Trauma and Orthopaedics Department, Sheffield Teaching Hospitals NHS Trust, Herries Rd, Sheffield S5 7AU, UK; Academic Unit of Bone Metabolism, The University of Sheffield, Sheffield S10 2RX, UK.
Trauma and Orthopaedics Department, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Ln, Warrington WA5 1QG, UK.
Foot Ankle Surg. 2021 Aug;27(6):673-676. doi: 10.1016/j.fas.2020.08.012. Epub 2020 Oct 11.
Charcot Neuro-arthropathy (CN) can occur spontaneously in a neuropathic foot but is often precipitated by an insult to the foot, such as trauma. We noted an association between 1st and 5th ray amputations and the development of midfoot CN in our clinics. We therefore set out to analyse our data over a 6-year period to evaluate and improve our practice.
Our project encompassed all diabetic adults with peripheral neuropathy undergoing an amputation of the first or fifth ray between January 2013 and January 2019. Patient demographics, stump length, progression to CN, imaging reports, the need for further operative management, length of stay and operating specialty were collected. Cases that developed CN after 1st or 5th ray amputation ("CN group") were compared with a cohort composed of patients that did not ("non-CN group").
We identified 92 patients (98 surgical episodes) who had previous 1st or 5th ray amputations [77 males (83.7%), 15 females (16.3%), mean age 61.5 ± 13.5]. Midfoot CN developed in 16 cases (17.4%; nine following 1st ray and seven following 5th ray amputation). This represented 30.9% of all our new CN cases. CN was diagnosed within six months in six cases and up to three years in the remaining 12. Five of the 1st ray amputations were conducted with a stump length of ≤10 mm from the tarsometatarsal joint and a further one had resorbed down to it before the Charcot process. Three of the 5th ray amputations were carried out leaving a stump length ≤25 mm. Receiver Operator Curve (ROC) analysis showed no obvious diagnostic value of stump length in predicting CN (area under the curve 0.42 (95% CI 0.26 - 0.59)). Following a logistic regression analysis into effect of age, gender and peripheral vascular disease, only age was found to significantly affect the risk of developing CN (Nagelkerke R = 0.122, p = 0.013).
This is the first report of midfoot CN developing after 1st or 5th ray amputations. The foot could be destabilised following these procedures, leading to increased pressures across the midfoot. Our small sample was unable to demonstrate a significant correlation between stump length and CN risk. However, more work is needed to ascertain this. Meanwhile, we believe this translates clinically into a need for enhanced foot protection following 1st and 5th ray amputations in our practice.
夏科氏关节病（CN）可在神经病变的足部自发发生，但通常由足部创伤等刺激引发。我们注意到第一和第五跖骨截肢与中足 CN 的发展之间存在关联。因此，我们着手分析我们在 6 年期间的数据，以评估和改进我们的实践。
我们的项目涵盖了所有因周围神经病变而接受第一或第五跖骨截肢的成年糖尿病患者，时间为 2013 年 1 月至 2019 年 1 月。收集患者的人口统计学数据、残端长度、CN 进展情况、影像学报告、进一步手术管理的需要、住院时间和手术专业。与未发生 CN 的患者（非 CN 组）相比，比较发生第一或第五跖骨截肢后发生 CN 的病例（“CN 组”）。
我们确定了 92 名患者（98 例手术）先前接受过第一或第五跖骨截肢[77 名男性（83.7%），15 名女性（16.3%），平均年龄 61.5 ± 13.5]。16 例发生中足 CN（17.4%；9 例为第一跖骨截肢，7 例为第五跖骨截肢）。这占我们所有新 CN 病例的 30.9%。6 例 CN 在 6 个月内确诊，12 例在其余时间确诊。第一跖骨截肢中有 5 例残端长度距跖跗关节≤10 毫米，进一步有 1 例残端吸收至跖跗关节。5 例第五跖骨截肢中有 3 例残端长度≤25 毫米。受试者工作特征曲线（ROC）分析显示，残端长度对预测 CN 无明显诊断价值（曲线下面积 0.42（95%CI 0.26-0.59））。对年龄、性别和外周血管疾病对 CN 影响的逻辑回归分析后，只有年龄显著影响 CN 的发病风险（Nagelkerke R = 0.122，p = 0.013）。
这是第一份报告，表明第一或第五跖骨截肢后会发生中足 CN。这些手术后，足部可能会不稳定，导致中足压力增加。我们的小样本无法证明残端长度与 CN 风险之间存在显著相关性。然而，还需要进一步的工作来确定这一点。同时，我们认为这在临床上意味着需要加强第一和第五跖骨截肢后的足部保护。
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