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Figure 1. Anteroposterior and lateral radiographs of patient
with Charcot arthropathy. (A, B) Normal radiograph at 2 years
before pancreas transplantation (C, D) Charcot arthropathy in
tarsal joint at 8 months after pancreas transplantation (patient
number 15 in Table 2). Subchondral sclerosis, osteophytosis,
destruction of articular cartilage, and reformation of the tarsal
joint architecture are observed.

number of cases lost to follow-up produces a potential bias.
It can be inferred that the epidemiology of diabetic foot
complications was more accurately described in this study,
because regular follow-ups were conducted in most cases of
pancreas transplantation, even though the patients' residences were distant and the symptoms were mild.
Previous studies have reported the prevalence of Charcot
arthropathy after simultaneous pancreas-kidney transplantation for type 1 diabetes from 9% (9 of 100 patients) to
12% (8 of 66 patients).7,11 In our study, Charcot arthropathy
was observed in 7 (3.2%) of the 218 subjects. Although the
prevalence was lower than the reported prevalence from
studies by Barrado and Giovanni, it was higher than the 1%
prevalence of Charcot arthropathy in diabetic patients.
Garcia suggested that excessive corticosteroid use is a
risk factor that causes Charcot arthropathy after surgery.7
Although methylprednisolone use trended higher in the
complication group than in the noncomplication group in
this study, the difference was not significant. The amount of
corticosteroid used after pancreas transplantation in this
study was relatively low. Although no significant differences were observed in cumulative steroid use between 2
groups, the relatively low prevalence of Charcot arthropathy might suggest that steroid use increases the risk of
Charcot arthropathy.

Foot & Ankle International 38(6)
Unlike other studies7,11 wherein preoperative HbA1c levels indicated the possibility of developing a Charcot joint,
no differences were observed in the HbA1c levels between
the 2 groups in this study. On the other hand, creatinine
level was observed to be higher in the complication group 1
year after surgery, which differs from the results of previous
studies and needs to be further investigated.
A case report by Vecchio6 indicated that 2 cases of Charcot
arthropathy were observed immediately after SKPT, whereas
a study by Caldara3 reported an occurrence of Charcot
arthropathy 11 years after successful pancreas transplantation. The average time to occurrence after pancreas transplantation in this study was 21.7 months. Charcot arthropathy
occurred within 9 months after pancreas transplantation in 4
of the 7 subjects. Therefore, more investigations should be
conducted on the occurrence of foot complications during the
early period after pancreas transplantation.
In this study, 15 subjects (6.9%) were treated for diabetic
foot ulcer, which is a lower prevalence compared to the
15% to 25% of diabetic patients who develop diabetic foot
ulcers in their lifetimes. Considering that the average follow-up period was 4.3 years in this study, further followups and observations might be necessary. Our study subjects
were actively examined even though they only presented
with mild foot discomfort. Except for 1 subject whose lower
limb below the knee was amputated, the diabetic foot ulcers
were well controlled in all other subjects without the need
for major amputations above the ankle joint level. Similar
to Charcot arthropathy results, diabetic foot ulcers occurred
within 1 year after pancreas transplantation in 11 of the 15
subjects. Therefore, early management and observation are
very important.
Although it is difficult to differentiate an insufficiency
fracture from other common traumatic fractures, insufficiency fractures were included as a complication in this
study. Unlike fractures caused by trauma, patients with
insufficiency fractures do not have previous histories of
trauma and pain. However, lack of appropriate management
can cause deformation or ulcers of the foot. Although the
prevalence of insufficiency fractures is not higher than the
prevalence of other complications, an insufficiency fracture
in the foot should be suspected as a diabetic complication
after pancreas transplantation.
There were several limitations in this study. First, this
was a retrospective study. Second, the average follow-up
period of 4.3 years is not sufficient, and further follow-ups
and observations could be necessary.
In conclusion, although pancreas transplantation in diabetic patients is known to reduce complications in other
organs, this study showed through analysis of a large case
series that diabetic foot complications could arise after successful pancreas transplantations. The diabetic foot complications that occurred happened more frequently within
the first year after surgery. Therefore, we believe foot

Table of Contents for the Digital Edition of Foot & Ankle International - June 2017