Charcot Neuro-Osteoarthropathy: A new Risk Class is Needed?

Abstract

Aim

Charcot neuro-osteoarthropathy (CNO) is not explicitly included by the International Working Group of Diabetic Foot (IWGDF) 2023 ulcer risk stratification system. We explored whether post-remission (chronic) CNO identifies a distinct high-risk recurrence phenotype compared with IWGDF risk class 3, and whether intensified podiatry surveillance is associated with improved outcomes.

Methods

Prospective, single-centre observational study (2023-2024). We compared IWGDF class 3 patients without CNO (high-risk; HR, n = 184) with patients with chronic CNO (n = 27), all ulcer-free at baseline, followed at 1-3-month intervals (Year 1). In Year 2, only CNO patients were followed at <=30-day intervals and outcomes were compared with their Year-1 data.

Results

During Year 1, chronic CNO was associated with higher re-ulceration (70.4% vs 33.1%) and amputation (18.5% vs 7.6%). Although Peripheral Arterial Disease (PAD) prevalence was higher in HR patients, revascularization rates among those with PAD were higher in the CNO cohort, likely reflecting differences in referral thresholds and care pathways rather than PAD prevalence alone. In Year 2, intensified surveillance in CNO patients was associated with a marked reduction in re-ulceration (18.5% vs 70.4%); trends towards fewer amputations and revascularizations were observed.

Conclusion

Chronic CNO appears to represent a distinct high-risk recurrence phenotype not fully reflected by current IWGDF risk stratification. While limited by sample size and single-centre design, these findings support further evaluation of CNO-specific surveillance strategies and consideration of CNO as a separate risk stratum within the IWGDF framework.