Tag Archives: Charcot arthropathy

Natural History of Diabetic Foot and Ankle Fractures: A Retrospective Review of 40 Patients

by Brian T. Dix, DPM1, Alan R. Catanzariti, DPM, FACFAS, Robert W. Mendicino, DPM, FACFASpdflrg

The Foot and Ankle Online Journal 6 (11): 1

Background: Ankle fractures in diabetics with secondary complications are more prone to postoperative complications than ankle fractures in diabetics without secondary complications. This study retrospectively compared the post injury complications of foot and ankle fractures in diabetics with and without secondary complications. Secondary complications of diabetes mellitus include peripheral arterial disease, nephropathy, and/or peripheral neuropathy. Uncomplicated diabetics did not have any of these end organ diseases associated with diabetes. Our hypothesis was that foot and ankle fractures in complicated diabetics would incur more post injury complications than uncomplicated diabetics.
Materials and Methods: We contrasted the post injury complications of foot and ankle fractures in 25 complicated diabetics with15 uncomplicated diabetics.
Results: At an average follow-up of 33.8 weeks we established that foot fractures in complicated diabetics had a non significant trend of a 2.8 times increase in overall post injury complications versus foot fractures in uncomplicated diabetics. Furthermore, with an average follow up of 28.8 weeks we demonstrated a non significant tendency of a 1.4 times increase in overall post injury complications of ankle fractures in complicated diabetics compared to ankle fractures in uncomplicated diabetics. Lastly, with a mean follow up of 33.7 weeks we found insignificant trends of a 1.7 times increase in overall post injury complications and a 2.8 times increase in noninfectious complications (malunion, delayed union, nonunion or Charcot neuroarthropathy) in complicated diabetic foot and ankle fractures contrasted to uncomplicated diabetic foot and ankle fractures.
Conclusion: Foot and ankle fractures in complicated diabetics are presumably at an increased risk of developing a post injury complication compared to uncomplicated diabetics. Specifically, foot fractures should be treated similar to ankle fractures in complicated diabetics with an extended period of non-weight-bearing in a total contact cast. Mandatory post injury clinical evaluation for peripheral arterial disease, peripheral neuropathy and nephropathy should be implemented. This analysis will be used as a template for a future prospective comparative study evaluating foot and ankle fractures in complicated and uncomplicated diabetics with a power analysis to achieve statistical significance.

Key words: Diabetes mellitus, ankle fracture, Charcot arthropathy

Accepted: October, 2013
Published: November, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0611.001

Address correspondence to:1Resident, Department of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA


In 2010 it was projected that 25.8 million people in the United States had diabetes mellitus representing 8.3% of the population with another 7 million undiagnosed.[1]

The first report of diabetes mellitus affecting bone healing was an animal study in 1968 by Herbsman, et al.[2] They found that rats with uncontrolled diabetes mellitus had reduced fracture healing compared to the healthy controls.

Other animal studies have confirmed these results and have found that fractures in diabetic rats treated with insulin improved bone healing.[3-6] In the earliest human case report, Cozen reviewed 9 diabetics with lower extremity fractures and contrasted them with 9 matched controls. He verified a delayed time to union in the diabetic patients.[7]

Several studies have demonstrated increased complications in diabetic ankle fractures compared to the healthy controls.[8-12] However, several recent studies have shown that ankle fractures in diabetics without comorbidities (uncomplicated diabetics) had complication rates similar to the controls. Conversely, complicated diabetics (peripheral neuropathy, nephropathy and peripheral arterial disease) had significantly increased complications.[13-15] However, to the best of our knowledge, in the English literature, there have been no studies examining the natural history of diabetic foot and ankle fractures concomitantly. Thus, a retrospective review of 40 patients with diabetes mellitus who sustained a foot and/or ankle fracture was performed.

Methods and Patients

On July 26, 2012, the Western Pennsylvania Allegheny Health System Institutional Review Board accepted this as an exempt study. A retrospective review of patient charts, radiographs, and operative reports with diagnosis codes for “diabetes mellitus” and “fracture” to the foot and/or ankle was assembled. Complicated diabetics were diagnosed with peripheral neuropathy (PN), peripheral arterial disease (PAD) and/or nephropathy. Uncomplicated diabetics did not have any of these end organ diseases.[16,17] PN was diagnosed when the patient could not detect the 5.07 Semmes Weinstein monofilament. PAD was diagnosed if the patient had been revascularized in the past or when the patient had non palpable dorsalis pedis or posterior tibial pulses.

Nephropathy was diagnosed when the patient had a serum creatinine of > 1.5.[11] Charcot neuroarthropathy was defined as bone fragmentation, bone absorption and boney consolidation.[18]

Superficial infections were categorized based on the need for only oral antibiotics and local wound care. Deep infections were delineated when the wound required intravenous antibiotics and surgical debridment.[11]

A nonunion was defined when a minimum of 9 months has passed and there are no interval changes consistent with a union on serial radiographs. A delayed union had decreased bone healing on serial radiographs.

Data was collected for patients treated between 1/1/2002 – 7/1/2012. Patients less than 18 years old and with incomplete medical records were excluded. The information gathered included age, sex, body mass index (BMI), fracture type, fracture location, fracture treatment, time to union, malunion, nonunion, infection, ulceration, Charcot neuroarthropathy, amputation, PN, nephropathy, and PAD.

The type of treatment was at the judgment of the attending foot and ankle surgeon. All patients with an ankle fracture underwent open reduction and internal fixation (ORIF) with plates and screw fixation of the fibula. Also, the medial malleolar fixation was accomplished with screws or tension banding. Syndesmotic fixation was accomplished with tri-cortical or quad-cortical screws when appropriate. All ankle fractures received preoperative antibiotics with continuation of antibiotics through the hospital course for open fractures. Non-weight-bearing (NWB) was generally instituted for a minimum of 7 weeks in a total contact cast (TCC) with transitioning to weight-bearing (WB) for a minimum of 4 weeks in a fracture walker for postoperative ankle fractures.

Forefoot fractures (toe and metatarsal) were commonly allowed WB in a surgical shoe or fracture walker for at least 2 weeks before transitioning to a sneaker. Patients were usually followed up at 2 week and subsequently 1 month intervals until fracture union. At most visits, medial oblique, anteroposterior and lateral radiographs were obtained to assess fracture healing.

NHDFTable1

Table 1: Frequency by diabetic group (complicated vs. uncomplicated).

NHDFTable2

Table 2: Time-based measures in weeks (complicated vs. uncomplicated).*

Results

There were a total of 40 diabetic foot and ankle fractures with an average follow up of 31.7 (4-137) weeks. Patient ages ranged from 43 to 85, with a mean of 62.00±10.34 (standard deviation). There were a total of 22 females (55%) and 18 males (45%). Patient BMI ranged from 21.81 to 56.35 with a mean of 34.11±5.91. Thirty seven (93%) experienced closed injuries while three (7%) experienced open injuries. Nineteen patients (48%) were treated non-operatively (toe, metatarsal and cuboid fractures) and 21 (52%) were treated operatively (ankle and a calcaneal avulsion fracture).

