title: Combined Internal and External Fixation for Diabetic Charcot Reconstruction: A Retrospective Case Series.
abstract: Diabetic Charcot neuroarthropathy is a complex, limb-threatening disease process with major lifestyle-altering repercussions for patients. When Charcot neuroarthropathy leads to unstable deformity, ulceration, and potential infection despite conservative therapies, foot and ankle surgeons often consider reconstructive limb salvage procedures to restore function. The purpose of the present study was to evaluate the clinical and radiographic outcomes of diabetic Charcot reconstruction using combined internal and external fixation. A total of 22 patients were reviewed; 16 (72.73%) midfoot and 6 (27.27%) tibiotalocalcaneal arthrodesis procedures were consecutively performed from March 2009 to May 2013. All surgical procedures were performed in nonacute phases of the Charcot process in patients with diagnosed diabetes mellitus and documented peripheral neuropathy. Patients were excluded from the study if they were not diabetic despite having undergone Charcot reconstruction, regardless of the fixation method, or if they did not complete radiographic imaging. During a mean follow-up period of 58.60 ± 42.37 (range 16 to 164) weeks, limb salvage was achieved in 20 patients (90.91%), and 2 (9.09%) required below-the-knee amputation at a mean of 42 ± 14.14 weeks. Wound dehiscence occurred in 8 (36.36%), pin tract infection in 10 (45.45%), and superficial wound infection in 9 (40.91%) and peaked in bimodal fashion at 4 and 8 weeks postoperatively. Radiographic analysis of the pre- versus postoperative alignment showed statistically significant changes in the lateral talo-first metatarsal angle (p = .02) and lateral talar declination angle (p = .01). The limb salvage rates with diabetic Charcot reconstruction are improving in part because of the continued development of increasingly superior modalities for both internal and external fixation.
authors.affiliation: Fellow, Silicon Valley Reconstructive Foot and Ankle Fellowship, Palo Alto Medical Foundation, Mountain View, CA. Electronic address: Kenneth.W.Hegewald@dmu.edu.
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Hegewald
authors.affiliation: Resident, Franciscan Foot and Ankle Institute, CHI Franciscan Health, Federal Way, WA.
authors.forename: Megan L
authors.initials: ML
authors.lastname: Wilder
authors.affiliation: Resident, Franciscan Foot and Ankle Institute, CHI Franciscan Health, Federal Way, WA.
authors.forename: Todd M
authors.initials: TM
authors.lastname: Chappell
authors.affiliation: Director, Franciscan Foot and Ankle Institute, and Medical Director, Foot and Ankle Service, CHI Franciscan Health, Federal Way, WA.
authors.forename: Byron L
authors.initials: BL
authors.lastname: Hutchinson
mesh_terms: D000328:Adult; D000368:Aged; D001174:Arthrodesis / Q000295:instrumentation* / Q000379:methods; D001177:Arthropathy, Neurogenic / Q000000981:diagnostic imaging* / Q000601:surgery*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D048909:Diabetes Complications / Q000175:diagnosis / Q000601:surgery*; D016267:External Fixators / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D005531:Foot Deformities, Acquired / Q000000981:diagnostic imaging / Q000601:surgery; D005593:Fracture Fixation, Internal / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D018889:Ilizarov Technique / Q000295:instrumentation*; D016268:Internal Fixators / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011859:Radiography / Q000379:methods; D019651:Plastic Surgery Procedures / Q000379:methods; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: Charcot; Ilizarov; bone; comorbidity; external fixation; infection; tarsal