and Charcot neuroarthropathy in industrialized and developing countries. The psychological consequences of DMT2 and Charcot neuroarthropathy are reviewed. Relevant data on morbidity and mortality of Charcot neuroarthropathy worldwide are included in this chapter.
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This chapter presents an in-depth analysis of the pathophysiology of diabetes. The diabetes-induced peripheral neuropathy is discussed with its manifestations. The concepts of symmetrical and asymmetrical peripheral neuropathy are also discussed. The metabolic syndrome and its definition and clinical characteristics are largely discussed. The pathogenesis and prevalence of Charcot neuroarthropathy in diabetic patients are revisited. Many conditions that influence the advent of Charcot are reviewed in this chapter. The frequent complications associated with Charcot neuroarthropathy seen in radiology are illustrated with MR images. Some nondiabetic conditions producing Charcot neuroarthropathy are briefly reviewed at the end of the chapter.
Treatment Failures in Diabetic Foot Osteomyelitis Associated with Concomitant Charcot Arthropathy: The Role of Underlying Arteriopathy
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Citation Excerpt :
The major factors leading to DFO are long-standing peripheral neuropathy and foot ulcers, with or without co-existent angiopathy. In contrast, CN is relatively rare, with an incidence in people with diabetes of 0.1–0.3%, but it too can be limb threatening (Fabrin et al., 2000; Gratwohl et al., 2021; Rajbhandari et al., 2002; Stuck et al., 2008). CN virtually always occurs in patients with peripheral neuropathy, but usually in the absence of severe peripheral arterial disease (Boulton and Whitehouse, 2000).
Therapy for diabetic foot osteomyelitis (DFO) with Charcot neuroosteoarthropathy is challenging. In patients with diabetic Charcot osteomyelitis (DCO), both the anatomic deformity and infection must be addressed. This study assessed the outcomes of DCO therapy and variables associated with treatment failure and compared them with outcomes of DFO cases.
A single-center, retrospective, case-control study was performed to compare 93 DCO episodes with 530 DFO episodes, using Kaplan-Meier survival curves and multivariate Cox regression analyses.
Clinical failure occurred in 21.5% of DCO compared with 22.3% in DFO episodes (p=0.89) and was associated with peripheral arterial disease (PAD) stages 3 or 4 (HR 6.1; CI 2.0-18.1) and chronic treatment with immunosuppressives (HR 7.4; CI 2.0-27.1). Major amputations were significantly more frequent in DCO (28% versus 13.6%; p<0.01) and associated with PAD stages 3 and 4 (HR 8.0; CI 2.2-29.4), smoking (HR 5.4; CI 1.2-24.6), alcohol abuse (HR 3.5; CI 1.1-10.6), and renal dialysis (HR 4.9; CI 1.3-18.9).
Clinical treatment failures did not differ between DCO and DFO. However, patients with DCO underwent major amputation twice as often as those with DFO. Unlike widespread belief, treatment failure in DCO patients may, similar to DFO, be associated with a striking epidemiological link to severe PAD.
The current burden of diabetic foot disease
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Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden.
Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%.
Infection develops in 50%–60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers.
Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.

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: Financial support was received from the Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, Illinois (LIP 42-512; Elly Budiman-Mak, MD, Principal Investigator). The article presents the findings and conclusions of the authors; it does not necessarily represent the Department of Veterans Affairs or Health Services Research and Development Service. The authors have no financial or personal conflict of interest to declare.

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Clinical research studyCharcot Arthropathy Risk Elevation in the Obese Diabetic Population

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Data and Study Sample

Results

Discussion

Limitations

Conclusions

Acknowledgments

Clin Podiatr Med Surg

Am J Prev Med

Diabetes Metab

The Charcot foot

Diabet Med

Charcot neuroarthropathy in diabetes mellitus

Diabetologia

The diabetic foot: Charcot joint and osteomyelitis

Nucl Med Commun

Health-related quality of life in patients with Charcot foot

Am J Orthop

Charcot foot

Long-term follow-up in diabetic Charcot feet with spontaneous onset

Diabetes Care

Charcot foot in diabetes: farewell to the neurotrophic theory

Horm Metab Res

Abnormalities of vasomotor regulation in the pathogenesis of the acute Charcot foot of diabetes mellitus

Int J Low Extrem Wounds

Normal and Abnormal Function of the Foot: Clinical Biomechanics

Basic Biomechnics of the Musculoskeletal System

Biomechanics of the foot in diabetes mellitus

The diabetic foot: from art to scienceThe 18th Camillo Golgi lecture

Diabetologia

Clinical research study
Charcot Arthropathy Risk Elevation in the Obese Diabetic Population