Twenty five patients possessed a previous diagnosis of complicated diabetes (63%) while fifteen patients had uncomplicated diabetes (37%).

Regarding type of injury, 17 patients experienced an ankle fracture (43%), 12 patients a metatarsal fracture (30%), nine patients a phalanx (toe) fracture (22%), one patient a calcaneal avulsion fracture (2.5%), and one patient a cuboid fracture (2.5%).

When evaluating BMI there was no difference between complicated diabetics (mean=32.64±5.10) and uncomplicated diabetics (mean=36.55±6.51), t (38) = 2.12, p = .25. There was no difference in age between complicated diabetics (mean = 62.32±10.65) and uncomplicated diabetics (mean=61.93±10.15), t (38) = .11, p = .91.

NHDFTable3

Table 3: Complications among foot fractures.

NHDFTabl4

Table 4: Complications among ankle fractures.

NHDFTable5

Table 5: Diabetes complications by post injury complications.

Also, there was no statistical difference between uncomplicated and complicated diabetes with regards to the frequency of sex and treatment (Table 1).

There was no statistical difference between complicated and uncomplicated diabetics regarding the number of weeks WB (8.56±5.64, 7.40±6.70, p = .56) and non-weight-bearing (7.93±4.17, 7.75±3.25, p = .90). Along with no statistical significance among complicated and uncomplicated diabetics (table 2) in weeks to clinical union (10.12±6.35, 9.27±3.44, p=.64) and radiographic union (14.76±7.20, 12.87±5.87, p = .40).

Twenty three foot fractures were included in the retrospective review with an average follow up of 33.8 weeks. (Table 3). Eighteen (78%) were complicated diabetics while five (22%) were uncomplicated diabetics. Ten (56%) of the complicated diabetics experienced a post injury complication.
Conversely, only 1 (20%) uncomplicated diabetic experienced a post injury complication. A two sided Fisher’s Exact test indicated no significant difference in proportion of patients experiencing post injury complications between complicated and uncomplicated diabetic groups (p = .32).

Moreover, there were a total of seventeen ankle fractures with a mean follow up of 28.8 weeks. (Table 4). Seven (41%) had complicated diabetes while 10 (59%) had uncomplicated diabetes. Among complicated diabetics, 4 (57%) experienced a post injury complication, whereas 4 (40%) of uncomplicated diabetics experienced a post injury complication. A two sided Fisher’s Exact test indicated no significant difference in proportion of patients who experienced a post injury complication between complicated and uncomplicated diabetic groups (p = .64).

NHDFTable6

Table 6: Complications among diabetes type.

NHDFTable7

Table 7: Complications among foot and ankle fractures.

Further analyses evaluated the relationship between severity of complicated diabetes (PN+ PAD + nephropathy) and the number of post injury complications sustained by each patient. Eighteen diabetics (72%) were diagnosed with one complicating factor, six (24%) were diagnosed with two complicating factors, and one (4%) was diagnosed with all three complicating factors.

Among all complicated diabetics, 11 (44%) patients experienced no post injury complications, 8 (32%) patients experienced one complication, five (20%) patients experienced two complications, and one (4%) patient experienced three complications (Table 5). A Pearson’s Chi-squared test was conducted indicating no relationship between number of diabetes complicating factors and number of post injury complications, χ2 (2, N = 25) = 3.96, p = .14.

NHDFTable8

Table 8: Non-infectious complications by diabetes type and total fractures.

The relationship between diabetes type and the presence of a post injury complication when collapsing across all types of injuries was conducted (Table 6).Fourteen (56%) complicated diabetics experienced one or more post injury complications. Among uncomplicated diabetics, 5 (33%) experienced one or more post injury complications. A two-sided Fisher’s Exact test indicated no relationship between diabetics type and the presence of injury complications (p = .20). All diabetic foot and ankle fracture complications are described in Table 7. There were no amputations performed in any of the complicated or uncomplicated diabetic foot or ankle fractures.

A non-infectious complication includes any complication involving a malunion, delayed union, nonunion or Charcot neuroarthropathy.13 A total of 9 (47%) complicated diabetic foot and ankle fractures experienced a non-infectious complication and 4 (19%) uncomplicated diabetics experienced a non-infectious complication (Table 8.) A series of Chi-Square analyses were conducted and found no statistical significant relationship between diabetes-type and number of non-infectious complications for foot fractures [χ2 (2, N = 23) = .66, p = .72.], ankle fractures [χ2 (2, N = 17) = 1.54, p = .46] and overall fractures [χ2 (2, N = 40) = 1.95, p = .38].

Discussion

This retrospective review of the natural history of 40 diabetic fractures is the first to evaluate foot and ankle fractures together. In regards to foot fractures (Figure 1), 56% (10/18) of foot fractures in the complicated group experienced a post injury complication while only 20% (1/5) of the uncomplicated group sustained a post injury complication (p = .32). Although not statistically significant, there was a 36% (2.8 times) increase in complications with complicated diabetics who sustained a foot fracture (Table 3). Kristiansen described a diabetic second metatarsal shaft fracture that was allowed to weight bear immediately with a bandage. Three months later the metatarsal fracture developed Charcot neuroarthropathy. He concluded that even metatarsal fractures should be immobilized and weight-bearing must be deferred until fracture healing is complete.[20] The foot fractures (metatarsal, phalanx, and cuboid) in this study were allowed to WB immediately in a surgical shoe or fracture walker. The authors hypothesize that a more aggressive immobilization regimen such as non-weight-bearing or total contact casting should be considered to decrease adverse outcomes in the complicated diabetic group.

NHDFfig1A NHDFfig1B

Figure 1: Radiographs demonstrating a distal phalanx fracture in a complicated diabetic.

NHDFfig2A NHDFfig2B

Figure 2: Initial and 12 week radiographs of a bimalleolar ankle fracture in a complicated diabetic.

In evaluating 17 operatively treated ankle fractures (Figure 2), the complicated diabetic group had a 57% (4/7) post injury complication rate while the uncomplicated diabetic group had 40% (4/10) post injury complication rate (p = .64). Many studies, including a meta-analysis of 356 ankle fractures, have established an overall increase in complications in diabetic ankle fractures compared to non diabetics.[21-27] Additionally, Wukich, et al., retrospectively confirmed that complicated diabetics had a 3.8 (p = .003) times amplified risk of a post injury complication.[11] In our study, there was a non significant trend of a 17% (1.4 times) increased complication rate for ankle fractures in the complicated diabetic group compared to the uncomplicated diabetic group. However, in the Wukich, et al., study there was total of 59 uncomplicated diabetics and 46 complicated diabetics which achieved statistical significance.[11] To attain statistical significance in our study, approximately 90 additional ankle fractures would need to be evaluated.

