Skip to main content

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