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Table 2 Summary of included articles and other documents: level of evidence, relevant themes and information contained within each article that addressed the research question under the contexts of assessment, diagnosis and management

From: Factors impacting the evidence-based assessment, diagnosis and management of Acute Charcot Neuroarthropathy: a systematic review

Author(s) Study Design/Country Level of Evidence Themes Assessment Diagnosis Management
Blume et al., 2014 [14]. Literature review/United States of America EO Health Organisation
Health Professional
Health professional knowledge to recognise symptoms of CN Health professional knowledge to utilise the appropriate pathology and imaging to diagnose CN. Resource limitation leads to more use of x-ray Health professional knowledge to utilise and apply the appropriate form of offloading
Bullen et al,. 2018 [15]. Delphi/
Scotland
EO Individual
Health Professional
Health professional knowledge to appropriately prepare individuals for the potential onset of CN Nil Health professional capacity to educate the patient to understand importance of offloading. Literacy capacity of individual
Chantelau, 2005 [16]. Case Controlled study/ Germany III-2 Health Professional Health professional knowledge to recognise symptoms of CN Delayed diagnosis. Health professional knowledge and confusion as to the appropriate form of imaging to use, Knowledge limitation leads to more use of x-ray Delayed diagnosis leads to delayed treatment such as offloading
Chantelau et al., 2007 [17]. Case Series/ Germany IV Individual
Health professional
Early symptoms such as deep dull aches often unrecognised by patient leading to delayed presentation. Health professional knowledge to recognise symptoms of CN Health professional knowledge and confusion as to the appropriate form of imaging to use Delayed diagnosis leads to delayed treatment. Health professional knowledge of utilizing the appropriate form of offloading impacts treatment duration
Chantelau et al., 2013 [18]. Retrospective Cohort study/ Germany IV Individual
Health Professional
Early symptoms such as deep dull aches often unrecognised by patient Delayed diagnosis. Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more use of x-ray Delayed diagnosis leads to delayed treatment. Health professional knowledge as to when to transition patient between various forms of offloading.
DiDomenico et al., 2018 [19]. Literature review/
United States of America
EO Individual
Health Professional
Underlying comorbidities of the individual patient such as diabetes and obesity has an impact on implementation of best practice Nil Complex condition requiring complete lifestyle modification
Dixon et al., 2017 [20]. Retrospective case series/
New Zealand
IV Individual
Health Professional
Early symptoms such as deep dull aches often unrecognised by patient leading to delayed presentation (17 weeks). Health professional knowledge (GP) to recognise symptoms of CN and refer appropriate service Delayed diagnosis. Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more under utilization of MRI Health professional knowledge of when to transition patients to footwear
Farid et al., 2008 [2]. Case Study/
United States of America
IV Individual
Health Professional
Underlying comorbidities of the individual patient such as diabetes and obesity has an impact on implementation of best practice Nil Health professional limited experience in appropriately being able to apply TCCs. Health professional ability to properly explain the treatment regimen to individual. Individual compliance with lack of understanding of the complexities of treatment of CN
Frykberg et al., 2012 [5]. Round Table Discussion/
United States of America
EO Individual
Health Professional
Underlying comorbidities of the individual patient such as diabetes, obesity has an impact on implementation of best practice Nil Health professional confusion as to which surgical procedure to use. Concern regarding informed consent, litigation and compliance with treatment protocols
Gil et al., 2013 [21]. Case Controlled study/
United States of America
III-2 Individual Nil Nil Health professional confusion as to which surgical procedure to use. Concern regarding informed consent, litigation and compliance with treatment protocols
Gooday et al.,
2020 [22].
Systematic Review/
United Kingdom
EO Health professional Nil Nil Health professional monitoring techniques inconsistent.