Compiling all diabetic foot and ankle fractures there were a total of 25 complicated and 15 uncomplicated fractures. Post injury complications occurred in 56% (14/25) of the complicated diabetics and in 33% (5/15) of the uncomplicated diabetics (p = .20). Also, 47% (9/19) of the complicated diabetics experienced a non-infectious complication compared to only 19% (4/21) of the uncomplicated diabetics (p = .38). Thus, there was a non significant tendency of a 23% (1.7 times) elevated risk of developing a post injury complication in the complicated diabetics with a 28% (2.4 times) increased risk of having a non-infectious complication. This increase is on par with Wukich, et al., who found a 3.4 times increased risk of developing a non-infectious complication ankle fractures in complicated diabetics. Also, the complicated diabetic group took almost 2 weeks longer for radiographic union compared to the uncomplicated diabetic group (14.76±7.20, 12.87±5.87, p = .40). While there was no statistical difference between the groups, the overall increase in healing time for all diabetic fractures is consistent with other studies.[2-7,12,22]

On the other hand, in our study no diabetic fractures resulted in an amputation. The literature has demonstrated amputation rates of diabetic ankle fractures ranging from 4 -17%.[9,23,28] Our 0% amputation rate is most likely due to the fact that we are not located at a level 1 trauma center and only had 3 (7%) open ankle fractures with no open foot fractures. Open diabetic ankle fractures traditionally have very poor outcomes with a 38% amputation rate in a case study by White, et al., in 2003.

A novel analysis evaluated the relationship between the severity of complicated diabetes and the number of post injury complications sustained by each patient. Eighteen diabetics (72%) were diagnosed with one complicating factor and seven (28%) were diagnosed with two or more complicating factors. Six (78%) of the diabetics with 2 or more complicating factors experienced at least one post injury complication compared to 8 (44%) of the diabetics with only 1 complicating factor (p = .14). This also showed a non significant propensity as the number of diabetic complicating factors increases, the amount of complications increases as well (1.7 times higher).

The most obvious weakness of our evaluation was the study being underpowered. This was because of the relatively small number of diabetic patients reviewed. Over 30 patients had to be excluded from the study due incomplete medical records including no height or weight being recorded, complications described too broad for interpretation, and radiographs/charts missing. These patients may have helped influence the data to become significant.

The other main weakness was the retrospective nature of the study. Retrospective studies are based on the correctness of patient charts/radiographs and thus information collected is only as accurate as the medical information documented. Also, this study also did not evaluate other complications such as deep vein thrombosis, thromboembolism, stroke, or myocardial infarction.

Furthermore, there could have been measurement bias as there was not a standard protocol initiated. However, all diabetic ankle fractures did receive ORIF with treatment based on standard fixation principles. Also, all diabetic foot fractures except one calcaneal avulsion fracture, were treated non-operatively in a surgical shoe or fracture walker.

Non-responder bias is also a part of this study since some patients were followed longer than others. If some patients were observed longer more complications could have been discovered. Most foot fractures were followed until fracture union and were not followed up thereafter. Moreover, there also could have been interview bias as the treating foot and ankle surgeon determined if there was a complication and recorded this in the patient’s clinical chart.

Conclusion

Although not statistically significant, the trend of increased complication rate for foot fractures in complicated diabetics leads us to believe that foot fractures should be treated in the same manner as ankle fractures in complicated diabetics. Post injury clinical evaluation for PAD, PN and nephropathy should be considered. This analysis will be used as a template for a future prospective study comparing complicated and uncomplicated diabetic foot and ankle fractures.

References
1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. [Website]
2. Herbsman H, Powers JC, Hirschman A, Shaftan GW. Retardation of fracture healing in experimental diabetes. Journal of Surgical Research 1968 8: 424-431. [PubMed]
3. Dixit PK, Ekstrom RA. Retardation of fracture healing in experimental diabetes. Indian J Med Res 1987 85: 426-435. [PubMed]
4. Macey LR, Kana SM, Jingushi S, Terek RM, Borretos J, Bolander ME. Defects of early fracture-healing in experimental diabetes. JBJS 1989  71A: 722-733. [PubMed]
5. Funk JR, Hale JE, Carmines D, Gooch HL, Hurwitz SR. Biomechanical evaluation of early fracture healing in normal and diabetic rats. J Orthop Res 2000 8: 126-132.
[PubMed]
6.  Gooch HL, Hale JE, Fujioka H, Balian G, Hurwitz SR. Alterations of cartilage and collagen expression during fracture healing in experimental diabetes. Connect Tissue Res 2000 41: 81-91. [PubMed]
7. Cozen L. Does diabetes delay fracture healing? Clin Orthop Relat Res 1972 82: 134-140. [PubMed]
8. Chaudhary SB, Liporace FA, Gandhi A, Donley BG, Pinzur MS, Lin SS. Complications of ankle fracture in patients with diabetes. J Am Acad Orthop Surg 2008 16: 159-170. [PubMed]
9. Flynn JM, Rodriguez-del Rio F, Piza PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000 21: 311-319. [PubMed]
10. SooHoo NF, Krenek L, Eagan MJ,  Complication rates following open reduction and internal fixation of ankle fractures. JBJS 2009 91A: 1042-1049. [PubMed]
11. Prisk VR, Wukich DK. Ankle fractures in diabetics. Foot Ankle Clin 2006 11: 849-863. [PubMed]
12. Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. JBJS 2008 90A: 1570-1578. [PubMed]
13. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. JBJS  2005 87B: 489-495. [PubMed]
14. Costigan W, Thordarson DB, Debnath UK. Operative management of ankle fractures in patients with diabetes mellitus. Foot Ankle Int 2007 28: 32-37. [PubMed]
15. Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int 2011 32: 120-30. [PubMed]
16. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992 45: 613-619. [PubMed]
17. Quan H, Parsons GA, Ghali WA. Validity of information on comorbidity derived rom ICD-9-CCM administrative data. Med Care 2002 40: 675-685. [PubMed]
18. Eichenholtz S. Charcot Joints. Springfield, IL: Charles C. Thomas; 1966.
19. Holm S. A simple sequentially rejective multiple test procedure. Scand J Statistics 1979 6: 65-70.
20. Kristiansen B. Ankle and foot fractures in diabetics provoking neuropathic joint changes. Acta Orthop Scand 1980 51: 975-979. [PubMed]
21. Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop Relat Res 1988 232: 210-216. [PubMed]
22. Low CK, Tan SK. Infection in diabetic patients with ankle fractures. Ann Acad Med Singapore 1995 24: 353-355. [PubMed]
23. Blotter RH, Connolly E, Wasan A, Chapman MW. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999 20: 687-694. [PubMed]
24. Flynn JM, Rodriguez-del Rio F, Pizá PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000 21: 311-319. [PubMed]
25. Lillmars SA, Meister BR. Acute trauma to the diabetic foot and ankle. Current Opinion in Orthopedics 2001 (2): 100-105.
26.Ganesh SP, Pietrobon R, Cecílio WA, Pan D, Lightdale N, Nunley JA. The impact of diabetes on patient outcomes after ankle fracture. JBJS  2005 87A: 1712-1718. [PubMed]
27. Kline AJ, Gruen GS, Pape HC, Tarkin IS, Irrgang JJ, Wukich DK. Early complications following the operative treatment of pilon fractures with and without diabetes. Foot Ankle Int 2009 30(11):1042-1047. [PubMed]
28.  White CB, Turner NS, Lee GC, Haidukewych GJ. Open ankle fractures in patients with diabetes mellitus. Clin Orthop Relat Res 2003 (414): 37-44. [PubMed]

