Is External Fixation Overutilized In Managing Charcot In The Diabetic Foot?

Author(s): 
By George Liu, DPM, FACFAS
Additionally, one cannot reasonably offload these deformities with casting or bracing without exposing the limb to areas of focal high pressures, leading to ulceration. With joint fragmentation, bone resorption and severe deformity that one sees with acute Charcot, internal fixation may not adequately achieve direct stabilization to maintain alignment of open arthrodesis. External fixation may span areas of demineralized bone and maintain the alignment in arthrodesis. In cases of correction of severe chronic Charcot, osseous correction may be limited by adapted soft tissue and neurovascular structures that may not tolerate acute, single stage correction without complications of soft tissue contracture, wound dehiscence or soft tissue necrosis. One may gradually correct deformities with circular spatial frame or hinge axis methods that allow concomitant soft tissue lengthening and relaxation to occur. Conservative Management: Can It Have An Impact? Plantigrade stable foot. Various authors consider a clinically stable, plantigrade, shoeable/braceable foot a successful and desirable outcome of treatment for Charcot neuroarthropathy.4,6,9,10,13-24 Despite significant radiographic patterns of breakdown that are common to see during the quiescent phase, there is little evidence to support elective prophylactic realignment procedures in these patients with clinically stable plantigrade feet that can be safely fit into extra-depth shoes or braces. Furthermore, complications associated with Charcot reconstruction with internal fixation, including limb loss, may not be considered reasonable risks in this lower risk patient group. Stage 0 and 1. In regard to clinical manifestations of acute Charcot neuroarthropathy in the absence of radiographic signs of joint destruction or deformity, which surgeons refer to as Stage 0 or pre-Charcot, various authors suggest it is best to use compression therapy and subsequent nonweightbearing cast immobilization.22,23,26 This conservative method, including total contact casting, is also widely advocated as the gold standard for Eichenholtz stage I Charcot. In this stage, one may see radiographic signs of early joint fragmentation, destruction and debris formation without significant fracture displacement, joint dislocation or mechanical axis malalignments. However, surgical intervention during these early stages of Charcot is controversial. There is only one level IV retrospective report in the medical literature supporting surgical intervention with internal fixation during the acute Eichenholtz stage I Charcot neuroarthropathy.24 Another report recommended surgical intervention during Eichenholtz stage I only if one encounters severe unstable reducible joint dislocations before seeing radiographic evidence of joint destruction and bone fragmentation.9 There have been anecdotal reports of utilizing external fixation for realignment stabilization for acute Charcot dislocations. However, further investigation is necessary to validate the efficacy of indirect stabilization in cases of Stage 0 and 1 without deformity. What You Should Know About Other Surgical Procedures For Charcot Exostectomy. Charcot rocker bottom foot deformity often leaves plantar osseous prominences, increasing the risk for tissue breakdown. Simple plantar exostectomies are generally successful with a reported average 84 percent healing rate and 20 percent recurrence of skin breakdown.6,9,14,15,21 With the procedure’s satisfactory success rates, less technical difficulty and lower complication rates, one may consider exostectomies for stable uncomplicated Charcot deformities with plantar prominences. Surgeons may consider realignment arthrodesis if plantar ulceration recurs. Proponents for arthrodesis may argue that recurrence of ulceration and progression of Charcot may be high with exostectomies as opposed to realignment arthrodesis. However, there is little uniform, long-term data to provide meaningful comparisons between the two treatment groups.

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