Long-term outcomes of diabetic neuro-osteoarthropathy treatment for the period from 2010 to 2014 in the diabetic foot department of the Scientific Research Center of the Federal State Budgetary Institution “NMRC of Endocrinology” of the Ministry of Health of the Russian Federation

Diabetic neuro-osteoarthropathy (DNOAP) is a progressive, degenerative process that is clinically manifested by inflammation, destruction and resorption of the bone tissue of the foot, leading to its deformation. With an increase in the life expectancy of patients with diabetes mellitus (DM), the incidence of DNOAP also increases. To date, the most effective method of treating patients with the acute stage of DNOAP is the individual relief dressing Total Contact Cast (TCC). Late and incomplete immobilization leads to pronounced deformity of the foot and the subsequent development of complications of DNOAP. In this case, surgical treatment is possible, the purpose of which is to create joint stability through arthrodesis and eliminate deformities (corrective osteotomy).

Objective. To evaluate the long-term results of surgical treatment of patients with DNOAP in the period from 2010 to 2014 in the amount of corrective osteotomy.

Materials and methods. From 2010 to 2014, 1.779 people with diabetes were treated in the diabetic foot department of the National Medical Research Center of Endocrinology of the Ministry of Health of the Russian Federation. Of these, 532 (30.0 %) people with duodenum. Based on the results of the examination, all patients were divided into the following groups: 53 (10.0 %) with acute stage of DNOAP (group 1), 266 (50.0 %) with subacute stage (group 2) and 213 (40.0 %) patients with chronic stage of DNOAP (group 3). To assess the degree of compensation of carbohydrate metabolism, the level of glycated hemoglobin (Hb_A1c) was determined by low-pressure liquid ion exchange chromatography on a Diastat analyzer (BioRad, USA) using a kit from the same manufacturer according to a unified methodology (norm up to 6.4 %). Infrared thermometry on the backs of the feet and ankles (electronic infrared thermometer DT-635, A&D Company Ltd., Japan) was performed as a diagnostic criterion for the acute stage of DNOAP and its monitoring. To assess the condition of the bone structures of the lower extremities in patients of groups 1, 2 and 3, digital radiography of the affected joints was performed in direct and lateral projections on the X-ray diagnostic complex Axiom Iconos R 200 (Siemens, Germany). MRI (GE SIGNA Pioneer magnetic resonance imaging) of the affected joints was performed as an additional diagnostic method for the acute stage of DNOAP. During the dynamic follow-up, all patients received a TCC once every 3–4 weeks and, if necessary, a replacement. The analysis of clinical data was performed using standard statistical processing methods using PC software: Microsoft Excel and Statistica 6.0.

Research results. In total, from 2010 to 2014, 532 people with DNOAP were treated, which accounted for 30.0 % of all patients treated in the department. Of these, there were 213 (40.0%) patients with type 1 diabetes and 319 (60.0 %) patients with type 2 diabetes. The state of carbohydrate metabolism was assessed by the level of glycated hemoglobin (Hb_A1c), which was 9.11 ± 1.6 % in group 1, 9.2 ± 1.53 % in group 2, and 7.2 ± 1.9 % in group 3 (M ± SD). A history of ulcerative foot defects was noted in 3 (5.7 %) patients of group 1, 85 (32.0 %) patients of group 2, and 194 (91.0 %) people of group 3. Ulcers were significantly more common in the group of patients with chronic stage DNOAP compared with groups 1 and 2 (p < 0.05). Various foot amputations in the anamnesis occurred in 6 (11.3 %) patients of group 1, in 101 (38.0 %) patients of group 2 and in 100 (47.0 %) patients of group 3. Patients in group 3 were significantly more likely to undergo amputations (p < 0.01). In the course of dynamic follow-up of patients in group 1 (n = 53), 85.0 % (n = 45) of patients managed to achieve remission within an average of 7 months after unloading the affected limb with the help of TCC. In 15.0 % (n = 8) patients, the transition to the subacute stage was diagnosed. In group 2 (n = 266), 92.0 % (n = 245) of patients achieved stabilization of the bone tissue of the affected joints while wearing TCC for an average of 11 months. 8.0 % of patients (n = 21) underwent surgical treatment (corrective osteotomy). In the 3rd group of patients (n = 213), 85.0 % (n = 180) are under dynamic observation, 15.0 % (n = 33) also underwent corrective osteotomy, after which the patients wore TCC for 12–16 months. A total of 54 patients (n = 54) underwent surgery for Charcot’s foot during this period. After surgical treatment, 44.4 % of patients (n = 24) wear complex orthopedic shoes (including at home), 5.6% (n = 3) have orthoses, and 50.0 % (n = 27) continue to wear CPR. Of these, 24.1 % (n = 13) had complications in the form of ulcerative defects of the affected foot, 20.4 % (n = 11), amputation at the border of the upper and middle third of the tibia in 1.9 % (n = 1) and death of 1.9 % (n = 1) from cardiovascular complications. No data have been obtained for the recurrence of DNOAP in the operated patients. 306 patients with DNOAP continued to be dynamically monitored, which accounted for 58.0 % of all patients with DNOAP. Of these, 56.0 % (n = 172) had complications in the form of ulcerative defects of the affected foot – 37.3 % (n = 114), amputations within the foot – 14.4 % (n = 44) and 0.3 % (n = 1) death from cancer. Recurrence of DNOAP developed in 4.2 % of patients (n = 13).

Conclusion. Due to the lack of up-to-date data on the prevalence of DNOAP and its high incidence among patients with DM, further epidemiological studies are needed. DNOAP requires a multidisciplinary approach in diagnosis and treatment, followed by dynamic monitoring of this category of patients. The surgical method of treatment in the amount of corrective osteotomy is preventive and relieves the patient from points of excessive pressure on the plantar surface of the foot. The development and widespread implementation of orthopedic care for this category of patients is of particular importance.

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