Delayed Diagnosis of Charcot and Successful Utilization of Internal and External Fixation: A Case Report

By Bilal Shamsi, BS, Jamil Hossain, BS, Gabriela Mendez, DPM

The Foot and Ankle Online Journal 5 (9): 2

Charcot osteoarthropathy is a chronic progressive disease that can affect those that suffer from any type of peripheral neuropathy, but most commonly seen in the patients with diabetic peripheral neuropathy. Disease progression can lead to devastating consequences such as ulceration, decrease in quality of life, osteomyelitis, deformity and limb loss. Therefore, early recognition and conservative management are hallmarks in the treatment and prevention of the disease. A staple of management includes appropriate offloading with the goal of creating a stable, plantar grade foot. Even with conservative treatment, the disease progression may lead to surgery or amputation. We briefly review the etiology and literature on the surgical management of Charcot as well as present a case report regarding staged surgical intervention utilizing the Taylor Spatial Frame™.

Key Words: Charcot osteoarthropathy, Taylor Spatial Frame™

Accepted: August, 2012
Published: September, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0509.0002


Neuropathic degenerative joint changes associated with tabes dorsalis were first described histopathologically in 1868 by Jean Marie Charcot, a French neurologist. [1]

For many years to follow, tabes dorsalis was considered to be the primary culprit in neuropathic arthropathy, until in 1936, William Reilly Jordan described Charcot’s disease as a complication of diabetic neuropathy. [2]

Other disease processes that may preclude development of foot and ankle Charcot osteoarthropathy (CO) include alcoholism, myelomeningocele, and leprosy. Prevalence of CO varies between .08% – 13.00%, and studies have indicated that two-thirds of those with Charcot foot have type 2 diabetes. [3-6]

More recently, diabetes has become the most common pre-existing etiological factor in the development of osteoarthropathy. [7]
The pathogenesis of Charcot is based on two well documented theories. The neurovascular theory proposes that prolonged autonomic neuropathy leads to a hyperemic state, which leads to bone demineralization and osteopenia. This predisposes the weakened foot to micro-fractures and dislocations. The neurotraumatic theory proposes that CO will develop after repeated trauma occurs to an insensate foot secondary to sensorimotor neuropathy. The loss of intrinsic muscle functions, coupled with an imbalance between flexors and extensors, all support this theory. [8] While both theories exhibit plausibility and indicate CO is due to a combination of the two, neither theory could completely explain the initial inflammatory reaction that is observed. Recent studies have suggested a new ‘inflammatory’ theory that includes the idea of an initial insult, noticed or unnoticed, that triggers an inflammatory cascade manifested by pro-inflammatory cytokines. [9]

Classically, CO’s disease progression is graded through 3 stages, known as the Eichenholtz classification, along with Stage 0 added by Shibata, et al.11 The acute phase, or stage 0, is characterized by erythema and edema, but no radiographic changes are seen. In stage 1, the developmental phase, there is characteristic bone resorption, fragmentation, and joint subluxation. Radiographs reveal evidence of debris formation and osseous fragmentation. Stage 2, or the coalescent phase, involves bone destruction followed by consolidation and fusion. Stage 3, or the reconstructive phase, is characterized by osteogenesis and bone remodeling. Therefore, any deformity that occurs as a result of unstable Charcot foot becomes permanent. [10,11]

The hallmarks of management in the acute phase include reducing the inflammatory process by immobilization, to relieve pain, and to preserve the bony architecture of the foot. Initial treatment in the acute stage involves strict immobilization and offloading [12] although the gold standard of treatment is total contact casting.

Other options include Unna’s boot with below the knee CAM Walker®, non-weightbearing and below the knee cast. It is important to remember that ulceration is not a contraindication to casting. However, casting should not be attempted in the presence of infection. With immobilization and offloading, most ulcers tend to heal. Care must be taken when casting to dorsiflex the foot with an unstable midfoot, instability or Lisfranc’s dislocation. Dorsiflexion at the level of midtarsal joint will increase the deformity and casting in this manner can furthermore progress the deformity. Rearfoot dorsiflexion can be difficult to achieve due to presence of significant equines contracture.

If there is delay in diagnosis or the patient presents late, the disease process progresses; often rapidly. Surgical intervention is usually reserved for obstinate cases such as recurrent ulcerations, osteomyeletis, or when a deformity cannot be managed with bracing or custom shoe gear. [13] Patients often present a challenge to the surgeon as they exhibit multiple co-morbidities. For example, patients can often present with signs and symptoms similar to a deep vein thrombosis (DVT), venous insufficiency or cellulitis. For this reason it is important to acquire a thorough history and physical in these patients, obtain the proper laboratory testing and keep a high index of suspicion for Charcot. This will necessitate sound recognition of the risks versus benefits of surgery. Many of these patients are misdiagnosed and are not properly treated. This ultimately leads to rapid foot break down, ulcers and infections of the bone and soft tissue structures due to inadequate care and misdiagnosis.

Case Report

A 70 year-old Caucasian male presented to a clinician at the Temple Foot and Ankle Institute with a chief concern of severe pain on the lateral aspect of the left foot and an ulcer on the medial plantar heel. The patient was previously being treated by an outside practitioner; where the culture and sensitivity revealed the presence of staphylococcus aureus.

The patient’s medical history was significant for uncontrolled type-2 diabetes mellitus, hypertension, chronic back pain and osteoarthritis. The patient’s past family history, surgical history and social history were all unremarkable.

Upon initial presentation, his review of systems revealed that the patient was mildly febrile with a temperature of 99.4°. A focused lower extremity examination revealed equinus contracture bilaterally and diffuse swelling of the left foot and ankle. Collapsed medial arches of the left foot along with plantar bony prominences were noted. There was severe pain reported in the left foot. An ulcer with the dimension of 6 x 4 cm was located on the lateral aspect of the calcaneus, a granular wound base and mild serosanguinous drainage was observed.

