Strengths and limitations
Charcot neuroarthropathy
REMISSION, RECRUITMENT
The strength of this study is the recruitment of study participants who are representative of the wider population of people living with Charcot neuroarthropathy. The study was embedded within clinical practice and study visits were designed to align with pre-existing clinical pathways for Charcot neuroarthropathy. The clinical team took responsibility for both clinical care and the research. This approach increased the number of people who were willing to participate in the research and contributed to the high retention levels observed in this study.One potential limitation of this study was that MRI sequencing protocol was not standardised; however, this study did not seek to provide a definitive answer as to the efficacy of using serial MRI to diagnose remission so was not necessary. The non-study MRIs that were completed may have contaminated the results, diluting the relationship between intervention and outcome. We do not know whether these MRIs reflected a change in practice due to study participation.The COVID-19 pandemic reduced data and intervention completeness and the clinical efficacy and patient reported outcomes that were collected. During the first wave of the UK COVID-19 pandemic, some hospitals involved in the study stopped or restricted research radiology imaging, reducing the number of completed study MRIs. This may have resulted in either an underestimation or overestimation of the time in cast/off-loading device. Our participants were considered a ‘clinically vulnerable’ group and advised by the UK government to only attend essential clinical visits which excluded study visits. Consequently, the end point time in cast/off-loading device and other outcomes were not always collected. Some clinical teams transferred participants from non-removable to removable offloading devices to reduce the number of follow-up appointments. Wearing removable devices is associated with increased time to remission [