Current Concepts With External Fixation And The Charcot Foot

Crystal L. Ramanujam, DPM, MSc, John J. Stapleton, DPM, FACFAS, and Thomas Zgonis, DPM, FACFAS

   However, even though the prevalence of Charcot neuroarthropathy is increasing in the diabetic population, most patients are unaware of the condition and do not seek medical attention until the later stages of Charcot neuroarthropathy. In the early stages of Charcot neuroarthropathy, patients are often diagnosed with cellulitis, infection, sprained ankle or foot ligaments or gout. Alternately, clinicians may test these patients for an incidence of superficial or deep vein thrombosis since plain foot and/or ankle radiographs initially may not show any osseous Charcot neuroarthropathy abnormalities. At that point, cumulative microtrauma from an unprotected weightbearing status may further lead to multiple foot and/or ankle fractures, joint dislocations with subsequent deformities, ulcerations and infections.

Pertinent Principles With Procedure Selection

The preoperative medical optimization, testing and counseling can be quite extensive in the patient with diabetic Charcot neuroarthropathy since the patient’s health is usually affected by multiple medical comorbidities including and not limited to the cardiac, renal and vascular systems. Once both the medical and surgical teams have clearly identified and addressed the preoperative concerns, the patient may proceed with the necessary surgical reconstruction. One can categorize the surgical procedure based on the location of the deformity, the presence of unstable joints, presence of ulceration and/or osteomyelitis.

   In patients with isolated diabetic Charcot midfoot deformities, surgeons may perform single or multiple joint arthrodesis procedures in either the medial or lateral columns of the foot. For example, one may combine a tarsometatarsal joint arthrodesis with a naviculocuneiform arthrodesis or with the entire medial column (talo-navicular-cuneiform-metatarsal) arthrodesis when necessary. In the absence of any wounds and/or osteomyelitis, rigid internal fixation (screws, plating, beaming) may play a key role in achieving the necessary stability and union at the arthrodesis site(s).

   Surgeons may also consider internal fixation when the patient presents with non-infected wound(s), no history of osteomyelitis and no growth of organisms after the initial surgical debridement of the wound(s) associated with the diabetic Charcot neuroarthropathy deformity. Medial column diabetic Charcot neuroarthropathy foot deformities are usually more stable in comparison to those at the lateral column in the chronic stages of Charcot neuroarthropathy, and one may address recurrent ulcerations with an exostectomy and plastic surgical closure of the non-infected wound when necessary. In the presence of medial and/or lateral column instability, an isolated, adjacent and/or entire column arthrodesis can result in long-term successful results.

   In contrast, when a patient with diabetic Charcot neuroarthropathy midfoot deformity presents with a history of osteomyelitis and/or infected ulcerations, a staged reconstruction may be necessary to eradicate the associated soft tissue and osseous infection before the definitive procedure.18 The initial surgical intervention includes a thorough surgical debridement and obtaining the necessary soft tissue and osseous specimens for microbiology and histopathology analysis. Following those results, a timely infectious disease consultation will provide further guidance for short- and long-term oral and/or parenteral antibiosis for the compromised patient with diabetic Charcot neuroarthropathy. The use of cemented non-biodegradable antibiotic beads and/or spacers may also be necessary for further local resolution of soft tissue and/or osseous infection, stability and the elimination of any large defects.6 In these surgical reconstruction procedures, external fixation provides an ideal surgical tool to address the diabetic Charcot neuroarthropathy deformity.

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