Manual muscle testing revealed no deficits. Protective sensation and vibratory sensation were both absent bilaterally upon examination with Semmes-Weinstein 5.07 monofilament and a tuning fork respectively. Capillary refill time was normal. However, his dorsalis pedis pulses and posterior tibial pulses of the left foot were non palpable due to edema but were obtained using a pulse Doppler. Skin temperature and edema of the left foot was significantly increased compared to the contralateral limb.

Initial radiographic examination of the left foot was negative for osteomyelitis, but revealed minimal mid-tarsal joint collapse along with a possible fracture at the base of the 2nd metatarsal. Extensive soft tissue edema of the entire left foot and left lower extremity, along with osteopenic bone was noted. The Meary’s angle of the left foot was mildly increased to 0.9°. The patient was diagnosed with cellulitis by the evaluating physician at that time and was dismissed from the clinic with prescription for Bactrim® and a Multi Podis® offloading-boot.

Upon his return to clinic approximately 2 months later, he was evaluated by the primary author, and radiographs revealed sub-talar joint dislocation, along with a progression of Meary’s angle to 18.4° and an extensive calcaneal varum deformity of 13.5°.

Note that the Meary’s angle is the most reliable radiographic measurement that can be used to note the progression of the midfoot Charcot arthropathy. An Magnetic Resonance Imaging (MRI) was then performed and showed extensive marrow edema of the hindfoot bones with fragmentation compatible with Charcot deformity. MRI could not completely exclude osteomyelitis at the level of fibula and cuboid due to abnormal low marrow signal, but the overall appearance indicated reactive edema. At this point, further microbiology testing revealed that there was a strong presence of Group B beta-hemolytic streptococcus. The patient was then switched to a course of clindamycin instead of Bactrim®.

Approximately 3 months after his initial presentation and failure of all conservative treatment options, including casting, offloading, and CAM Walker®, surgical intervention was then discussed with the patient and his family.

The patient then elected to undergo staged surgical correction for Charcot deformity. The surgical procedure proposed included realigning the STJ utilizing the Taylor Spatial Frame™ followed by beaming of the rearfoot and forefoot in more anatomical position. The corrected position was assessed radiographically using the Meary’s angle and Calcaneal axial angle. Surgical intervention was planned once the ulcer was healed in order to decrease the risk of bone infection.

Upon administration of general anesthesia and use of an ipsilateral pneumatic thigh tourniquet, the patient’s lower extremity was prepped and draped in sterile fashion and attention was initially drawn to the equinus contracture. A Hoke percutaneous tendo- Achilles lengthening was then performed paying particular attention to the medial aspect of the leg. A C-arm was utilized to identify the cuboid, and a trephine was then utilized to obtain a bone specimen of the cuboid to rule out osteomyelitis. The sample was sent for microbiology and pathology for further evaluation which later revealed bone necrosis but no osteomyelitis.

Next, medial and lateral incisions were made along the level of the subtalar joint (STJ) extending from the distal aspect of the fibula and medial malleolus in order to visualize the subtalar joint.

The calcaneus was noted to be subluxed and positioned lateral to the talus intraoperatively. After the release of the subtalar joint, the incision site was primarily closed. This concluded the STJ release portion of the procedure, and following this a partial tendo-Achilles lengthening was performed.

Focus was then given to the tibial fixation. Two 155mm full and 155m long foot rings, part of the Taylor Spatial Frame (TSF), were placed on the midshaft of the tibia and another on the distal aspect of the tibia utilizing crossed smooth K-wire in orthogonal fashion. The rings were connected to each other by three threaded rods. Application of the foot plate was performed attaching the foot plate to the heel and the metatarsals using two crossing olive wires on each points of fixation.

Appropriate tensions were applied to all crossing wires according to their site of fixation to prevent any excessive movement of the device. Six TSF struts were added to the total configuration which extended from the distal tibial ring to the footplate. Following the application of the device, the STJ was distracted with proper visualization under C-arm to correct the medial calcaneal varus and to distract the STJ to its proper length. This was done using the TSF struts. Intra-operative and postoperative radiographs demonstrate that some significant distraction was achieved.

Next a stirrup wire was added to the frame. It is important to utilize the stirrup wire technique when doing any type of distraction procedure with the TSF to prevent any pain created from the tension of the device. In this case the stirrup wire is inserted into the talar neck directly under fluoroscopy utilizing the lateral view and the wire is then attached to the proximal tibial ring. No tension is required when inserting the stirrup wire. This was to allow distraction of the STJ specifically without distracting the ankle joints or any other joints proximally.

This also reduces pressure and tension on the proximal and distal wires and prevents unnecessary bending of these wires. The patient was then given a TSF prescription which outlines daily strut management. It allows 1mm movement on all of the struts to allow distraction and correction of varus deformity in a slow and progressive manner. X-rays were taken during each visit afterwards to appreciate the distraction and correction of the translational and varus deformity as noted previously. This was noted via Meary’s angle which went from 18.4°, eventually progressing to 2.1°.

The patient was prophylaxed for DVT and was discharged uneventfully after a brief hospital stay. He then returned to the clinic weekly thereafter for dressing changes and management, and thus the postoperative course for the first staged intervention was uneventful.

The patient returned to the operating room at 12 weeks, after finishing two course of the TSF prescription, for removal of the frame, and to undergo a triple arthrodesis and midfoot fusion with beaming. Following administration of general anesthesia and application of a pneumatic thigh tourniquet, bone marrow aspiration utilizing the Ignite system allowed for collection of 6 cc of bone marrow aspirate at the proximal medial tibia. The existing pins were removed, showing no signs of infection or purulent drainage, followed by the removal of the TSF.

Postoperatively, it was approximated that there was 0-5* degrees of valgus of the hindfoot and forefoot was neutral to the rearfoot. The patient had no complications and went on to have an unremarkable postoperative course. To date, the patient is 1 year postoperative, ambulating, and is without complications (Figures 1, 2, 3, 4, 5 and 6).

Figure 1 Preoperative anteroposterior and medial oblique radiographs showing severe talar head dislocation.

Figure 2  Preoperative lateral radiograph showing midfoot collapse.

Figure 3 Postoperative anteroposterior radiograph showing external fixation via Taylor Spatial Frame.™

Figure 4 Postoperative lateral radiograph showing external fixation via Taylor Spatial Frame.™

Figure 5  Three months postoperatively, the anteroposterior and medial oblique radiographs show arthrodesis with medial and lateral column beaming.

Figure 6 Three month postoperative lateral radiograph showing arthrodesis and beaming allowing for a stable, plantigrade foot.

The patient was seen with no pain to the left foot and ankle. He had excellent dorsiflexion and plantarflexion. His only complaint at this time was heel pain.

