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

By George Liu, DPM, FACFAS

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.
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.

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