Jansen et al., 2016 [23]. Qualitative, Survey/
Denmark
IV Health Professional Health professional knowledge to recognise symptoms of CN Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more use of x-ray Health professional monitoring techniques inconsistent. Health professional limited experience in appropriately being able to apply TCCs
Jeffcoate, 2015 [24]. Literature review/
United Kingdom
EO Individual
Health Professional
Early symptoms such as deep dull aches often unrecognised by patient leading to delayed presentation. Health professional knowledge to recognise symptoms of CN Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more use of x-ray Health professional limited experience in appropriately being able to apply TCCs. Inconsistent treatment protocols and lack of agreed outcome measures
Loupa et al., 2019 [25]. Case study/
Greece
IV Individual
Health Professional
Health professional misdiagnosis and delayed diagnosis, lack of awareness Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more use of x-ray Delayed treatment as a result of delayed diagnosis. Individual compliance through treatment process impacted success
McIntyre et al., 2007 [26]. Retrospective audit - case control study. Qualitative structured interviews/ Canada IV Environment
Individual
Cultural environment and proximity to services. Aboriginal patients younger, less education, employment, greater burden of disease, financial disadvantage, less patient understanding of their condition Nil Nil
Metcalf et al.,
2018 [27].
Retrospective audit - case control study/
United Kingdom
IV Health Professional Health professional knowledge to recognise symptoms of CN and refer appropriate service Nil Nil
Milne et al., 2013 [6]. Systematic review/ Australia EO Health Organisation
Environment
Individual
Health Professional
Health professionals require a high index of clinical suspicion otherwise mis/delayed diagnosis occurs. Critical gap in education of the community and health professional knowledge of CN and prompt referral to a multidisciplinary clinic Health professional knowledge to utilise the appropriate pathology and imaging to diagnose CN. Resource limitation leads to more use of x-ray Management driven by expert consensus rather than rigorous evidence-based practice. Health professional expertise in the application of TCC critical and resource intensive. Variability in the advice provided by health professionals regarding protected weightbearing. Adherence of patients to the use of removable cast walkers variable. Geographical location is a consideration in the treatment of CN
O'Loughlin et al., 2017 [28]. Retrospective audit - case series/
Ireland
III-2 Health Professional Health professional knowledge of CN results in mis/delayed diagnosis. Patient presentation not timely and the urgent nature of condition not clear when they experience symptoms. There is an underrepresentation of CN in the community. Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more use of x-ray Health professional knowledge gap leads to delayed treatment. More frequent ulceration in the context of acute CN with removable cast walkers than non-removable cast walkers. Outcomes better with non-removable cast walkers. Significant health burden once ulcer occurs
Pakarinen wt al., 2009 [29]. Cross Sectional study/
Finland
III-2 Individual Nil Diagnosis made within three months associated with better patient physical and social outcomes. Social functioning and physical condition of the patient decreases with non-surgical treatment
Perrin et al., 2010 [30]. Case Study/
Australia
IV Health Professional Health professional misdiagnosis and delayed diagnosis, lack of awareness Health professional knowledge and confusion as to the appropriate form of imaging to use. Knowledge limitation leads to more use of x-ray Delayed treatment as a result of delayed diagnosis Early implementation of offloading of TCC would have been more ideal
Petrova et al., 2017 [31]. Literature review/
United Kingdom
EO UK/Kings College NHS Trust Foundation Health professionals high index of suspicion necessary. Nil Health professional limited experience in appropriately being able to apply TCCs. Inconsistent treatment protocols
Rettedal et al., 2018 [32]. Retrospective audit - case series/
United States of America
IV Individual
Health Professional
Nil Nil Anatomic location of CN and patient medical factors such as glycated haemoglobin, nutrition can determine outcome of surgical reconstruction, patient psychosocial factors and family support
Robinson et al., 2015 [33]. Literature review and case review/
United States of America
EO Individual Nil Nil Patient education and clinician understanding of clinical parameters underpinning CN management imperative and could increase compliance
Sanders, 2008 [34]. Literature review/
United States of America
EO Health professional Health professional observation is paramount, high level of clinical suspicion necessary, recognition of acute CN is variable Nil Health professional confusion as to which surgical procedure to use. Concern regarding informed consent, litigation and compliance with treatment protocols
Schmidt et al., 2017 [7]. Survey/
United States of America
IV Individual
Health Professional
Health professional poor knowledge leads to misdiagnosis Early stages of the condition not recognised by the patient as they are neuropathic resulting in referral delay Ambiguous diagnosis criteria means actual incidence and prevalence may not be known Nil
Schmidt et al.,
2018 [35]
Literature review/
United States of America
EO Individual
Health Professional
Health professionals must rely on clinical judgement. Health professional poor knowledge leads to misdiagnosis. Non-specific clinical findings. Patient unable to detect symptoms Ambiguous diagnostic criteria Nil
Schmidt et al.,
2019 [36]
Observational Cohort study/
United States of America
III-2 Health Professional Health professional poor knowledge leads to misdiagnosis Nil Primary outcomes improved with dedicated specialist care. Improved patient education and compliance improves outcomes.