Upon clinical examination it was noted that the foot was in plantigrade position and there were no increase in temperature. His gait was noted to be calcaneal gait. The patient presented with diabetic shoes and he has been going through physical therapy. It was discussed with the patient that his gait was calcaneus gait. He had limited plantarflexion which limited push-off and put more force on his heel. Gel pads were dispensed for further comfort. X-rays showed no bony changes and complete consolidation of the areas. He has had no ulceration since the procedures. The areas corresponding with the screw insertion were asymptomatic.

Discussion

Currently there are no comparative studies that have been published in regards to the surgical choices for CO treatment. The timing of surgical intervention remains controversial due to this lack of literature & there is insufficient data indicating a support for a particular approach, be it internal or external fixation.14 The Taylor Spatial Frame as methods of achieving an acceptable outcome in the Charcot patient is relatively new, with sparse literature reported in regards to Charcot deformity. [15,16]

While comparative studies of external versus internal fixation remain elusive in the treatment of CO deformity, anecdotal literature does exist in regards to correction of foot and ankle deformity utilizing the Ilizarov frame. El-Gafary, et al., reported that arthrodesis controlled by Ilizarov frame was a successful means of achieving a stable, plantigrade foot in 20 patients studied.17 In a non-peer reviewed retrospective of 100 CO patients managed with the Ilizarov frame, Cooper found a 96% salvage rate, with only 5 developing CO on the ipsilateral side after removal of the initial frame, and 2 resulting in a BKA. [18] The Ilizarov frame demonstrates efficacy, but is not without its share of complications including but not limited to pin-tract infections, skin necrosis, osteomyelitis and hardware failure.

The most common complication is reported to be pin tract infections with frequencies reported as high as 60%. [19] A retrospective review conducted by Rogers, et al., of 15 patients who underwent Charcot reconstruction or soft-tissue unloading surgery over a 12 month period reported that 31% percent experienced serious pin tract infections, 25% pin fractures, and 56% wound dehiscence. [20]

More recently, Grant, et al., performed a retrospective study on the use of beaming the medial and lateral columns on radiographic alignment in 71 Charcot foot reconstructions over a 14 year period. They reported a low-rate of 6% fixation failure and reported that beaming either one or both columns statistically improved radiographic alignment as well as maintained surgical correction. [21]

The Taylor Spatial Frame™ as a surgical modality is also not without its complications such as hardware failure, pin tract infections, fractures, skin necrosis and operator error. Successful application of the TSF involves appropriate deformity planning, familiarity with the TSF software and additional training. Patient compliance is also an essential factor to a successful outcome.

There are some distinct advantages of the TSF over the traditional Ilizarov hardware. It is generally less time consuming to construct and the mounting process is deemed to be easier than Ilizarov. TSF also allows for multiaxial deformity correction and protect at-risk structures, all the while allowing for ease of postoperative strut adjustment. [22]

The treatment of Charcot remains a challenge to patients and surgeons alike. While huge strides have been made in increasing the knowledge available in treatment modalities, concrete research is needed, specifically peer-reviewed prospective comparative studies on the efficacy of internal and external fixation methods in the management of CO. [23]

Conclusion

Appropriate judgment as well as sound knowledge and application of surgical modalities are vital for treatment of advanced stages of CO. Application of external and internal fixation described here are the surgeon’s preference in the management of progressive and unstable CO. It is known that the number of patients with diabetes is increasing, and with that, we can expect that there will be rise in reported CO. Recently, an international taskforce of experts on Charcot agreed that surgical management could be considered a primary treatment modality due to the common failures of non-surgical management Thus far, the data has been inconclusive in terms of determining whether one form of fixation (internal, external or combined) is better than the other. Despite numerous studies and increasing knowledge of the pathogenesis and management of Charcot, it remains a complex and challenging syndrome for the foot and ankle surgeon to treat successfully. The TSF is another modality, which despite lacking evidence-based studies in the treatment of Charcot, can be added to the foot and ankle surgeon’s armament in the management of this difficult condition.

References

1. Charcot JM. Sur Quelques arthropathies qui paraissent dependre d’une lesion du cerveau ou de la moelle epiniere. Arch Physiol Norm Pathol 1868 1: 161-178. [PubMed]
2. Jordan WR. Neuritic manifestations in diabetes mellitus. Arch Intern Med 1936 57: 307-366.
3. Shibuya N, La Fontaine J, Frania SJ. Alcohol induced neuroarthropathy in the foot: A case series and review of literature. J Foot Ankle Surg 2008 47: 118-124. [PubMed]
4. NagarkattI DG, Banta JV, Thompson JD. Charcot arthropathy in spina bifida. J Pediatric Orthop 2000 20: 82-87. [PubMed]
5. Horibe S, Tada K, Nagano J. Neuroarthropathy of the foot in leprosy. JBJS 1988 70B: 481-485. [PubMed]
6. Frykberg RG, Belczyk R. Epidemiology of the Charcot Foot. Clin in Podiat Med Surg 2008 25:17-28. [PubMed]
7. Armstrong D, Peters E. Charcot’s Arthropathy of the foot. International Diabetes Monitor 2001 13:1-5. [PubMed]
8. Molines L, Darmon P, Raccah D. Charcot’s foot: Newest findings on its pathophysiology, diagnosis, and treatment. Diabetes Metabolism 2010 36: 251-255. [PubMed]
9. Jeffcoate WJ, Game F, Cavanagh PR. The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet 2005 366: 2058-2061. [PubMed]
10. Eichenholtz SN. Charcot Joints. Springfield, IL. Charles C Thomas, 1966.
11. Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy. JBJS 1990 72A: 749-756. [PubMed]
12. Botek G, Anderson M, Taylor R. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleveland Clinic J Medicine 2010 77: 593-599. [PubMed]
13. Petrova N, Edmonds M. Charcot Neuro-Osteoarthropathy – Current Standards. Diabetes Metab Res Rev 2008 24 (Suppl 1): S58-S61.[PubMed]
14. Wukich DK. Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications 2009 23: 409-426. [PubMed]
15. Zgonis et al. Surgical Management of the unstable diabetic Charcot deformity using the Taylor spatial frame. Clin Podiatr Med Surg 2006 2: 467-483.
16. Lamm BM, Gottlieb HD, Paley D. A two-stage percutaneous approach to Charcot diabetic foot reconstruction. J Foot Ankle Surg 2010 49: 517-522. [PubMed]
17. El-Gafary et al. The Management of Charcot joint disease affecting the ankle and foot by arthrodesis controlled by an Ilizarov frame. JBJS 2009 91B: 1322-1325.
18. Cooper PS. Application of external fixators for management of Charcot deformities of the foot and ankle. Foot Ankle Clin 2002 7: 207-254. [PubMed]
19. Wukich DK, Belczyk RJ, Burns PR, Frykberg RG. Complications encountered with circular ring fixation in persons with diabetes mellitus. Foot Ankle International 2008 29: 994-1000. [PubMed]
20. Rogers LC, Bevilacqua NJ, Frykberg RG, Armstrong DG. Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle. J Foot Ankle Surg 2007 46: 372-375. [PubMed]
21. Grant WP, Garcia-Lavin S, Sabo R. Beaming the columns for Charcot diabetic foot reconstruction: A retrospective analysis. J Foot Ankle Surg 2011: 1-8. [PubMed]
22.Wukich DK, Belcyzk RJ. An introduction to the Taylor spatial frame for foot and ankle applications. Oper Tech Orthop 2006 16: 2-9. [Website]
23. Roukis TS, Zgonis T. The management of acute Charcot fracture-dislocations with the Taylor’s spatial external fixation system. Clin Podiatr Med Surg 2006 23: 467-483. [PubMed]


