Is External Fixation Overutilized In Managing Charcot In The Diabetic Foot?
External fixation product training seminars can demonstrate the basic methods of frame application but these seminars cannot prepare surgeons to deal with the more difficult aspect of external fixation — outpatient management. Ensuring successful outcomes of external fixation require weekly pin tract care and surgeon availability. If occurrence of a tibial pin tract infection is sufficient to influence a surgeon to abandon the frame, then one should reconsider the utilization of the external fixator for Charcot reconstruction. Patient acceptance. Reports of depression, destructive behavior, social isolation and sleeping disorders have been associated with external fixation use. Social support systems or groups can provide a practical exchange of information that helps patients cope with common issues regarding external fixation treatment. Without patient acceptance of external fixation, compliance issues and early abandonment of external fixation may compromise the outcomes for success. In Conclusion What is the strongest evidence we have? For the most part, a majority of the current peer-reviewed literature indicates that internal fixation methods for salvaging acute and chronic Charcot deformities have been successful with an average reported fusion rate of 87 percent.9,10,13,16,20,24 The majority of the published information regarding external fixation for Charcot is primarily limited to non peer-reviewed articles, technique descriptions, observational studies and few level IV retrospective analyses.17,19,27,41-47 Only one level II prospective analysis of neutral circular frames for reconstruction of non-plantigrade Charcot midfoot deformities has demonstrated good clinical restoration with plantigrade feet ulcer and infection free at a one-year follow-up.48 Without case controlled, randomized clinical trials, advocates of this method have not produced the level of evidence to demonstrate that external fixation methods improve limb salvage rates beyond traditional offloading practices and internal fixation. In other words, one can successfully manage a majority of Charcot with conservative therapy and external fixation is not a substitute for cases in which internal fixation works well. Is there a place for circular frames in diabetic Charcot neuroarthropathy? The answer is yes. There are promising retrospective analyses, early prospective studies and anecdotal evidence, which deserve further attention. However, we must continue to critically investigate the best indications of external fixation use, moving from an “in my hands” approach to prospective comparative trials. At this point, the indications for Charcot reconstruction with external fixation seem to be few and far between. Dr. Liu is a Clinical Associate Professor in the Department of Orthopaedics at the University of Texas Health Science Center at San Antonio, Tx. He received his fellowship training in trauma and reconstruction at the University Hospitals of Dresden, Germany and Catania, Italy. Dr. Liu currently practices at the Austin Diagnostic Clinic multispecialty group in Austin, Tx. Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C.