Current Concepts With External Fixation And The Charcot Foot
In the diabetic population, external fixation may be indicated in the acute management of certain ankle fractures and/or dislocations to provide further stabilization in the presence of dense peripheral neuropathy. In addition, external fixation can also supplement the use of internal fixation in order to avoid the possible development of acute Charcot neuroarthropathy with unstable fracture patterns and early, unwanted weightbearing status. Other indications include the management of limb-threatening wounds associated with Charcot neuroarthropathy that require adjunctive wound care, plastic surgery, and/or offloading to promote healing of the associated soft tissue envelope.21 In addition, surgeons can use external fixators to shorten osseous segments to obtain wound closure as they provide simultaneous compression, stabilization and the ability to make necessary adjustments if necessary during the postoperative period.
One should exercise caution in considering external fixation when dealing with severely immunocompromised patients who have severe peripheral vascular disease and critical limb ischemia not amenable to revascularization, certain cases of untreated active infection with systemic manifestations and/or non-ambulatory patients with severe multiple medical comorbidities. As such, amputation may be preferable in similar clinical case scenarios in order to avoid devastating postoperative surgical outcomes. Obtaining a thorough social history is important to identify and address concerns pertaining to excessive smoking and/or alcohol consumption, family support and psychosocial issues, adherence with treatment and medications, working status and/or activity level since these factors all have equal importance in facilitating optimal outcomes.
If postoperative complications with external fixation occur, it is necessary to address these in an expedited manner to avoid any unwanted results including wire or half-pin breakage, osseous and soft tissue infections, external fixation instability, malunion, nonunion, fractures and/or joint dislocations. As we mentioned previously, patients with Charcot neuroarthropathy may present with decreased bone mineral density and cortical stiffness. Accordingly, close postoperative monitoring, gait training and guidance is necessary to avoid any major complications. Extensive training with the diabetic Charcot neuroarthropathy deformity and utilization of external fixation are necessary to minimize the incidence of postoperative complications.
The history, clinical presentation and treatment of each Charcot neuroarthropathy deformity of the foot and ankle may be different and dependent on the severity of multiple systemic and/or clinical manifestations. Despite the availability of improved technological advancements such as external fixation in treating these deformities, additional studies with higher levels of evidence and cost analysis are necessary to determine its exact efficacy in this varied patient population.
Dr. Ramanujam is an Assistant Professor/Clinical in the Department of Orthopaedic Surgery within the Division of Podiatric Medicine and Surgery at the University of Texas Health Science Center San Antonio in San Antonio.
Dr. Stapleton is the Chief of Podiatric Surgery at Lehigh Valley Hospital in Allentown, PA, and a Clinical Assistant Professor of Surgery at the Penn State College of Medicine in Hershey, PA. He is a Fellow of the American College of Foot and Ankle Surgeons, and is an Associate in Foot and Ankle Surgery with VSAS Orthopaedics in Allentown, PA.
Dr. Zgonis is an Associate Professor and the Externship and Fellowship Director in Reconstructive Foot and Ankle Surgery in the Department of Orthopaedic Surgery within the Division of Podiatric Medicine and Surgery at the University of Texas Health Science Center San Antonio in San Antonio. He is a Fellow of the American College of Foot and Ankle Surgeons.