Address correspondence to: Temple University School of Podiatric Medicine, 8th & Race St., Philadelphia, PA 19107. Department of Surgery. Email: Gabriela.mendez@temple.edu

1  Submitted as 4th year student, Temple University School of Podiatric Medicine. Philadelphia, PA
2  Submitted as 4thyear student, Temple University School of Podiatric Medicine, Philadelphia, PA
3  Clinical Assistant Professor, Temple University School of Podiatric Medicine – Dept of Surgery, Philadelphia, PA

© The Foot and Ankle Online Journal, 2012

15 Diagnoses, 9 Surgical Procedures, 1 Device – Multiple Applications of the MiniRail

by Thomas Merrill, DPM1, Mario Cala, DPM2, Victor Herrera, DPM3, Alan E. Sotelo DPM4

The Foot and Ankle Online Journal 5 (8): 2

The last decade has seen an increase in the successful application and use of external fixators. More complex procedures involving the ankle and leg require Ilizarov circular or ring fixators for stability and strength. Procedures involving the forefoot and rearfoot (excluding the ankle) do very well with the application of MiniRail fixators. The use of Unilateral MiniRail External Fixation System has grown in popularity over the last decade and has seen a high degree of success. From 2009 to 2011 and application of 29 MiniRail External Fixators were placed on 26 patients ranging in age from 23 to 79. A total of 9 different procedures were performed on the population with 15 different diagnoses. Mini-Rail External Fixators have also been found to be successful in the presence of comorbidities such as in patients with diabetes mellitus, smokers, osteomyelitis and avascular necrosis and have been shown to be definitive in cases where internal fixation has failed. All patients went on to full recovery with no complications or recurrences.

Key words: MiniRail, external fixator, Charcot arthropathy, osteomyelitis, nonunion

Accepted: July, 2012

Published: August, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0508.0002


Unilateral MiniRail External Fixation System is a device used in the treatment of bone conditions and deformities of the foot. In the last decade this application has evolved and become more popular with the development of systems that allow a greater understanding of this technique. External fixation is divided into two main categories: circular frames and unilateral rails;[1,2] however the use of Ilizarov-type circular frames is reserved for more complex deformities in the foot and ankle as well as the distal leg. MiniRail external fixators have been described in the use of a variety of procedures, more commonly used in forefoot surgery.[1,3,4] In this paper we put together a total of nine different surgical procedures used to treat fifteen different foot conditions and deformities as well as trauma. All conditions were treated with unilateral external fixation system with excellent results. These procedures include arthrodesis of the first metatarsal cuneiform joint (with two revisions of this procedure not previously using a MiniRail), medial column fusion, open and closed reduction of Lisfranc fracture-dislocation injuries, metatarsal callus distraction, correction of first and fifth metatarsal fractures, sliding calcaneal osteotomy, first metatarsal cuneiform fusion and first metatarsal phalangeal joint fusion.

External fixation systems have been shown to be advantageous over internal fixation for various reasons. Placement of an external fixator is done percutaneously thus eliminating any unnecessary incisions and risk of infection.[1] Dehiscence and the need for wound care are thus prevented. Associated treatments such as dressing changes, skin grafting, bone grafting and irrigation are possible without disturbing the correction or fixation. Any post-operative condition that may arise such as ulcerations or pin-track infections may be easily accessed and cared for; a luxury not enjoyed by a plate or screw. External fixators can also be applied in the presence of a bone infection. The percutaneous placement of pins eliminates guesswork involved in deciding how to correct the deformity since the pins can be placed at a safe distance from the infection. External fixators can also be safely used in the presence of comorbidities such as diabetes mellitus, smokers, osteomyelitis and avascular necrosis.[1-3]

As with any external fixation system, early weight bearing is not only allowable but encouraged as this expedites bone healing. Immediate motion of the proximal and distal joints is also allowed aiding in the reduction of edema and preventing capsular fibrosis, joint stiffening, muscle atrophy and osteoporosis. When it comes to multi-planar deformities, external fixators provide neutralization and stabilization with adjustable amounts of compression or distraction. This allows correction (compression or distraction) throughout the post-operative period through a minimally invasive procedure and a multifunctional correction.[1,2] Finally, once the desired correction has been achieved, the pins are removed and the patient is left with no internal hardware that may cause pain in the future.

Disadvantages of the unilateral MiniRail system are mainly due to the complexity of the system and difficulty in application and manipulation. This difficulty can be overcome, as with any technical and mechanical difficulty, through surgeon education, training and experience. Another disadvantage of external fixator systems is the cost of the equipment, including the tools needed for application and removal. Although major incisions are avoided as well as placement of internal hardware, the risk of pin track infection and possible neurovascular damage continue to be a realistic risk.[1-3] As stated earlier however, most of these problems can be solved by early detection, quick action and by surgeon education and experience.

Materials and Methods

A total of 29 Orthofix MiniRail external fixators were placed on 26 patients with 15 different diagnoses who underwent 9 different surgical procedures. The patients ranged in age from 23 to 79 years with 8 male (30%) and 18 female (70%) patients. Each patient was educated at length about both internal and external fixation. All advantages and disadvantages including complications as well as recovery time and weight bearing status after surgery were discussed with the patients in detail. All patients who opted for the MiniRail external fixator received pre-operative and post-operative instructions for careful management of the MiniRail. All patients received prophylactic intravenous antibiotic therapy 30 minutes pre-operative and post-operative weekly pin care (cleansing and dressing changes).

In the study, compression-stabilization techniques were used in 26 out of the 29 procedures, within these cases 20 were Arthrodesis and 5 were fracture management techniques. One sliding osteotomy with fixation and 3 distraction- stabilization procedures were also performed (Table 1). All patients had weekly post-operative adjustments of the mini-rail except for the callus distraction patient who performed his own adjustments daily. Intra-operative x-rays were performed to confirm position and stabilization with follow-up x-rays performed at 3 weeks and 8 weeks post-operative. The average post-operative period with the MiniRail was 8 weeks with weight bearing beginning as early as one week post-operative with the aid of a surgical shoe and crutches.