Sinacore et al., 1999 [37]. Literature review/
United States of America
EO Individual
Health professional
Patients delay in seeking assessment/management, identification and appropriate referral by clinicians. Patient understanding of acute CN a risk factor Nil No clear indicators of when a patient can transition between the varies stages of restricted mobilisation, extent of injury and pattern, greater weightbearing mid foot and hindfoot-healing longer
Wade, 2016 [38]. Literature review/
United States of America
EO Individual
Health professional
Health professionals require a high index of clinical suspicion otherwise mis/delayed diagnosis occurs. Critical gap in education of the community and health professional knowledge of CN and prompt referral to a multidisciplinary clinic Negative x-ray can delay healing, diagnosis not always confirmed by imaging Patient education and clinician understanding of clinical parameters underpinning CN management imperative and could increase compliance
Welch et al., 2014 [39]. Survey/
United Kingdom
IV Health Organisation
Health professional
Health professional knowledge, lack of confidence, unwillingness to perform crucial foot assessments if clinical indicators not present, poor resource, lack of time, incomplete assessments Health professional knowledge to utilise the appropriate pathology and imaging to diagnose CN. Resource limitation leads to more use of x-ray Nil
Wennberg et al., 2017 [40]. Cross Sectional study/
Sweden
III-2 Health Organisation
Individual
Health professional
Lack of recognition, delayed assessment/diagnosis Health professional knowledge to utilise the appropriate pathology and imaging to diagnose CN. Resource limitation leads to more use of x-ray Limited treatment options, MRI would provide earlier diagnosis, anxiety and depression of patient
Wukich et al., 2009 [41]. Literature review/
United States of America
EO Health Organisation
Individual
Health professional
Missed cases, high index of suspicion, clinician dependant, delayed patient presentation, Health professional knowledge to utilise the appropriate pathology and imaging to diagnose CN. Resource limitation leads to more use of x-ray Patient education and clinician understanding of clinical parameters underpinning CN management imperative and could increase compliance
Baker IDI, 2011 [4]. Guideline/
Australia
EO Australia Access to health services in rural remote areas Nil Nil
Diabetes Canada, 2008 [42]. Guideline/
Canada
EO Canada/ Diabetes Canada High degree of suspicion necessary Nil Nil
IWGDF, 2019 [3] Guideline/
Netherlands
EO Netherlands/Meeting of experts High degree of suspicion necessary Nil Nil
Rogers et al., 2011 [1]. Expert Opinion/
France
EO Paris/Meeting of experts Early detection on inflammation. Health professional knowledge Nil Nil
  1. The information extracted from the included articles was consolidated into broad themes in order to contextualise the challenges in implementing evidenced-based practice for acute CN. These themes were health organisational and environmental factors, individual factors and health professional factors