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

Author(s): 
By George Liu, DPM, FACFAS
Normal bone density. When patients have normal bone mineralization, one may consider internal fixation the method of choice that can provide stable compression to fusion sites and avoid the risk of external fixation complications.19,27 Even in cases of severe dislocations during acute Charcot with the absence of profound joint fragmentation and bone resorption, internal fixation may provide stable fixation and reduction of deformity.9 Early Weightbearing: Is It Worth The Cost And Potential Risks Of Ex-Fix? Patient can maintain non-weightbearing or a partial weightbearing regimen. Facilitating early protected weightbearing while maintaining alignment of the arthrodesis site can be an advantage of external fixation. Ilizarov supported early weightbearing in lower extremity external fixation cases, observing that controlled weightbearing stimulus via “shared loading” promotes bone regeneration. Allowing early weightbearing to stimulate healing of the fusion site has been a common indication for external fixation. However, a patient capable of non-weightbearing with crutches is likely capable of performing touch toe weightbearing for shared loading of the arthrodesis with internal fixation and in a contact cast. If a patient’s postoperative regimen for arthrodesis involves non-weightbearing and the patient is able to safely maintain non-weightbearing, external fixation may be unconventional in this circumstance and one may not be able to justify the disproportionate cost of external fixation over the lower cost of internal fixation. Understanding The Importance Of Appropriate Patient Selection Poor rehabilitation and health status. The rationale of limb salvage for some surgeons is the association between increased energy expenditure with loss of limb length and a 66 percent increased incidence of contralateral limb loss within five years.28-30 Though one may attribute the relationship of contralateral limb loss after the index amputation to increased mechanical stress on the remaining limb leading to ulceration and infection, surgeons must also consider the event of limb loss as a marker of the disease state of diabetes. The development of Charcot is not a result of a local phenomenon but is a reflection of the overall disease state of diabetes. Charcot develops as a result of profound neuropathy including autonomic nerve dysfunction, all of which are functions of longstanding diabetes and neuropathy.31,32 Researchers have associated the presence of autonomic neuropathy and renal disease with increased cardiovascular risk and mortality in patients with diabetes.33-35 One retrospective analysis involving diabetic patients with Charcot neuroarthropathy reported a 45 percent mortality rate with a mean interval of 3.7 years.36 This is not considerably different from prospective data on three-year mortality rates (reported near 38 percent) of diabetic patients with major limb amputations.37 With poor rehabilitative outcomes in patients with diabetes and cardiovascular disease, and mortality rates similar in Charcot disease and amputation, limb salvage in cases of severe deformity, ulcer and frank infection may not be an economic nor appropriate option when amputation is likely the ultimate result. One should not consider amputation as a failure but as a reasonable treatment option for Charcot limb deformities in patients who have accumulated risk factors for poor outcomes for limb salvage. Your tolerance of risk. Although one can generally reduce complications with experience, bear in mind that even experts have quoted a 100 percent complication rate when it comes to external fixation with Charcot reconstruction. Common complications of pin tract infections include cellulitis, osteomyelitis, external fixation component failure, unscheduled trips to the operating room for half pin or fine wire exchange, frame loosening requiring adjustments and stress fractures of the tibia. It is not a question of if one will encounter a complication but when.

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