Ten Lapidus fusions were performed with 4 pins placed perpendicular to the long axis of the bone: 2 in the medial cuneiform and 2 in the shaft of the first metatarsal. Prior to pin insertion, the first metatarsal cuneiform joint was prepared under fluoroscopy with temporary fixation through the use of 0.45 Kirschner wire. After placement of the MiniRail, compression was then achieved with an Allen wrench.

     

Figure 1 Examples pre-operative evaluation of 1st and 2nd metatarsophalangeal joint (MPJ) with varus deformity (A and B). First MPJ fusion with MiniRail (C and D). Post-operative evaluation after 1st MPJ fusion and external fixator removal (E and F).

Two revisional Lapidus fusions were performed after failed procedures with internal fixation resulted in non-union. The screws were removed and the joint was prepared once again for the Lapidus procedure described above. Three medial column fusions were performed with a talo-navicular joint fusion involving the use of 2 pins in each bone and compression through the rail with early weight bearing after 1 week and post-operative adjustments made every other week.

Table 1 Summary of diagnoses and procedures performed.

 

Figure 2 Example pre-operative (A) and Post-operative (B) radiograph evaluation of metatarsal cuneiform fusion and brachymetatarsia deformity.

 

Figure 3 Example metatarsal cuneiform joint fusion.

Three Lisfranc’s fracture-dislocations, two fifth metatarsal fractures and one first metatarsal fracture-dislocation were reduced with a total of 6 MiniRails with compression through fracture defect. Five first metatarsal-phalangeal joint fusions were performed with 4 pin compression at the joint through the neck of the first of the metatarsal and the first proximal phalanx.

Two Brachymetatarsia callus distraction procedures were performed with MiniRail placement along the metatarsal shaft. Daily adjustments of the MiniRail were performed for callus distraction by the patient at home. One sliding Calcaneal osteotomy procedure was performed and a MiniRail external fixator was used for compression and stabilization of the osteotomy.

   

Figure 4 Example midfoot osteoarthritis.

 

Figure 5 Example brachymetatarsia with MiniRail external fixator and k-wire fixation.

Results

Of the 29 procedures, all patients went on to full recovery with no complications or recurrence. The average time of duration with MiniRail external fixator was 8 weeks with removal at that time +/- one week. After removal of the MiniRail external fixator, all patients had an average recovery period of approximately 3 weeks at which time patients were allowed to transition out of their post-operative shoes and into athletic shoes. By one month following removal patients were cleared to return to all normal pre-operative activity without restrictions. Physical therapy was highly recommended to all patients to regain muscle strength and balance and averaged 3 weekly physical therapy sessions for 3 weeks. Most patients were allowed to begin physical therapy a week after removal of the external fixator. To date there have no recurrences and patient satisfaction has been overall positive with results. There was no need for further corrective procedures and all patients went on to full recovery.

Discussion

The use of external fixation devices has been in practice for many years. Today the use of external fixators has become a popular methodology for treating a great variety of conditions with minimally invasive procedures. While the larger ring fixators are reserved for more complex conditions (ankle fractures, limb lengthening, Charcot reconstructions), MiniRail external fixators have been a staple for the minimally invasive surgical correction of various forefoot and midfoot conditions as well as some Calcaneal and rear foot conditions.

  

Figure 6 Example Lisfranc fracture dislocation pre-operative (A) and post-operative (B), and follow-up evaluation (C).

 

Figure 7 Example fifth metatarsal fracture non-union repair using MiniRail.

   

Figure 8 Example Tarsal coalition fixed with MiniRail.

In this study, 26 patients underwent a total of 9 different surgical procedures with application of 29 MiniRail external fixators to correct conditions in 15 different diagnostic categories. All patients received pre-operative education and weekly post-operative adjustments and pin care with follow up x-rays at 3 and 8 weeks. The patient population ranged in age from 23-79 years of age with females outnumbering males 18 to 8 respectively.

Since 2009 we have found MiniRail external fixators to be superior over internal fixation for the various reasons listed above. The success rate is exceptionally high with patients able to ambulate very early after surgery and the ability to perform any necessary adjustments post-operative make the MiniRail system a very useful device.[4,5] It should also be noted that satisfaction is overall very positive considering they are able to ambulate early on and they have the peace of mind knowing that any correction needed can be easily adjusted at any time. Patient complaints are minimal and are generally geared toward the bulky dressings and uncomfortable post-operative shoe gear however any complaints of pain or discomfort are virtually non-existent. Finally, it is of importance to note once again that this device can be safely and successfully used on patients with comorbidities that would otherwise lead failure with internal fixation such as patients who are smokers, have bone infections or suffer from chronic system illnesses such as diabetes mellitus.[5,6]

We will continue to use MiniRail external fixators for future cases and hope to broaden the scope of indication for the device. Although this study has a very small sample population, the degree of success we have experienced thus far will propel us forward to continue.

References

1. LaBianco GL, Vito GR, Rush SM. External fixation. In: Banks AS, Downey MS, Martin DE, Miller SJ, (editors). McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 1. 3rd edition. Philadelphia: Lippincott, Williams & Wilkins; 2001. p. 107–38.
2. Seibert FJ, Fankhauser F, Elliott B, Stockenhuber N, Peicha G. External fixation in trauma of the foot and ankle. Clinics in Podiatric Medicine and Surgery 20(1): 159-180, 2003. [PubMed]
3. Treadwell JR. Rail external fixation for stabilization of closing base wedge osteotomies and Lapidus procedures: a retrospective analysis of sixteen cases. J Foot Ankle Surg 2005 44: 429-436. [Website]
4. Hamilton GA, Mullins S, Schuberth JM, Rush SM, Ford L. Revision Lapidus arthrodesis: rate of union in 17 cases. J Foot Ankle Surg 2007 46: 447-450. [PubMed]
5. Gamble J, Decker S, Abrams RC: Short first ray as a complication of multiple metatarsal osteotomies. Clin Orthop 1982 164: 241–244. [PubMed]
6. Levine SE, Davidson RS, Dormans JP, et al: Distraction osteogenesis for congenitally short lesser metatarsals. Foot Ankle Int 1995 16:196-200. [PubMed]


Address correspondence to: Thomas Merrill, DPM, Barry University/ Mercy Hospital, Miami, FL

1Diplomate, American Board of Podiatric Surgery
2Sport Medicine Fellow at Barry University/ Mercy Hospital, Miami, FL
3Senior Resident at Barry University/ Mercy Hospital, Miami, FL
4Resident at Barry University/ Mercy Hospital, Miami, FL

© The Foot and Ankle Online Journal, 2012