For years, clinical treatment of
Charcot foot involved a combination of braces and crow
walkers. Recently, however, foot and ankle surgeons have grown increasingly
interested in treating Charcot foot using their own methods.
“There is plenty of interest in surgical treatment, but the problem
is that the majority of patients are diabetic and morbidly obese,” Michael
Pinzur, MD, foot and ankle surgeon at Loyola University Health System, said
“They have a lot of medical problems and probably half of the patients we
operate on have infections. It makes the surgical treatment and the standard
methods of treatment difficult.”
Correcting the deformity of the foot is not overly difficult, according
to Pinzur. Most complications occur during post-surgical treatment due to a
high incidence rate of infection. Infection could lead to the internal fixation
falling apart, permanently damaging the foot, he told O&P Business
News.
A surgical technique that secures the foot bones with an external frame
has enabled more than 90% of patients to walk normally again, Pinzur explained.
The circular external fixator contains three rings that surround the foot and
lower calf. The rings have stainless steel pins that extend to the foot and
secure the bones following surgery.
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| Pinzur’s research of 26 patients, who used an external fixator following surgery, found that 24 patients, or 92%, had no ulcers or bone infections. |
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| Source: Michael Pinzur |
“The nice thing about this method is that you make a small
incision, remove the infected bone and correct the deformity,” Pinzur
explained. “But rather than relying on the local bone to hold the implant,
we use the external fixation device. We drill wires through the bone and we
attach them under tension to a ring.”
According to Pinzur, this technique allows the bone to remain stabilized
and maintain the correction until it heals.
Unlike traditional treatments that would require putting the leg in a
cast, limiting the patient’s movement, patients treated with the external
fixator have the ability to bear weight on the healing leg. A patient treated
with bracing methods typically requires the use of a wheelchair for as many as
9 months. The external fixator, however, is attached to the treated leg for a
total of only 2 to 3 months.
If the patient is obese, Pinzur would use additional wires to strengthen
the construct of the bone.
“That is the beauty of this system,” Pinzur added. “It is
an inherently strong device that has the ability to withstand large amounts of
weight.”
Pinzur has performed this surgical technique on more than 200 patients.
He explained that his patients have an average body mass index of 39.6, which
is about 350 pounds. In his estimation, about half of his patients have been
diagnosed with bone infections and osteomyelitis prior to surgery. Despite
these obstacles, Pinzur has still been able to reach a high success rate using
the circular external fixator.
“The definition of successful outcome is to be infection-free and
able to walk in the community while wearing standard and commercially available
diabetic shoes,” he explained. “Using that high bar, we were still
able to reach successful outcomes.” — by Anthony Calabro
Perspective
I agree that Charcot foot deformity correction is not the major
challenge despite the unique and bizarre case presentations that may be
encountered, but rather the management of the complex diabetic patient
throughout the postoperative period.
Successful surgical outcomes for the Charcot foot and ankle are mostly
being obtained by integrating a multidisciplinary health care team to address
these medical co-morbidities and to “limit” any post-operative
complications.
The application of circular external fixation “Ilizarov Frame”
has been used for many years to accomplish deformity correction and address
nonunions/malunions of the foot and ankle. Its application requires a great
deal of experience and needs to be highly considered when surgically managing
the diabetic Charcot foot and ankle.
External fixation is unique in its ability to address various foot and
ankle conditions and especially in managing acute and/or chronic Charcot
diabetic ulcerations or joint infections. Our treatment goal is for patients to
be ulcer and infection free while resuming an ambulatory status. In my
experience, most of the post-operative Charcot reconstruction patients need
custom molded shoes and/or braces.
Lastly, diabetic patients will require extensive education and
understanding on the causes and management of Charcot neuroarthropathy and
advice on prevention of future complications.
Thomas Zgonis, DPM, FACFAS
Division chief of podiatric medicine and surgery for the
Department of Orthopaedic Surgery at the University of Texas Health Science
Center, San Antonio
