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

Author(s): 
By George Liu, DPM, FACFAS

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.
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.

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